Every finding on record at Landmark at 95th Rehabilitation and Nursing Center

Based on observations interviews and record review, the facility failed to ensure that two residents (R118 and R34) received incontinent care; and failed to ensure that five residents' (R2, R19, R56, R139 and R141) facial hair and nails were properly groomed. This failure has affected seven of 57 residents reviewed for personal hygiene and care. Findings include: R34's Face Sheet documents that R34 is [AGE] year old with diagnoses including but not limited to: polyarthritis, calcific tendinitis of unspecified shoulder, cellulitis of left lower limb, other specified disorders of muscle, and chronic kidney disease. R34's BIMS (Brief Interview of Mental Status) score dated 6/26/26 is 4, which indicates severe cognitive impairment. R118's Face Sheet documents that R118 is [AGE] year old with diagnoses including but not limited to: Alzheimer's disease, dementia, muscle weakness, abnormalities of gait and balance, adult failure to thrive and acute kidney failure. R118's BIMS (Brief Interview of Mental Status) score dated 7/7/26 is 99, which indicates that R118 was not able to answer questions in order to determine cognition. R56's Face Sheet documents that R56 is [AGE] year old with diagnoses including but not limited to: weakness, adult failure to thrive, other lack of coordination, limitation of activities due to disability and unspecified dementia. R56's BIMS (Brief Interview of Mental Status) score dated 6/1/26 is 2, which indicates severe cognitive impairment. During facility survey on 8/24/26 at 10:40 am, Surveyor walked into R118 and R34's room and smelled a strong odor of urine. At that time, R118 was observed with wet pants and wet bed sheet. On 8/24/26 at 10:50 am, V12 (CNA/Certified Nurse Assistant) walked into R118 and R34's room and stated the following, I got here at 7:30 am and did rounds. I believe (R118) was changed before the previous shift left (near 7:00 am). She (R118) didn't look wet when I saw her earlier. She was already dressed. I haven't checked (R34's) incontinent brief yet because I was helping with breakfast. I don't usually work this unit. My patients on the first floor are taken care of. At that time, V12 began to remove the wet clothes from R118 and stated the following, Now I smell the urine is pretty strong. On 8/24/26 at 10:55 am, R34 stated the following, I didn't know I was full of s***. I was changed last night sometime. I guess I sh*** while I was sleeping. Nobody even changed me. At that time V12 (CNA) began to remove R34's incontinent brief which was saturated with a yellow and brown substance. On 8/24/26 at 10:57 am, V12 assisted R34 rolling on her left side in bed in order to remove R34's bed linen. At that time, R34's bed was observed with a wet fitted sheet, wet bed pad and a folded wet flat sheet which were all layered underneath R34's buttock region. On 8/24/26 at 11:00 am, V12 (CNA) stated the following, I didn't know that (R34's) bed was wet. She (R34) should only have one bed pad on top of her sheet. On 8/24/26 at 11:43 am, V3 (ADON/Assistant Director of Nursing) went to R56's room with Surveyor and observed R56 in bed with overgrown facial hair and nails. At that time, V3 stated the following, (R56's) nails need to be trimmed, and his facial hair is overgrown. On 8/26/26 at 12:07 pm, V2 (DON) stated the following, Residents should be provided with incontinent care every two hours and as needed to prevent any skin alterations or skin breakdown. It is also necessary to keep them comfortable, clean and dry. Residents also deserve to have their hair and nails kept groom and neat, especially if they depend on staff for ADL (Activities of Daily Living) care. R118's Section GG- Function Abilities assessment dated [DATE] documents: R118 is dependent on staff with toileting and maintaining perineal hygiene; R118 is dependent on staff with bathing. R34's Section GG- Functional Abilities assessment dated [DATE] documents, R34 is dependent on staff for maintaining perineal hygiene/ toileting and transferring to a toilet or commode; R34 requires maximal assistance rolling left to right in bed; R34 is dependent on staff to move from a lying position to a sitting position. R56's Section GG- Functional Abilities assessment dated [DATE] documents: R56 requires maximal assistance with maintaining personal hygiene. Facility policy titled, Activities of Daily Living (undated) documents, Residents are given daily care and HS (bedtime) care by a CNA or a Nurse to promote hygiene, provide comfort and a homelike environment. R2's Face Sheet dated 08/26/2026 documented, in part, that R2 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism, pulmonary embolism, anemia, acute kidney failure, diabetes mellitus, severe protein-calorie malnutrition, bipolar disorder, depressive disorder, and dementia. R2's Minimum Data Set (MDS), Cognitive Patterns and Brief Interview for Mental Status (BIMS), dated 06/26/2026 documented a score of 3, indicating severe cognitive impairment. R2's MDS Functional Abilities section dated 06/26/2026 documented a personal hygiene score of 2, indicating R2 required substantial/maximal assistance from staff to complete personal hygiene tasks, including shaving, grooming, and nail care. On 08/24/2026 at 11:42 AM, R2 was observed in his room watching television. R2 was alert to self and responded to interview questions. R2 was observed with full facial hair and stated he would like to have it cut. R19's Face Sheet dated 08/26/2026 documented, in part, that R19 was admitted to the facility on [DATE] with diagnoses including dementia, essential hypertension, bradycardia, anemia, chronic kidney disease, restlessness, and agitation. R19's MDS, Cognitive Patterns and BIMS, dated 08/01/2026 documented a score of 8, indicating moderate cognitive impairment. R19's MDS Functional Abilities section dated 08/01/2026 documented a personal hygiene score of 3, indicating R19 required partial/moderate assistance from staff to complete personal hygiene tasks, including shaving and grooming. On 08/24/2026 at 11:48 AM, R19 was observed walking in his room with a slow, steady gait. R19 was able to make his needs known and denied pain or discomfort. R19 was observed with facial hair and long fingernails. R19 stated he would like to be shaved and have his fingernails cut. On 08/24/2026 at 11:49 AM, V4 (Licensed Practical Nurse/Infection Preventionist [LPN/IP]) observed R19's fingernails and stated they were long and could contribute to infection. V4 stated it was the nursing aides' responsibility to provide shaving and nail care and that these tasks should have been completed for R19. R139's Face Sheet dated 08/26/2026 documented, in part, that R139 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, chronic embolism, mild protein-calorie malnutrition, and lymphedema. R139's MDS, Cognitive Patterns and BIMS, dated 08/18/2026 documented a score of 15, indicating R139 was cognitively intact. R139's MDS Functional Abilities section dated 08/18/2026 documented a personal hygiene score of 2, indicating R139 required substantial/maximal assistance from staff to complete personal hygiene tasks, including shaving and grooming. On 08/24/2026 at 12:16 PM, R139 was observed resting in bed. R139 stated she would like to be shaved and did not like having facial hair because she is a woman. R139 stated staff told her they did not have time to shave her. R139 also stated she would like her long fingernails cut. On 08/24/2026 at 12:23 PM, V4 observed R139 and stated R139's fingernails were too long and her facial hair should be removed. R141's Face Sheet dated 08/26/2026 documented, in part, that R141 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis of the right dominant side, cerebral infarction, chronic obstructive pulmonary disease, essential hypertension, benign neoplasm of the brain, seizures, depression, weakness, and reduced mobility. R141's MDS, Cognitive Patterns and BIMS, dated 06/26/2026 documented a score of 2, indicating severe cognitive impairment. R141's MDS Functional Abilities section dated 06/26/2026 documented a personal hygiene score of 2, indicating R141 required substantial/maximal assistance from staff to complete personal hygiene tasks, including shaving and grooming. On 08/24/2026 at 11:16 AM, R141 was observed lying in bed with long fingernails with dark debris underneath them. R141 had a right-hand contracture with the hand folded inward. R141 stated he would like to be shaved and have his fingernails cut because they were too long. On 08/24/2026 at 11:17 AM, V33 (Certified Nursing Assistant [CNA]) stated she had not yet provided care to R141 and that she should cut his fingernails and shave him. V33 stated long fingernails could place staff at risk of being scratched by the resident. V33 further stated it was her responsibility to provide residents with grooming care, including bathing, shaving, and nail care. On 08/24/2026 at 11:52 AM, V4 stated R141 had very long fingernails that should be trimmed because they could cause injury to the resident and/or staff while providing care. V4 also stated R141 had full facial hair that needed to be shaved. On 08/26/2026 at 12:10 PM, two days after the initial observation, R141 was observed sitting in his wheelchair in the dining room with full facial hair. R141 stated he was still waiting to be shaved since the surveyor observed him on 08/24/2026. On 08/26/2026 at 12:16 PM, V40 (CNA) stated she was responsible for R141's care that morning and afternoon. V40 stated she should have shaved R141 and would shave him at that time. On 08/26/2026 at 12:24 PM, V19 (LPN) stated he was R141's nurse and that R141 should have been shaved that morning during AM care. V19 stated it was the nursing aide's responsibility to complete the task. On 08/26/2026 at 1:47 PM, V3 (Assistant Director of Nursing [ADON]) verified that R141 had not been shaved. On 08/26/2026 at 11:59 AM, V2 (Director of Nursing [DON]) stated the expectation was for nurses to ensure activities of daily living (ADL) care, including bathing, grooming, shaving, and nail care, was completed by nursing aides for residents requiring assistance. V2 stated the nurse was responsible for ensuring the aides provided the care after receiving direction. V2 further stated nursing aides were expected to assist residents with their daily needs and report concerns to the nurse.

Based on observations, interviews and record review, the facility failed to ensure that residents' room floors (R34, R72, and R118) were not filled with debris and dirt; failed to ensure that residents (R34, R72, R106, and R118) had clean bed linen and privacy curtains; and failed to ensure that residents (R22 and R66) did not have holes in their bedroom wall. This failure has affected six residents from a sample of 57 residents reviewed for environment. Findings include: R72's Face Sheet documents that R72 is [AGE] year old with diagnosis including but not limited to: Heart failure, unspecified dementia, unspecified abnormalities of gait and mobility, cellulitis of right lower limb, primary generalized osteoarthritis, and disorder of kidney and ureter. R72's BIMS (Brief Interview of Mental Status) score dated 6/26/26 is 3, which indicates severe cognitive impairment. R34's Face Sheet documents that R34 is [AGE] year old with diagnosis including but not limited to: polyarthritis, calcific tendinitis of unspecified shoulder, cellulitis of left lower limb, other specified disorders of muscle, and chronic kidney disease. R34's BIMS (Brief Interview of Mental Status) score dated 6/26/26 is 4, which indicates severe cognitive impairment. During survey on 8/24/26 at 10:40 am, Surveyor walked into R34's room and smelled a strong odor of urine. On 8/24/26 at 10:50 am, V12 (CNA/ Certified Nurse Assistant) entered R34's room and stated the following, I smell the urine is pretty strong. At that time, Surveyor noted the floor near R34's bed linen was soiled with a yellow substance, and R34's privacy curtain was observed with a brown stain on it. On 8/24/26 at 10:57 am, V12 assisted R34 rolling on her left side in bed in order for V12 to remove R34's bed linen. At that time, R34's bed was observed with a wet fitted sheet, wet bed pad and a folded wet flat sheet which were all layered underneath R34's buttock region. V12 grabbed clean linen and placed clean linen on top of R34's visibly wet, soiled bed mattress. On 8/24/26 at 10:58 am, V14 (Maintenance Director) stated the following, The CNAs are supposed to clean the mattress, not housekeeping. We will clean the mattress if they ask. Yes, her (R34's) floor is dirty. It needs to be stripped and waxed. The brown stain on her privacy curtain can be pudding, feces or anything. A lot of curtains need to be cleaned. We are in the middle of getting them all cleaned. On 8/24/26 at 11:19 am, R72 was observed sitting in bed. At that time, Surveyor noted the following: debris on the floor near R72's bed; R72's waste basket over-flowed; and soiled bed linen with yellow and brown stains. On 8/24/26 at 12:07 pm, V14 (Housekeeping Director) stated the following, We have seven staff members for all shifts. I am in the middle of hiring more housekeeping staff. On 8/25/26 at 12:18 pm, V3 (ADON/Assistant Director of Nursing) went to R118's room with Surveyor and observed brown and yellow stains on R118's bed sheet. At that time, V3 stated the following, Her (R118's) bed sheet needs to be changed, there is garbage on the floor, and her garbage is over-flowing. I will make sure that her room is cleaned. On 8/26/26 at 12:07 pm, V2 (DON) stated the following, I would expect for the CNA to clean the mattress if it is visibly wet. I don't know where the gnats are coming from. I have seen the gnats in residents' rooms, but their (residents') rooms should be clean and comfortable. Facility Housekeeper Job Description documents, Under the direction of the Director of Housekeeping, the Housekeeper is responsible for cleaning residents' rooms and other interior and exterior facility areas and assisting in maintaining a clean and attractive environment for the residents. On 8/24/2026 at 10:45am surveyor observed an open area (exposing the drywall) at the top of the baseboard behind R22's bed. There is a hole in the wall behind R22's bed to the right. On 8/24/2026 at 10:47am surveyor observed a linear opening (hole) in the wall, on the same side as the bathroom, close to the floor in R66's room. On 8/25/2026 at 8:21am surveyor observed an open area (exposing the drywall) at the top of the baseboard behind R22's bed. There is a hole in the wall to the right side of R22's bed. On 8/25/2026 at 11:16am V18 (Maintenance Director) stated it is not a homelike environment for a resident to have holes in the wall and the purpose of making sure all holes have been repaired is to prevent rodents, fires from spreading and to provide a homelike environment to the residents. V18 stated he was only told about the open area behind R22's bed. On 8/25/2026 at 12:58pm surveyor reviewed the Job Order Binder for the second floor and there was nothing listed for the last two months about the holes in the wall for R22 and R66. On 8/26/2026 at about 12:30pm surveyor observed the same hole in the wall behind and to the right side of R22's bed and the same hole in R66's room. On 8/26/2026 at 12:41pm V47 (License Practical Nurse-LPN) stated that is a hole in R66's room and said that it should not be there. V47 stated when we (staff) find these types of issues, we are to notify the V18 and no, a room with a hole in the wall is not a homelike environment. Job Description titled Maintenance Director dated 1/1/2024 documents, in part assist with all aspects of cleaning and maintaining the facility interior, ensure residents' rooms are clean, safe, comfortable, and maintained in an attractive manner and that residents' personal items are safeguarded. Resident Rights dated 9/2025 documents, in part, your facility must provide services to keep your physical and mental health, and sense of satisfaction and ensure understanding of, and compliance with, all rules regarding residents' rights. R106's Face Sheet dated 08/26/2026 documented, in part, that R106 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis of the left dominant side, essential hypertension, dementia, diabetes mellitus, anemia, and depressive disorder. R106's Minimum Data Set (MDS), Cognitive Patterns and Brief Interview for Mental Status (BIMS), dated 07/22/2026 documented a score of 12, indicating moderate cognitive impairment. On 08/24/2026 at 11:30 AM, R106 was not in the room. R106's empty bed was observed with a large brown soiled ring on the bed sheet. On 08/24/2026 at 11:35 AM, V4 (Licensed Practical Nurse/LPN), who stated she was responsible for R106 at that time, entered the room and observed R106's bed. V4 identified the brown soiled area on the bed sheet as urine. V4 stated the soiled bed sheets should have been changed when R106 was transferred out of bed, and the bed should have been cleaned to maintain the resident's dignity. On 08/24/2026 at 12:24 PM, V3 (Assistant Director of Nursing/ADON) observed R106's soiled bed. V3 identified the brown ring on the bed sheet as urine and stated bed sheets should be changed daily and as needed to ensure residents were treated with dignity. On 08/25/2026 at 1:23 PM, V19 (LPN) observed R106's bed with soiled linen. On 08/25/2026 at 1:29 PM, V28 (Certified Nursing Assistant/CNA) stated she was assigned to R106 and had assisted R106 with care that day but had not gotten around to changing the bed sheets. V28 identified the brown ring on the sheets as urine. V28 stated she normally changed the bed sheets daily. On 08/25/2026 at 1:30 PM, R106's bed was observed for a second consecutive day with a large brown soiled ring on the bed sheet. R106 returned to the room in a wheelchair and stated she had gotten out of bed much earlier and did not know why staff had not changed her linen. R106 stated staff left her sheets like this a lot and would sometimes attempt to change the linen when she returned to the room to take a nap. On 08/25/2026 at 1:32 PM, V3 (ADON) entered R106's room and observed the soiled bed sheets. V3 identified the brown ring on the bed sheet as urine and stated the sheets should be changed daily and as needed when soiled. V3 stated the soiled sheets should have been removed. On 08/25/2026 at 1:34 PM, V2 (Director of Nursing/DON) observed R106's bed with a brown soiled ring on the bed sheet. V2 stated the bed sheets should have been removed once R106 was taken out of bed and the mattress should have been cleaned and disinfected. On 08/26/2026 at 1:12 PM, V4 (Infection Preventionist) stated all managers participated in the facility's Guardian Angel Program and were responsible for going into residents' rooms to check room cleanliness, including clean linen, bedrooms, and bathrooms, to ensure the rooms were neat and presentable.

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and pest-free environment by failing to ensure resident rooms were free from gnats and by failing to promptly remove urine-soiled linens that attracted gnats. The facility also failed to ensure staff reported and documented pest sightings in accordance with the facility's pest control policy. This deficient practice affected two residents (R90 and R106) reviewed for environmental concerns in a sample of 57 residents. Findings include:R90's Face Sheet dated 08/26/2026 documented, in part, that R90 was admitted to the facility on [DATE] with diagnoses including chronic systolic heart failure, morbid obesity, weakness, reduced mobility, dementia, pressure ulcer of the sacral region, lymphedema, chronic kidney disease, and lack of coordination.R90's Minimum Data Set (MDS), Cognitive Patterns and Brief Interview for Mental Status (BIMS), dated 07/14/2026 documented a score of 15, indicating R90 was cognitively intact.R106's Face Sheet dated 08/26/2026 documented, in part, that R106 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis of the left dominant side, essential hypertension, dementia, diabetes mellitus, anemia, and depressive disorder.R106's MDS, Cognitive Patterns and BIMS, dated 07/22/2026 documented a score of 12, indicating moderate cognitive impairment.On 08/24/2026 at 11:30 AM, R106 was not in the room. R106's empty bed was observed with a large, soiled brown ring on the bed sheet. Multiple black flying insects were observed on and around the soiled area of the linen and on the privacy curtain.On 08/24/2026 at 11:35 AM, V4 (Licensed Practical Nurse/LPN), who stated she was responsible for R90 and R106 at that time, entered the room and observed R106's bed. V4 identified the black flying insects as gnats and stated the brown soiled area on the bed sheet was urine. V4 stated the sheets should have been changed when R106 was transferred out of bed and the bed should have been cleaned to maintain the resident's dignity. V4 further stated R90 should not have to wave gnats away while in her room because that is not fair to her.On 08/24/2026 at 11:37 AM, R90 was observed resting in bed, alert and responsive, and able to make her needs known. R90 was observed waving her hand in the air and stated the gnats were all over the room and disturbed her while she was eating and drinking. R90 stated staff just cannot get rid of the gnats, that the gnats were very bad, and that their presence made her feel uncomfortable.On 08/24/2026 at 12:24 PM, V3 (Assistant Director of Nursing/ADON) observed R106's soiled bed and gnats on and around the soiled area. V3 identified the brown ring as urine and stated the bed sheets should be changed daily and as needed to ensure residents were treated with dignity.On 08/25/2026 at 1:23 PM, V19 (LPN) observed R106's bed and stated the black flying insects appeared to be gnats and the dark brown ring on the bed sheet appeared to be urine. V19 stated he was not the nurse assigned to the room and would obtain the nursing assistant to address the concern.On 08/25/2026 at 1:29 PM, V28 (Certified Nursing Assistant/CNA) stated she was assigned to R106 and had assisted R106 with care that day but had not gotten around to changing the bed sheets. V28 stated the brown ring on the sheets was urine and acknowledged gnats were flying around the bed and room. V28 stated she changed the bed sheets daily and reported gnats to the nurse when observed. V28 stated she had not been instructed to document her observations of gnats in residents' rooms.On 08/25/2026 at 1:30 PM, R106's bed was observed for a second consecutive day with a large brown soiled ring on the bed sheet. R106 returned to the room in a wheelchair and stated she had gotten out of bed much earlier and did not know why staff had not changed her linen. R106 stated staff left her sheets like this a lot and would sometimes attempt to change the linen when she returned to the room to take a nap. R106 further stated there were a lot of gnats in the room and that they were always flying around.On 08/25/2026 at 1:32 PM, V3 (ADON) entered R106's room and observed the bed sheets. V3 stated the sheets should be changed daily and as needed when soiled and identified the brown ring on the bed sheet as urine.On 08/25/2026 at 1:34 PM, V2 (Director of Nursing/DON) observed R106's bed with a brown soiled ring and gnats flying in the room. V2 stated the bed sheets should have been removed once R106 was taken out of bed and the mattress should have been cleaned and disinfected. V2 identified the black flying insects as gnats.On 08/26/2026 at 11:48 AM, V36 (Maintenance Director) stated the facility uses an outside pest control company to treat and spray for insects. V36 stated the pest control company comes to the facility twice monthly and that he believed twice-monthly treatment was effective. V36 stated he depended on facility staff to notify him of rooms requiring treatment. V36 stated staff should inform him when gnats were observed and acknowledged residents could become frustrated from having to wave gnats away. V36 was unable to provide documentation demonstrating that R90 and R106's room had been reported to him or placed on the list for pest control treatment.On 08/26/2026 at 11:59 AM, V2 (DON) stated she could imagine that gnats flying around a resident's room could cause the resident to feel uncomfortable.On 08/26/2026 at 12:45 PM, R106 was observed lying in bed with multiple gnats on the privacy curtain and flying around the bed. R106 stated she was trying to take a nap and the gnats continued to fly around the room. R106 was alert and responsive, denied pain, and was able to make her needs known.On 08/26/2026 at 2:53 PM, V1 (Administrator) stated residents had expressed concerns regarding gnats flying around the facility. V1 stated the facility had contacted the city the previous week because he believed the gnats could be associated with the city sewage system and a facility drain connected to the city drains. V1 stated the facility was treating the gnats, the pest control company came every two weeks, and he had spoken with the pest control company and directed them to treat for gnats.Review of the facility's pest control service inspection reports dated 04/22/2026 through 08/06/2026 documented gnats as a target pest on 07/10/2026. The documentation presented for review did not identify additional dates during this period when gnats were specifically treated and did not identify R90 and R106's room as having received treatment for gnats.Review of the facility's concern binder dated 04/01/2026 through 08/24/2026 did not contain documentation indicating residents or family members had reported concerns regarding gnats.Review of the facility's Pest Control Policy dated 2024 documented, in part, that the purpose of the policy was to ensure a pest-free environment through procedures for the prevention, monitoring, and control of pest infestations. The policy directed the pest control provider to conduct regular inspections, apply pest control measures, and provide detailed reports regarding pest activity and treatment. The policy further directed employees to immediately report pest sightings to the designated pest control coordinator and required maintenance of a pest-sighting log for tracking and follow-up. The policy instructed staff who observed pest activity to document the sighting on the pest control log located at the nurses' station.Despite repeated observations of gnats in R90 and R106's room over three consecutive days, resident complaints regarding the gnats, staff acknowledgment of the presence of gnats, and repeated observations of urine-soiled linen in R106's bed, the facility was unable to provide documentation demonstrating that the pest sightings in the residents' room had been reported, logged, tracked, and addressed in accordance with the facility's pest control policy.

Based on interview and record review the facility to seek medical attention right away for one resident (R2) who was on anti-coagulant medications after the resident told the nurse he was in an incident with another resident and an injury was noted to his face. Subsequently the resident was not sent to the hospital until a day later after a mark was noted and where resident required hospitalization for a Intracranial Hemorrhage and Hematomas to other parts of his body. Findings Include:R2 has diagnosis not limited to Seizures, Anemias, Transient Ischemic Attack (Tia), and Cerebral Infarction, Abnormalities of Gait and Mobility, Major Depressive Disorder, Epilepsy, Atherosclerotic Heart Disease of Native Coronary Artery, Dementia, Schizophrenia, Bipolar Disorder, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Essential (Primary) Hypertension, Altered Mental Status, Anxiety Disorder, Major Depressive Disorder and Chronic Kidney Disease. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating intact moderate impairment.On 06/17/26 at 11:25 AM V12 (Licensed Practical Nurse) stated I was not here on 06/01/26. I was here 06/02/26 Tuesday. I did my rounds and noticed R2 had a red mark on the right side of his cheek area. I asked him what the mark was from and R2 said he got into it with another resident. I asked did you tell somebody, and he said I told the nurse. On 06/03/26 Wednesday when I was here therapy came up for R2. R2 did not want to go to physical therapy because he was in pain and did not feel like participating that day. V16 (Contracted Physical Therapist) came to me, and I told V16 that R2 told me prior to that. I did not see any documentation at that time. V16 made his supervisor aware and V1 (Administrator) and V10 (Psychiatric Rehabilitation Service Director) were made aware. I was the one that did the only documentation and an assessment. The resident-to-resident altercation V1 and V10 did the actual interview. R2 had a red mark to the right cheek and discoloration to the right hip as well. Initially I got orders to do an Xray then it was changed, and the order was to send R2 out. I don't know what happened. No one reported it at shift change, and no one told me anything. He did not mention the other resident name but once interviewed V1 and V10 went directly to R24's room and R24 admitted they had an altercation. R2 was wheelchair bound and was alert and oriented x 2-3. R2 self-propelled himself in the wheelchair and self-transferred from bed and to the toilet. R24 used a rolling walker, was a standby assist.On 06/17/26 at 01:35 PM V15 (Contracted Director of Rehab) stated V16 (Contracted Physical Therapist) reported to me in the morning of 06/03/26. I asked V16 to screen R2 to see if he was appropriate for therapy services. V16 said he went to R2's room and observed R2 with bruises on the face and hip. V16 questioned R2 and he was complaining of a lot of pain with movement. V16 asked what happened and R2 said he had an altercation with another resident. V16 went and informed the nurse, then he came to the gym and told me what was going on. I went to the morning meeting and let V1 (Administrator) know. I did not see R2.On 06/17/26 at 02:24 PM Per telephone interview V16 (Contracted Physical Therapist) stated I was told by my boss to assess and evaluate R2. I proceeded to R2's room, introduced myself, and proceeded with the evaluation. R2 demonstrated a decline in function, and he could not move. During my assessment I noted a bruise on R2's forehead and lower part of his right jaw. I asked R2 he had a fall, and he said no. I did range of motion and proceeded to the lower extremity. During the assessment I observed a bruise to R2's right hip area. R2 had pain when I tried to be gentle. R2 said he could not turn, and I reported to V12 (Licensed Practical Nurse) about the bruises on R2's face, right hip and another bruise close to the right ankle near the chin. R2 required extensive assistance. I reported to my boss for her to report it in the morning meeting. The lump on R2's forehead was the size of an egg. On the jaw I could not see the extent, but the redness was the size of my palm.On 06/17/26 at 02:50 PM V20 (Certified Nurse Assistant) stated I heard about the altercation between R2 and R24. I worked Monday morning on 06/01/26. V16 (Contracted Physical Therapist) asked V12 (Licensed Practical Nurse) about R2 and was he beaten up. V16 took me in the room and R2 said he got into a fight the other day with a tall black guy that walks around. R2 had a knot on his forehead that was turning green. R2's right jaw had a green, purple knot that was small. The green part was big. The bruise on R2's right hip was from the hip to mid-thigh red in color. R2 was in pain when I touched his leg. R2 said that he got pushed down to the ground, it happened in the evening, and a nurse and certified nurse assistant picked him up. I don't know who it was that picked R2 up, that is the mystery.Progress note dated 06/03/26 19:48 document in part: Nursing Progress Note Text: Resident observed with discoloration to the forehead and discoloration to the right side of his face. Further skin assessment revealed discoloration to the right hip area. Attending physician and gave orders to send resident to for evaluation.Hospital record dated 06/03/26 document in part: Chief Complaint: Assault victim. Visit diagnosis: Intracranial hemorrhage. Presenting after physical assault 2 days ago at the nursing facility. He states that a nursing home resident attacked him after a verbal altercation. He was sitting in a wheelchair during this time as he was punched in the face. Significant bruising and swelling to the right maxilla with bruising extending into the right jaw on the right neck down into the right clavicle area. Small bruise to the left inner knee. Large bruise to the right hip. Right hip series: Pain Trauma with bruising. CT (Computed Tomography) Angio neck with and without contrast: Impression: 2. Right facial and neck soft tissue swelling with right malar soft tissue mass approximately 88 Hounsfield units in density, likely hematoma given history of trauma. CT angiogram of the Extracranial Carotid arteries with infusion and IV contrast with 3-d Rotational Reconstructed Images. Indication: neck trauma. Neck pain and swelling with bruising. There is swelling throughout the neck and face with a rounded 2 - 3 centimeters mildly hyperdense mass in the right malar region. Per EMS (emergency medical services) the nursing home stated that R2 was assaulted. R2 has bruising on the right side from head to hip. R2 is on aspirin and Eliquis. R2 states that he has pain everywhere.Progress note dated 06/04/26 00:01 document in part: Nurses Notes Text: Update, the patient has been admitted to Hospital ED (emergency department). The Nurse stated that the patient has been Dx (diagnosis) with bleeding on the brain. Nurse stated that the patient will be transferred to a trauma hospital.Hospital records dated 06/05/26 document in part: admission Complaint: Intracranial hemorrhage. Eliquis 5 mg (Milligrams) Twice a day. R2 was brought as a trauma transfer after an assault at his nursing facility. Imaging showed a hypodensity which may reflect a small parenchymal or subarachnoid hemorrhage versus calcification. Physical Exam: Head; Hematoma right lower face. Smaller one on left forehead. Skin: extensive bruising. CT Head without Contrast: There is a right upper lip subcutaneous hematoma. Assessment and Plan: Trauma/assault, Head injury, Right buccal hematoma, Right hip/thigh hematoma.Initial Abuse Reportable document in part: Incident date: 06/03/26. Residents involved R2 and R24. Brief Description of Incident: 06/03/26 11:00 administrator was made aware of R2 having a bruise on his face; alleging an altercation with R24. Immediate Action Taken: Initiated body assessment for both residents. R2 does not feel safe in the facility.Abuse Reportable Final report document in part: Conclusion: R2 ambulates in a wheelchair. R2 stated he was struck in the hallway all over after dinner. R2 stated R24 did not like how I was talking to the ladies. R2 stated incident happened on Sunday in the hallway. Administrator noted a bruise on forehead and right cheek. R2 showed administrator bruise on right thigh. R2 stated it was R24. R24 was interviewed by administrator. R24 stated R2 walked behind the ladies. Administrator asked what ladies, R24 stated V13 (Licensed Practical Nurse). R24 stated it occurred a couple days ago after dinner. R24 stated he didn't hit R2 that hard and that it occurred after dinner. R2 was sent to the emergency room and transferred to another hospital due to trauma. Both residents were involuntarily discharged from the facility. 24-hour paper documentation reviewed: the date for 06/01/26 is missing. V12 (Licensed Practical Nurse) on Tuesday (06/02/26) morning admitted seeing the bruise on R2 indicating the incident occurred sometime Monday evening 06/01/26 On 06/17/23 at 03:48 PM V1 (Administrator) stated I was informed on 06/03/26 at morning meeting from therapy that R2 had a bruise. R2 had a bruise on his forehead, cheek and right thigh. I interviewed R2 and he said that he got jumped by a tall African American. It is R24 and I've had problems with him before. I asked a couple more questions and went to R24. R24 was able to recall the incident, and he said R2 was being mean to the ladies, V13 (Licensed Practical Nurse). R24 only hit R2 once in his back. Both R2 and R24 said it was a couple days ago after dinner on 06/01/26. We narrowed down a day to Monday 06/01/26. V18 (Agency Registered Nurse), V13 (Licensed Practical Nurse) and two other nurses, none of them recalled. There was no documentation. I interviewed as many certified nurse assistants as I could. A few did not return my call, and no one admitted to it. I in serviced that we are all mandated reporters and it is an injustice if not reported. We never found out exactly what happened. R2 said it happened in the hallway. R2 uses foul language with the nurse and R24 felt he was protecting them. I feel that is why R24 struck R2. I did not substantiate the allegation of abuse. The definition of abuse is intentional harm. In looking at R24's BIM's score, Medication Administration Record and notes. I did not see any behaviors. I don't believe R24 meant to cause R2 any harm. I feel R24 did not understand the gravity of what could have happened. I did see R2's bruises. R2 ambulates in the wheelchair. If R24 hit R2 in the back and R2 had fallen out of the wheelchair he could have fallen on his thigh on the side and hit his face. In my opinion I don't know if he could get back in the wheelchair. If it would have been a fall it should have been reported or it should have been reported because R24 made contact, and the resident was on the floor. Even if it was not witnessed the bruise should have been reported. The hospital report has R2 was transferred to another hospital because of the suspicion of a hematoma. The bruises should have been reported immediately to V2.On 06/18/26 at 08:54 AM Per telephone interview V18 (Agency Registered Nurse) stated I worked 06/01/26 7am -7pm. I don't recall any bruises on R2's face. R2 was in his room pretty much the whole shift. R2 asked to get in the wheelchair when the 3 pm - 11 pm shift started, and I assisted R2 into the wheelchair.On 06/17/26 at 03:05 PM V21 (Certified Nurse Assistant) stated I did not witness R2 and R24 altercation. After the fact, I prepped R2 to go to the hospital. R2 had a bruise on the forehead over the left eye and a large purplish bruise on the right hip. R24 [NAME] around a lot and requires a lot of redirections.On 06/18/26 at 08:22 AM Per telephone interview V26 (Certified Nurse Assistant) stated I washed R2 on Monday 06/01/26 it was like 5pm after dinner. On Tuesday 06/02/26 afternoon R2 said he was beat up. R24 is violent.Witness statement dated 06/03/26 document in part: V12 (Licensed Practical Nurse) Statement of Witness: Upon rounds R2 told V12 he had an altercation with another resident after V12 saw a red mark on R2's face. R2 stated he reported it to the nurse. Staff made me aware of an alleged allegation with R2 and another resident. Policy:Titled Charting and Documentation revised 04/25 document in part: Resident records will be maintained in accordance with regulatory requirements and standards of professional practice. All services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record. Policy Interpretation and Implementation: 1. All observations, services performed, etc. must be documented in the resident's clinical records. 2. Medical records and documentation in resident records will be complete, accurate and organized. 5. All incidents, accidents or changes in resident's condition must be recorded.Titled Abuse Prevention Program revised 03/01/21 document in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. III. Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics: Staff obligation to prevent and report abuse, neglect, exploitation, mistreatment, any crime against the residents. What constitutes abuse (physical, mental, sexual, verbal) neglect, exploitation, mistreatment, and misappropriation of resident property. An employee's obligation under the law (Elder Justice Act) for reporting a suspected crime to the facility, the state survey agency, and local law enforcement: the time frames for reporting; and management's obligation to prohibit retaliation against anyone who makes a report. V. Identification of Allegations/Internal Reporting Requirements: Employees are required to immediately report any incident, allegation or suspicion of potential abuse they observe, hear about, or suspect to the administrator. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, or other abnormalities as they occur. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the Administrator. If the resident complains of physical injuries or if harm is suspected, the resident physician will be contacted for further instructions. If you suspect abuse: Complete an incident Report immediately. Investigation: all incidents, allegations or suspicions of abuse, or a crime against a resident will be documented. Abuse and Crime Reporting: This facility will not tolerate abuse or mistreatment against a resident by anyone, including staff members, other residents and staff of other agencies. All personnel must promptly report any incident or suspected incident of resident abuse. 1. Abuse: the willful infliction of injury resulting physical harm or pain. Willful, as used in this definition of abuse, means individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 4. Physical Abuse: Hitting, slapping, pinching, kicking etc. Procedure: Any alleged violations involving mistreatment, abuse, neglect or reasonable suspicion of a crime against a resident must be reported to the Administrator or Director of Nursing. Additionally, the person(s) observing an incident of resident abuse or suspected resident abuse must immediately report such incidents to the charge nurse who will immediately report the allegation to the administrator, regardless of the time lapse since the incident occurred. Upon receiving reports of physical abuse, the charge nurse will immediately examine the resident. Findings of the examination must be recorded in a separate incident report and the resident's medical record.Titled Resident Rights Policy and Procedure undated document in part: The facility will protect and promote the rights of each resident.

Based on interview and record review the facility failed to protect one resident (R2) out of four residents who were reviewed for abuse and the facility failed to report a suspicion of abuse and/or unknown injury to the abuse coordinator. Subsequently the resident sustained multiple bruises and trauma.Findings Include:R2's Progress note dated 06/03/26 19:48 document in part reads: Nursing Progress Note Text: Resident observed with discoloration to the forehead and discoloration to the right side of his face. Further skin assessment revealed discoloration to the right hip area. Attending physician notified and gave orders to send resident to hospital for evaluation.On 06/17/26 at 03:05 PM V21 (Certified Nurse Assistant) stated I did not witness R2 and R24 altercation. After the fact, I prepped R2 to go to the hospital. R2 had a bruise on the forehead over the left eye and a large purplish bruise on the right hip. R24 walks around a lot and requires a lot of redirections.R2's Hospital record dated 06/03/26 document in part reads: Chief Complaint: Assault victim. Visit diagnosis: Intracranial hemorrhage. Presenting after physical assault 2 days ago at the nursing facility. He states that a nursing home resident attacked him after a verbal altercation. He was sitting in a wheelchair during this time as he was punched in the face. Significant bruising and swelling to the right maxilla with bruising extending into the right jaw on the right neck down into the right clavicle area. Small bruise to the left inner knee. Large bruise to the right hip. Right hip series: Pain Trauma with bruising. CT (Computed Tomography) Angio neck with and without contrast: Impression: 2. Right facial and neck soft tissue swelling with right malar soft tissue mass approximately 88 Hounsfield units in density, likely hematoma given history of trauma. CT angiogram of the Extracranial Carotid arteries with infusion and IV contrast with 3-d Rotational Reconstructed Images. Indication: neck trauma. Neck pain and swelling with bruising. There is swelling throughout the neck and face with a rounded 2 - 3 centimeters mildly hyperdense mass in the right malar region. Per EMS (emergency medical services) the nursing home stated that R2 was assaulted. R2 has bruising on the right side from head to hip. R2 is on aspirin and Eliquis. R2 states that he has pain everywhere.R2's Progress note dated 06/04/26 00:01 document in part reads: Nurses Notes Text: Update, the patient has been admitted to Hospital ED (emergency department). The Nurse stated that the patient has been Dx (diagnosis) with bleeding on the brain. Nurse stated that the patient will be transferred to a trauma hospital. R2's Hospital records dated 06/05/26 document in part reads: admission Complaint: Intracranial hemorrhage. Eliquis 5 mg (Milligrams) Twice a day. R2 was brought as a trauma transfer after an assault at his nursing facility. Imaging showed a hypodensity which may reflect a small parenchymal or subarachnoid hemorrhage versus calcification. Physical Exam: Head; Hematoma right lower face. Smaller one on left forehead. Skin: extensive bruising. CT Head without Contrast: There is a right upper lip subcutaneous hematoma. Assessment and Plan: Trauma/assault, Head injury, Right buccal hematoma, Right hip/thigh hematoma.Facility's Initial Abuse Reportable document in part reads: Incident date: 06/03/26. Residents involved R2 and R24. Brief Description of Incident: 06/03/26 11:00 administrator was made aware of R2 having a bruise on his face; alleging an altercation with R24. Immediate Action Taken: Initiated body assessment for both residents. R2 does not feel safe in the facility.Facility's Abuse Reportable Final report document in part: Conclusion: R2 ambulates in a wheelchair. R2 stated he was struck in the hallway all over after dinner. R2 stated R24 did not like how I was talking to the ladies. R2 stated incident happened on Sunday in the hallway. Administrator noted a bruise on forehead and right cheek. R2 showed administrator bruise on right thigh. R2 stated it was R24. R24 was interviewed by administrator. R24 stated R2 walked behind the ladies. Administrator asked what ladies, R24 stated V13 (Licensed Practical Nurse). R24 stated it occurred a couple days ago after dinner. R24 stated he didn't hit R2 that hard and that it occurred after dinner. R2 was sent to the emergency room and transferred to another hospital due to trauma. Both residents were involuntarily discharged from the facility. 24 hour paper documentation reviewed: the date for 06/01/26 is missing. V12 (Licensed Practical Nurse) on Tuesday (06/02/26) morning admitted seeing the bruise on R2 indicating the incident occurred sometime Monday evening 06/01/26. V12 stated that she did not report to management: if she reported it, she felt she would be retaliated against. R2 stated R24 made contact in the hallway after dinner. Body check completed noted R2 to have a bruise on forehead, right thigh and redness to the right cheek. R24 did make contact lightly with R2's backOn 06/17/23 at 03:48 PM V1 (Administrator) stated I was informed on 06/03/26 at morning meeting from therapy that R2 had a bruise. R2 had a bruise on his forehead, cheek and right thigh. I interviewed R2 and he said that he got jumped by a tall African American. It is R24 and I've had problems with him before. I asked a couple more questions and went to R24. R24 was able to recall the incident, and he said R2 was being mean to the ladies, V13 (Licensed Practical Nurse). R24 only hit R2 once in his back. R2 said it happened in the hallway. R2 uses foul language with the nurse and R24 felt he was protecting them. I feel that is why R24 struck R2. I did not substantiate the allegation of abuse. The definition of abuse is intentional harm. In looking at R24's BIM's score, Medication Administration Record and notes. I did not see any behaviors. I don't believe R24 meant to cause R2 any harm. I feel R24 did not understand the gravity of what could have happened. I did see R2's bruises. R2 ambulates in the wheelchair. If it would have been a fall it should have been reported or it should have been reported because R24 made contact, and the resident was on the floor. Even if it was not witnessed the bruise should have been reported .Both R2 and R24 said it was a couple days ago after dinner on 06/01/26. We narrowed down a day to Monday 06/01/26.The hospital report has R2 was transferred to another hospital because of the suspicion of a hematoma. The bruises should have been reported immediately to V2. Altercations should be reported immediately once the residents are separated and safe. On 06/18/26 at 08:22 AM Per telephone interview V26 (Certified Nurse Assistant) stated I washed R2 on Monday 06/01/26 it was like 5pm after dinner. On Tuesday 06/02/26 afternoon R2 said he was beat up. R24 is violent.On 06/17/26 at 11:25 AM V12 (Licensed Practical Nurse) stated I was not here on 06/01/26. I was here 06/02/26 Tuesday. I did my rounds and noticed R2 had a red mark on the right side of his cheek area. I asked him what the mark was from and R2 said he got into it with another resident. I asked did you tell somebody, and he said I told the nurse. On 06/03/26 Wednesday when I was here therapy came up for R2. R2 did not want to go to physical therapy because he was in pain and did not feel like participating that day. V16 (Contracted Physical Therapist) came to me, and I told V16 what R2 told me prior to that. I did not see any documentation at that time. V16 made his supervisor aware and V1 (Administrator) and V10 (Psychiatric Rehabilitation Service Director) were also made aware. I was the one that did the only documentation and an assessment. The resident-to-resident altercation V1 and V10 did the actual interview. R2 had a red mark to the right cheek and discoloration to the right hip as well. Initially I got orders to do an Xray then it was changed, and the order was to send R2 out. I don't know what happened. No one reported it at shift change, and no one told me anything. He did not mention the other residents name but once interviewed V1 and V10 went directly to R24's room and R24 admitted they had an altercation. R2 was wheelchair bound and was alert and oriented x 2-3. R2 self-propelled himself in the wheelchair and self-transferred from bed and to the toilet. R24 used a rolling walker, was a standby assist.Witness statement dated 06/03/26 document in part: V12 (Licensed Practical Nurse) Statement of Witness: Upon rounds R2 told V12 he had an altercation with another resident after V12 saw a red mark on R2's face. R2 stated he reported it to the nurse. Staff made me aware of an alleged allegation with R2 and another resident. On 06/17/26 at 01:58 PM V10 (Psychiatric Rehabilitation Service Director) stated I was not at work when the incident between R2 and R24 happened. There was an altercation between R2 and R24.On 06/17/26 at 02:24 PM Per telephone interview V16 (Contracted Physical Therapist) stated I was told by my boss to assess and evaluate R2. I proceeded to R2's room, introduced myself, and proceeded with the evaluation. R2 demonstrated a decline in function, and he could not move. During my assessment I noted a bruise on R2's forehead and lower part of his right jaw. I asked R2 he had a fall, and he said no. I did range of motion and proceeded to the lower extremity. During the assessment I observed a bruise to R2's right hip area. R2 had pain when I tried to be gentle. R2 said he could not turn, and I reported to V12 (Licensed Practical Nurse) about the bruises on R2's face, right hip and another bruise close to the right ankle near the chin. R2 required extensive assistance. I reported to my boss for her to report it in the morning meeting. The lump on R2's forehead was the size of an egg. On the jaw I could not see the extent, but the redness was the size of my palm.On 06/17/26 at 01:35 PM V15 (Contracted Director of Rehab) stated V16 (Contracted Physical Therapist) reported to me in the morning of 06/03/26. I asked V16 to screen R2 to see if he was appropriate for therapy services. V16 said he went to R2's room and observed R2 with bruises on the face and hip. V16 questioned R2 and he was complaining of a lot of pain with movement. V16 asked what happened and R2 said he had an altercation with another resident. V16 went and informed the nurse, then he came to the gym and told me what was going on. I went to the morning meeting and let V1 (Administrator) know. I did not see R2.On 06/17/26 at 02:50 PM V20 (Certified Nurse Assistant) stated I heard about the altercation between R2 and R24. V16 (Contracted Physical Therapist) asked V12 (Licensed Practical Nurse) about R2 and was he beaten up. V16 took me in the room and R2 said he got into a fight the other day with a tall black guy that walks around. R2 had a knot on his forehead that was turning green. R2's right jaw had a green, purple knot that was small. The green part was big. The bruise on R2's right hip was from the hip to mid-thigh red in color. R2 was in pain when I touched his leg. R2 said that he got pushed down to the ground, it happened in the evening, and a nurse and certified nurse assistant picked him up. On 06/18/26 at 08:54 AM Per telephone interview V18 (Agency Registered Nurse) stated I worked 06/01/26 7am -7pm. I don't recall any bruises on R2's face. R2 was in his room pretty much the whole shift. R2 asked to get in the wheelchair when the 3 pm - 11 pm shift started, and I assisted R2 into the wheelchair.R24 has diagnosis not limited to Cerebral Infarction, Aphasia Following Cerebral Infarction, Transient Cerebral Ischemic Attack, Essential (Primary) Hypertension, Chronic Migraine with Aura, Muscle Wasting and Atrophy, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Dementia in other Diseases Classified Elsewhere, Mild, with Agitation, Dementia in other Diseases Classified Elsewhere, Moderate, with Mood Disturbance, Depression and Anxiety Disorder.Care plan document in part: Focus: R24 have impaired cognition/function or impaired thought process related to diagnosis Cerebral Vascular Accident. Focus: I require psychotropic medication to help manage and alleviate behaviors. Focus: I am at risk for increasing confusion related to diagnosis of dementia.Policy:Titled Abuse Prevention Program revised 03/01/21 document in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. III. Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics: Staff obligation to prevent and report abuse, neglect, exploitation, mistreatment, any crime against the residents. What constitutes abuse (physical, mental, sexual, verbal) neglect, exploitation, mistreatment, and misappropriation of resident property. An employee's obligation under the law (Elder Justice Act) for reporting a suspected crime to the facility, the state survey agency, and local law enforcement: the time frames for reporting; and management's obligation to prohibit retaliation against anyone who makes a report. V. Identification of Allegations/Internal Reporting Requirements: Employees are required to immediately report any incident, allegation or suspicion of potential abuse they observe, hear about, or suspect to the administrator. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, or other abnormalities as they occur. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the Administrator. If the resident complains of physical injuries or if harm is suspected, the resident physician will be contacted for further instructions. If you suspect abuse: Complete an incident Report immediately. Investigation: all incidents, allegations or suspicions of abuse, or a crime against a resident will be documented. Abuse and Crime Reporting: This facility will not tolerate abuse or mistreatment against a resident by anyone, including staff members, other residents and staff of other agencies. All personnel must promptly report any incident or suspected incident of resident abuse. 1. Abuse: the willful infliction of injury resulting physical harm or pain. Willful, as used in this definition of abuse, means individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 4. Physical Abuse: Hitting, slapping, pinching, kicking etc. Procedure: Any alleged violations involving mistreatment, abuse, neglect or reasonable suspicion of a crime against a resident must be reported to the Administrator or Director of Nursing. Additionally, the person(s) observing an incident of resident abuse or suspected resident abuse must immediately report such incidents to the charge nurse who will immediately report the allegation to the administrator, regardless of the time lapse since the incident occurred. Upon receiving reports of physical abuse, the charge nurse will immediately examine the resident. Findings of the examination must be recorded in a separate incident report and the resident's medical record.Titled Resident Rights Policy and Procedure undated document in part: The facility will protect and promote the rights of each resident.

Based on observations, interviews, and record reviews, the facility failed to provide effective pest control for six [R1, R4, R15, R16, R22, R23] residents in the sample of 25. These failures have the potential to affect all 157 residents residing in the facility. Findings Include, R1's clinical record indicates the following in part: R1's medical diagnosis of schizoaffective disorder, depression, anxiety disorder, movement disorder, type II diabetes, chronic obstructive pulmonary disease, essential hypertension, liver disease, morbid obesity, transient ischemic attack and cerebral infarction, chronic kidney disease, edema, and chronic pain. R1's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively intact, care plans, medication administration record, treatment administration record, and progress notes. On 6/16/26 at 1:15PM, observed R1 resting in bed alert and oriented x3. Observed more than eight flying bugs in R1's room flying around R1 as he ate apple sauce. R1 stated, These gnats flying around for a couple of months are landing on my meal trays, my face, body, and it's very disgusting. I reported all the nets, and the staff see them as well. During the survey dates of 6/16/26 and 6/17/26, Observed gnats flying in R1, R4, R15, R16, R22 and R23 rooms. On 6/16/26 at 2:05 PM, R5 [President of Resident Council] stated, The gnats have been a problem for a few months. The administration is aware, and the exterminator comes out, but the gnats are still here. I think it comes from all the food left lying around. On 1/16/26 at 2:05PM, R22 stated, The gnats are terrible. They fly around all day in my face, food trays and drinks. They have been in my room for a few weeks. On 16/26 at 2:15PM R23 stated, These flying bugs come out when the food trays come out. The bugs just will not leave. On 6/16/26 V6 [Maintenance Director] and surveyor observed many gnats flying around in R15 and R16's room.On 6/16/26 at 3:35 PM, V6 stated, There has been a gnat problem since the spring. The exterminator comes out twice month and treats the drains. If nursing staff do not pick up the food trays from the resident's rooms, then the gnats will keep coming and multiplying. Reviewing the exterminator invoices from March to June, the facility was treated with bio snake for fruit flies, the gnats were not treated. On 6/17/26 at 3:35PM, V5 [Housekeeping Director] stated, The housekeeping department try to keep the rooms clean as possible. The resident hoard food in their rooms. The are two housekeepers on each floor every day from 7AM to 3PM, and a janitor from 3PM to 10PM. The gnats that's; flying around everywhere would clear up if the food trays were not left in the rooms, and residents need to eat in the dining rooms. On 6/16/26 at 1:15PM, V30 [Certified Nurse Assistant], surveyor observed many gnats in R4's room. R4 stated, The gnats have been flying all over me and my food for months. The facility administration has not addressed the bugs. I have not seen any exterminator in my room, this is unsanitary. On 6/16/26 at 1:20PM, V30 stated, These gnats have been here in the facility since the springtime. It's just the season for them to be here. The gnats are all over the facility, from the resident's hording food. On 6/17/26 at 4:10PM, V1 [Administrator] stated, The exterminator comes out twice a month. The gnats are only in rooms where there is leftover food. Staff continue to encourage residents to eat in the dinner rooms. The exterminator will be out to treat the gnats. Reviewed facility's pest control invoices: 3/26 to 6/26. No treatment for the gnat flies noted. 6/8/26: Bio Snake uses to treat the fruit flies. 5/12/26:Kitchen, dish room with food and food related debris have accumulate within the cracks and beneath broken floor tiles. additionally standing water in these areas contributes to the formation of organic waste. These conditions create an ideal environment for fruit flies and other organic waste pests to feed and reproduce. Policy in part:Pest Control PolicyThe purpose of this policy is to ensure a pest free environment within our facility by outlining procedures for the prevention, monitoring, and control of pest infestation.

F761Based on observation, interview, and record review, the facility failed to properly store medications requiring refrigeration for four residents (R7, R8, R9, and R10). This failure has the potential to affect all four residents reviewed for physical environment and medication storage. The findings include: R7's face sheet shows admission on [DATE] with diagnoses not limited to Other mechanical complications of femoral arterial graft (bypass), Cellulitis of groin, Carrier or suspected carrier of methicillin resistant staphylococcus aureus, Dehiscence of amputation stump, acquired absence of left leg above knee, Urinary tract infection, Bacteremia, Sepsis. R8's face sheet shows admission on [DATE] with diagnoses not limited to Diabetes mellitus due to underlying condition with hyperglycemia, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R9's face sheet shows admission on [DATE] with diagnoses not limited to Chronic obstructive pulmonary disease, Type 2 diabetes mellitus without complications, Hemiplegia, unspecified affecting left nondominant side, Chronic kidney disease stage 3. R10's face sheet shows admission on [DATE] with diagnoses not limited to Type 2 diabetes mellitus with hyperglycemia, Hemiplegia affecting right dominant side, Functional quadriplegia. On 6/12/26 at 12:04 PM Surveyor inspected the first floor medication storage room in the presence of V6 (RN / Registered Nurse). Inside the room, three refrigerators were observed. Two of the refrigerators were functioning, and one refrigerator containing medications was not operational and had no power. The thermometer inside the non functioning refrigerator displayed a temperature of 80 F. V6 stated that the power outage caused by a storm began approximately two days prior. He reported that he was unsure why the refrigerator was not working. V6 attempted to unplug and reconnect the unit, but it did not restore power. V6 confirmed that the thermometer inside the refrigerator continued to show a temperature of 80 F. The following medications were stored in the non functioning refrigerator: R7's Daptomycin IV. Pharmacy label shows keep refrigerated. R8's Multidose Ozempic injection. Pharmacy label shows keep in refrigerator. R9's Unopen multidose Lantus pen, Unopen multidose Lispro Kwik Pen. Pharmacy label shows refrigerate until opened R10's unopen multidose Lispro KwikPen, unopen multidose Lantus KwikPen. Pharmacy label shows refrigerate until openedDuring the observation in the first floor medication room, the surveyor requested V2 (DON / Director of Nursing) to come to the area. Upon entering, V2 observed that one of the medication refrigerators was not working and had no power while containing medications. V2 stated that the thermometer inside the refrigerator showed a temperature of 80 F.On 6/12/26 at 3:11 PM, V2 (Director of Nursing) stated that medications requiring refrigeration should be stored in a working, functioning refrigerator. V2 reported that there had been a power outage since Wednesday afternoon, and she had assumed the refrigerator was plugged into an emergency outlet and remained operational. V2 stated that medications requiring refrigeration must be maintained at proper temperatures and the refrigerator must be working properly. She stated that if medications are not kept at the appropriate temperature, the medications may become ineffective and therefore must be stored correctly.R7's POS (Physician Order Sheet) shows active order not limited to: Daptomycin Solution Reconstituted 500 MG. Use 500 mg intravenously every 24 hours for Infection for 36 Days. From 6/6/2026 to 7/12/2026.R8's POS shows active order not limited to: Ozempic (1 MG/DOSE) Subcutaneous Solution Pen-injector 4 MG/3ML (Semaglutide) Inject 0.25 ml subcutaneously one time a day every Monday.R9's POS shows active order not limited to: Insulin Lispro Injection Solution 100 UNIT/ML (Inject as per sliding scale: if 200 - 249 = 1 units rotate injection sites; 250 - 299 = 2 units rotate injection sites; 300 - 349 = 3 units rotate injection sites; 350 - 399 = 4 units rotate injection sites, subcutaneously four times a day for hyperglycemia. Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 15 unit subcutaneously at bedtime.R10's POS shows active order not limited to: Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 12 unit subcutaneously at bedtime. Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 2 unit subcutaneously one time a day. Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 3 unit subcutaneously in the morning. Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector inject 3 units sub-q every morning; inject sub-q four times daily per sliding scale: 200-250=2 units; 251-300=4 units; 301-350=6 units; 351-400=8 units; 401-450=10 units; call md if blood glucose > 451. Facility's Medication storage policy dated 3/2023 shows in part: Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit. are kept in a refrigerator. Medications requiring storage 'in a cool place' are refrigerated unless otherwise directed on the label. A thermometer must be kept in the refrigerator containing medications to allow proper temperature monitoring.

Based on interviews and record review, that facility failed to ensure that one resident (R1) was free from verbal abuse by a staff member. This failure has affected one (R1) resident from a sample of nine residents reviewed for abuse. Findings include:R1 is a [AGE] year old with diagnosis including but not limited to: End stage renal disease, chronic obstructive pulmonary disease, depression, hypotension and constipation.R1's BIMS (Brief Interview of Mental Status) score is 15, which indicates cognitively intact.On 4/27/26 at 10:00 am, V1 (Administrator) stated the following, I was notified via telephone on yesterday around 1:00 pm about the complaint from R1. The manager on duty (V9/ Restorative Director) called and she stated that V8 CNA (Certified Nurse Assistant) had used profanity with R1.On 4/27/26 at 3:30 pm, R1 stated the following, The other day (4/26/26), V8 placed cream on top of feces on my butt. I asked her to clean me again and I complained to the nurse. After an hour she came into my room and started arguing with me and I reminded her that she was being recorded. She (V8) stated that she does not care about me calling the State (Illinois Department of Public Health). I asked her four times to leave his room. She stated she does not care about this job because she would have another job in no time. She then told me that I would still be crippled in my bed while she works somewhere else. She would not leave my room and just stayed there to argue. I stated that I did not want V8 as my CNA. I just don't want her to take care of me anymore because she is ghetto. I don't want her to get in trouble. I am happy here. I don't want to go to another facility. I feel safe here.At that time, R1 played a video and audio recording of the exchange between he and V8 on 4/26/26 during the night shift. The recording documented the following: R1 asked V8 to leave his room for the second time and reminded her that his camera was recording; V8 started laughing and stated, I'm so scared.; R1 told V8 that she should be scared of losing her job; V8 stated, I could get another job and you would still be lying here in this bed.On 4/28/26 at 10:00 am, V9 (Restorative Director) stated the following, I was manager on duty on Sunday 4/26/26 between 9am -5 pm when R1 asked to speak with me. He had stated that he had an issue with the overnight CNA (V8). He complained that she did not clean him good enough after he had a bowel movement and that they (R1 and V8) had a verbal disagreement. R1 stated that V8 began to use profanity towards him and told him that she did not care that he was recording. He stated that he had asked her to leave his room, and she had refused. R1 no longer wants her (V8) to provide care for him anymore.On 4/28/26 at 2:10 pm V1 (Administrator/ Abuse coordinator), stated the following, It is absolutely not ok for a staff member to go back and forward in a verbal altercation with a resident. The staff member needs to respect the resident and leave the room when asked to. V8 has been suspended pending investigation.On 4/28/26 at 2:30 pm V8 (CNA) stated the following, R1 is on a buddy system, so we (staff) never render care or go to his room alone. On that day (4/26/26) I had cleaned him after he had a bowel movement. He activated his call light around 2 am and complained to the nurse (V3) about not being cleaned properly. I (V8) went and asked him (R1) what the issue was and he started yelling and stating that he was still dirty and smelled feces. I did not take anyone with me to his room at that time. R1 continued yelling at me and stated that I should not be caring for him and that I should not be in the building. I did tell him that I could get another job and that he would still be there (at the facility). I should have left his room when he asked instead of arguing with him, but I was just confused about his allegations.Facility Incident Report dated 4/26/26 at 2:10 pm documents the following, on 4/26/26 R1 asked to speak to the Manager on duty (V9) to report an alleged verbal disagreement with and V8 (CNA). R1 reports feeling safe. Investigation initiated and V8 was sent home pending investigation.Facility policy titled Abuse Prevention Program dated 3/1/21 documents, it is the policy of this facility to prohibit and prevent residents abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility; Verbal abuse is any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability.

Based on observation, interview and record review the facility failed to provide wound care treatments for two residents R1 and R5, failed to notify the physician when wound worsened for one resident (R1) resulting in R1 being sent to the hospital for wound infection and needing further surgical interventions, failed to assess and treat wounds for one resident (R5) resulting in R5 not receiving wound care for 12 days. These failures affected two residents (R1 and R5) out of 3 residents reviewed for wound care.Findings include:R1's medical diagnoses include but are not limited to dehiscence of amputation stump, bacteremia, sepsis, acquired absence of left leg, pulmonary hypertension, post-traumatic stress disorder, heart failure.R1's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 12, indicating R1's cognition is moderately impaired.R1's care plan dated 02/28/26 documents in part, Enhanced Barrier Precautions: I am in enhanced barrier precautions for: Wounds or skin opening requiring a dressing. Enhanced precautions will be maintained and I will not exhibit signs of active infection thru next review. Set up isolation per facility protocol. Follow the enhanced precautions guidelines.R1's care plan dated 02/28/26 documents in part, I am at increased risk for impaired skin integrity related to left below knee amputation (BKA), bypass grafts, extremities left leg. I will not develop any skin integrity issues thru next review, unless the disease process causes unavoidable deterioration. Administer wound care treatments per MD (Medical Doctor) orders. Weekly skin checks per facility policy.R1's physician order dated 02/24/26 at 7am documents in part, Paint left BKA with betadine, apply adaptic , calcium alginate and cover with ABD (abdominal) pad, kerlix and tape daily and PRN (as needed). Every day shift. Start 02/24/26.Review of R1's treatment administration record (TAR) has no documentation for treatment on 02/24/26, 02/25/26 and 02/26/26.R1's progress note dated 03/12/26 documents in part, Upon doing rounds, the pt (patient) complained of phantom pain. His wound was assessed and right below knee wound dehiscence was noted. The doctor and NP (Nurse Practitioner) was call and gave orders to send the pt back to the ER (emergency room) for further evaluation.R1's hospital records dated 03/13/26 documents in part, He was sent in from the nursing home because he has had increased drainage for the past week. Left-sided BKA (below knee amputation) wound dehiscence. Concern for infection. Patient reports drainage started occurring one week ago and became increasingly difficult to mange, thus nursing home sent him here.R1's discharge hospital records dated 03/24/26 documents in part, Left BKA wound dehiscence with infection s/p (status post) AKA (above knee amputation) revision by vascular. Right heel stage 2, POA (present on admission). cover with alginate and bordered foam, change daily.On 04/03/26 at 10:27am observed V3 (Wound Care Coordinator/WCC) cleansing R1's right heel wound and apply foam dressing.On 04/03/26 at 10:27am V3 (WCC) stated that she had just discovered the wound to R1's right heel. V3 stated that she would apply a treatment of her recommendation until the wound care doctor sees R1 for wound care.Review of R1's physician orders indicate that R1 had no physician order for right heel wound until 04/03/26, although discharge hospital records dated 03/24/26 documents that R1 had active right heel wound and discharge orders for that wound.R5's medical diagnoses include but are not limited to peripheral vascular disease, venous insufficiency, lymphedema, non-pressure chronic ulcer of other part of right lower leg with unspecified severity.R5's admission date to the facility is dated 02/26/26.R5's progress note dated 02/26/26 at 9:25pm documents in part, Resident has DX (diagnosis) of chronic embolism and thrombosis of lower extremity;non pressure chronic to left lower leg, etc. (etcetera).Physician (V26) notified and order to continue orders. Will continue plan of care.R5's care plan dated 02/26/26 documents in part, I have an alteration in skin integrity: Right lower leg, Left lower leg. I will be free of any additional skin integrity issues, unless the disease process causes further unavoidable deterioration through the next review.Provide treatment as per MD order.Review of R5's physician orders shows that R5's initial wound care orders were not entered until 03/09/26, indicating R5 did not have wound orders from admission on [DATE], a total of 8 days.R5's physician order dated 03/09/26 documents in part, Right lower leg: Cleanse with NSS (Normal Saline Solution), pat dry, apply collagen and cover with ABD, wrap with kerlix and ace wrap every day and prn (as needed) for soiled/dislodged.On 04/03/26 at 11:37am R5 stated that she had been in the facility for over a week without having her wounds changed. R5 stated that she kept asking the nurses to change her wound dressing and they would tell her that there was no one there that could do it.On 04/03/26 at 3:16pm V2 (Director of Nursing/DON) stated that it is the expectation of the facility that nurses document everything that they do. V2 stated that if it is not documented, it looks as though it wasn't done.V2 stated that residents are admitted to the facility with orders from the discharging facility and it is her expectation that the nurse transcribes those orders on admission. V2 stated that a resident should not be in the facility with an open wound with no orders. V2 stated that not treating a resident's wound could cause infection or the wound could deteriorate.On 04/03/26 at 4:21pm V2 (Director of Nursing) stated that the facility does not have a policy for wound care assessments. V2 stated that the admitting nurse is expected to do a wound assessment on admission and document the resident's wounds. V2 stated that wound assessments are done every seven days by the wound care nurse. V2 stated that if there are any changes to an incision, the nurse should notify the resident's physician.Review of R1's records indicate that R1 had a wound assessment done on 02/24/24 and not until 14 days later on 03/10/26. R1 was sent out to the hospital on [DATE] for pain to the wound and admitted with diagnosis of wound infection.On 04/03/26 at 3:51 V26 (Medical Doctor/MD) stated that he was not aware that his residents R1 and R5 had not received wound care treatment. V26 stated that it is his expectation that the nurses follow the physician orders. V26 stated that it is a standard of care and is expected that the physician's orders are carried out. V26 stated that wounds that are not changed can get worse, can lead to infection and even mortality. V26 stated that wounds should be addressed on the day of admission and followed up with the appropriate treatment plan. V26 stated that a newly admitted resident or a resident returning from the hospital should have orders from the discharging facility and those orders should be continued until the resident is seen by the wound care nurse or the wound care doctor. V26 stated that if R1's wounds were not treated as ordered, R1's infection could have come from the facility not treating R1's wounds.Facility's undated policy titled Wound Cleansing and Dressings documents in part, Policy: It is the policy of this facility to perform wound dressing changes as ordered by the physician using clean technique on all chronic or contaminated wounds. A moist wound environment is most favorable for optimal wound healing.Facility's policy titled Guidelines for Observing and Implementing Resident Rights dated 07/12/23 documents in part, Policy: It is the policy of the facility to observe and implement resident rights as dictated by CMA. These rights and protections are mandated by Federal and State laws. These rights and protections are a requirement in edicare and/or Medicaid certified nursing homes. Each resident has the right to be treated with dignity and respect. An interaction between a resident and a staff member, temporary staff member, volunteer, visitor, or any other person must be conducted in such a way as to enhance the resident's self-esteem and self-worth while meeting the resident's needs. The preferences and goals of the resident should be honored as much as possible and the resident's comfort, safety and overall welfare must be promoted, protected, and enhanced at all times. To achieve this staff will 1. Treat each resident with respect and dignity. 2. Care for each resident in a manner and environment that promotes the maintenance of/or enhances the resident's quality of life. 5. Provide equal access of quality of care.Facility's undated policy titled Physician Orders (Following Physician Orders) documents in part, Policy: It is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. Procedure: 1. The facility must have orders from the physician upon admission for: c. Routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. 3. Orders that accompany the resident on admission will be clarified by the physician through action of the nurse who will contact the physician for clarification upon the resident's admission.

Based on observation, interview and record review, the facility failed to wear PPE (Personal Protective Equipment) for one resident (R1) who is on EBP (Enhanced Barrier Precautions) while providing wound care. The facility failed to identify one resident requiring EBP with an indwelling catheter and pressure ulcer. This failure affected two residents (R1 and R4) out of three residents reviewed for infection control.Findings include: R1's medical diagnoses include but are not limited to dehiscence of amputation stump, bacteremia, sepsis, acquired absence of left leg, pulmonary hypertension, post-traumatic stress disorder, heart failure. R1's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 12, indicating R1's cognition is moderately impaired. R1's care plan with date initiated 12/29/25 documents in part, Enhanced Barrier Precaution: I am in enhanced barrier precautions for: Wounds or skin opening requiring a dressing. Enhanced precautions will be maintained and I will not exhibit signs of active infection thru next review. Reinforce proper handwashing, follow personal equipment protocols and educate me and visitors on protocols as needed. Seet up isolation per facility protocol. Follow the enhanced precautions guidelines. On 04/03/26 at 10:27am observed V3 (Wound Care Coordinator) performing wound care to R1 with no PPE gown on. On 04/03/26 at 10:27am V3 (WCC) stated that she doesn't know what EBP is. V3 stated that she doesn't think that she needs a gown on while performing wound care for R1. On 04/03/26 at 10:59am observed V4 (Infection Preventionist/IP) taping EBP sign outside of R1 bedroom door and placing PPE bin in the hallway next to R1's bedroom. On 04/03/26 at 3:16pm V2 (Director of Nursing/DON) stated that staff should wear PPE when doing wound care to the residents. V2 stated that there should be a sign on the resident's door indicating that the resident is on EBP and PPE should be available outside the resident's room. On 04/03/26 at 3:42pm V4 (IP) stated that R1 should have been on EBP precautions before she placed the signage outside of R1's door. V4 stated that staff should be wearing PPE when caring for R1 to prevent the transfer of germs to R1. V4 stated that if germs are transferred to the resident, they could get an infection and may need antibiotics. Facility's policy titled Guidelines for Enhanced Barrier Precautions (EBP) An extension of Personal Protective Equipment (PPE) Revised 12/2022 documents in part, Policy: It is the policy of the facility to ensure that additional and appropriate PPE is utilized., when indicated, to prevent the spread of Multidrug-resistant Organism also known as MDROs. Enhanced Barrier Precautions (EBP): Enhanced Barrier Precautions are defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of DROs in the form of blood or body fluids, onto the hands and/or clothing of the rendering caregiver. EBP is to be used when Contact Precautions do not otherwise apply and where there is a diagnosis of a MDRO or a colonized MDRO. Thes precautions are generally in place for the duration of the resident's stay, or until there is resolution of the wound or discontinuation of the device that placed the resident at higher risk Who is at High Risk for acquiring or spreading a MDRO? . Resident with wounds regardless of MDRO status. Resident care activities at which time EBP is to be practiced are: Wound care. On 4/3/26 at 10:27AM the surveyor entered R4's room, no precautions identified on the door. Upon entering the room urinary catheter drainage tube visible. R4 said I have this catheter because I was not able to urinate. When they checked my bladder I was holding my urine. Air pump visible on the foot of the bed. R4 said I have a sore on my butt. On 4/3/26 at 10:52AM V2, Director of Nursing, said R4 has been in that room since admission. There is no Enhanced barrier Precautions (EBP) sign on her door (observed with surveyor in the hall). V2 said R4 should have a sign on her door. V2 said the purpose of EBP is to prevent the spread of infection.

Based on observations, interviews and records reviewed the facility failed to ensure medications were securly stored, in accordance with professional standards and not left at the bedside of a visually impaired resident, (R4). This failure has the potential to affected of 1 of 3 residents reviewed for quality of care. Findings include:According to R4's face sheet was admitted to the facility on [DATE]. R4's diagnosis include but are not limited to Multiple Sclerosis, Generalized Anxiety, Insomnia, Chronic Idiopathic Constipation, legal Blindness, Conductive Hearing Loss.On 4/3/26 at 10:27AM the surveyor observed 2 pills at bedside, on bedside table, within easy reach of R4. One pill is white, round, and scored. The second pill is oval, clear, light orange in color. R4 said I can't see well. Surveyor observed hand written notes in large print with black marker. The surveyor showed R4 her identification badge and R4 said I can't see it. R4 asked the surveyor to write her name on a paper, big with a marker because she can't see the writing from a pen.On 4/3/26 at 10:42AM V13, RN, said R4 hasn't taken any pills from me today. The surveyor reported to the nurse 2 pills on the table and asked V13 to accompany her to R4's room. V13 asked R4 what the pills are, R4 said I don't know what they are. V13 took the pills from R4's room. Surveyor and nurse went to the medication cart. R4 compared the pills to what she has in her cart for R4. Orange pill is Lubiprostone 24 mg scheduled for 9:00PM and the white pill is Trazadone 50mg scheduled for 9:00PM. On 4/4/26 at 2:30PM V2, Director of Nursing, said I expect the nurse to administer the medications as prescribed by the doctor. The nurse should let them know what medications they are giving. V2 said the nurse should not set the medication in the cup down and walk away. V2 said the nurse should watch that the medications are taken. V2 said the nurse should not leave the resident before all the medications are taken. V2 said if the nurse leaves before the medication is taken, the resident might not take the medication and someone else may come and take it. V2 said Trazadone is for depression or insomnia. V2 said it is a risk to have a medication in the room. A resident with vision impairment, such as blindness, would not be approved to have self administration of medications.Review of R4's assessments does not include self administration assessment.R4's Order Summary Report 3/1/26-4/30/26 includes an order for Lubiprostone 24mcg capsule two times a day, diagnosis of constipation. Trazadone tablet 50mg at bedtime. Diagnosis Insomnia.Review of R4's medication administration record notes Trazadone scheduled daily at 9:00PM and Lubiprostone scheduled twice daily at 9:00AM and 5:00PM. (The surveyor is unable to identify what day the medication were left at R4's bedside.)R4's care plan include focus for cognitively impaired related to Blind and Hard of Hearing and risk for constipation.According to mayoclinic.org Lubiprostone is used to treat constipation.The facility policy Medication Storage in the Facility dated March 2023 states medications and biologicals are stored safely, securely, and properly.

Based on observation, interview, and record review the facility failed to provide a safe and sanitary functional environment (the second-floor unit soiled utility room). This failure has the potential to affect all 72 residents residing on the second floor unit.Findings include: On 3/19/26 at 1:00 pm, Surveyor toured the second-floor unit and observe the second floor soiled utility room, door broken and unable to close with the door standing partially open. The soiled utility room contained overflowing garbage on the floor, garbage in the sink, a biohazard box located in the sink, and floors with visible black debris and dirt. On 3/19/26 at 1:20 pm, Surveyor brought this observation to V13 (Housekeeping Aide), and he stated that housekeeping is responsible for cleaning the soiled utility rooms in the facility and that he does not clean the soiled utility room because he feels the floor technicians should be responsible for making sure that the soiled utility rooms in the facility are clean. V13 also stated that it is unsafe and unsanitary for the soiled utility room to go without being cleaned. On 3/19/26 at 1:25 pm, Surveyor brought this observation to V12 (Housekeeping Director) and V12 stated that it is the responsibility of the housekeeping department to ensure the soiled utility room is cleaned daily for the sanitation of the building. V12 explained that the housekeepers are responsible for ensuring the room is free from trash, swept and organized. V12 then explained that it is the responsibility of the floor technicians to keep the floor waxed and free of dirt and debris.On 3/19/26 at 1:37 pm, this observation was brought to V11 (Maintenance Director), and he stated, The door is broken again? The staff bust the door open when they can't get in there. V11 explained that he has repaired the second floor soiled utility door several times after being cited by the local state agency for the door not being locked and that staff continues to break down the door. V11 then explained that the second-floor soiled utility door contains access to the second floor linen chute and that the door should be locked at all times for safety. V11 also explained that he does not feel that a resident can fit down the laundry chute but if a resident attempts to go down the laundry chute they could injure themselves. The facility's job description dated 1/29/24 and titled Director of Housekeeping documents in part: Position Summary: Under the direction of the administrator, the director of housekeeping is responsible for the daily operations of the housekeeping department, including staffing, supply ordering and supervision. The person holding this position is held accountable for the decision making and carrying out the signed duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. 4. Ensures cleaning schedules are followed and coordinates daily housekeeping services with other departments. 7. Supervises housekeeping personnel and schedules adequate coverage assigned duties and evaluates work performance as necessary. D. Roles Responsibilities - Safety: Make schedule rounds checks equipment and checks for hazards. 6. Recognizes removes and reports potential hazards. 8. Ensures that housekeeping personnel follow established safety regulations and the use of equipment and supplies at all times.

Based on interview and record review, the facility failed to ensure that residents wear appropriate footwear to prevent falls, for one of three residents reviewed for falls (R3) in the sample of 18. This failure resulted in R3 falling and sustaining a subarachnoid hemorrhage and subdural hematoma.Findings include:R3's face sheet documents R3 is an [AGE] year-old with diagnoses including but not limited to: Other Pulmonary Embolism with Acute Cor Pulmonale, Essential (Primary) Hypertension, Stenosis of Coronary Artery Stent, Sequela and Dementia in Other Diseases Classified Elsewhere. R3's MDS (Minimum Data Set of 1.22.2026) documents a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment.2.25.2026 facility's final incident report documents, in part: the facility completed its investigation through medical record review and interviews. It was determined that (R3) was in a supervised area and abruptly stood up to ambulate and lost her balance. Prior to the fall, (R3) was sitting in a chair with her walker. The other staff in the surrounding area provided witness statements that (R3) got up to ambulate and lost her balance and fell before staff could intervene. (R3) was observed with a raised area to the back of her head. She denied pain or discomfort. Due to the resident being on a blood thinner she was ordered to be sent to the hospital. Received report from the hospital that (R3) had a nontraumatic subarachnoid hemorrhage.3.5.2026 at 12:19 PM, V12 (Restorative Nurse) said regarding R3's fall of 2.17.2026, that's another fall that occurred when I was not here. My recollection is that staff said she had just got up, that she was coming from her room, walking down hallway near the nurses' station, and she fell somewhere at the nurses' station. The nurse said she was facing away from the resident and did not see R3 fall but heard it and went to help the resident. I was told that R3 may not have been wearing appropriate footwear. So, my intervention probably was to ensure that resident is wearing appropriate footwear. We encourage our residents to wear closed shoes, if issues with swelling, then non-skid socks.3.5.2026 at 2:53 PM, V4 (LPN-Licensed Practical Nurse) said R3 had a fall. It was dinnertime. R3 was walking with her walker down the hallway to the dining room for dinner. I didn't see her fall; I had my back to her. I heard her walker; I saw her on the floor. R3 was unable to tell what happened but said she did not hit her head. She was wearing slides (Slide shoes (or sliders) are open-toed, backless footwear characterized by a thick strap across the top of the foot for easy, slip-on, and slip-off use.). That was her preferred footwear. When asked if slides were appropriate footwear for resident, V4 said honestly, no, she shouldn't have been wearing slides. She was sent to the hospital for evaluation and treatment for an unwitnessed fall on blood thinners.3.10.2026 at 9:13 AM via telephone V31 (Nurse Practitioner) said, I received a voice message from the nurse at the facility that R3 was sent to the hospital for a witnessed fall with head strike. Given her history of blood thinners, it was the right thing to do. I always send them out with a hit to the head and on blood thinners because there's a chance that they could have a bleed (brain hemorrhage) and if left untreated they could die. Given her age, she should have proper foot gear, something with a grip, a closed toe/heel shoe or socks with a grip so that they (residents) can ambulate properly and reduce the likelihood of a fall. I'm not sure what a slide is. Surveyor explained what a slide is. V31 said I wasn't there but that form of footwear is not appropriate.2.17.2026 4:40 PM, Nursing Progress Note (completed by V4) documents, in part: Resident was ambulating with walker. Walked behind the nurses' station to go towards the dining room lost her balance and fell backwards. Resident wearing slides at the time of fall. Appeared to hit her head on the floor. Resident on blood thinners. V31 (NP) called and gave orders for resident to go to (local hospital).2. 218.2026 at 3:49 PM, Nursing Progress Note documents, in part: Called (local hospital) to check status of resident and was told by ER resident had been transferred to (receiving hospital). This writer called (receiving hospital) and was told resident was not in their possession.2.19.2026 7:28 AM, Nursing Progress Note documents, in part: Writer called (receiving hospital) to follow up on the resident. Spoke with (RN), he states the resident has been admitted to Neuro ICU admitting diagnoses subarachnoid hemorrhage.2.17.2026 at 7:43 PM, Hospital Progress Note documents, in part: History obtained from patient's daughters at the bedside. [AGE] year-old female history of dementia, on Eliquis who presents to the emergency department for evaluation after fall. Daughters were told patient had a mechanical fall in the nursing home, landed on her head. Reports headache, neck pain as well as bruising around her left wrist.2.17.2026 at 10:16 PM, CT (Computed Tomography) of head impression documents, in part: focal left parafalcine (lesion refers to a distinct, localized abnormality (such as a tumor, meningioma, or other mass) situated on the left side of the falx cerebri, which is the dural membrane separating the two hemispheres of the brain) hyperdensity favoring meningioma over acute subdural hemorrhage.Top of FormBottom of Form2.18.2026 at 1:56 PM, MRI Brain with/without contrast impression documents, in part: 1. Tiny left frontal, parietal temporal and occipital subdural hematoma (a thin, widespread collection of blood between the brain surface and its outer covering, a serious condition that can potentially require surgical drainage ([NAME] holes) or close observation). 2. Small focus of subarachnoid hemorrhage within a sulcus left parafalcine posterior front lobe (a small focus of subarachnoid hemorrhage (SAH) within a sulcus of the left posterior frontal lobe is a localized brain bleed. Head trauma is the most common cause of focal subarachnoid head trauma).2.18.2026 at 10:42 AM, Hospital Progress Note documents, in part: Patient signed out pending CT. Patient CT head negative on preliminary read. Patient was subsequently discharged . I received a call from radiology after patient had already left the emergency department that there could be a potential small subarachnoid versus meningioma. The patient was brought back from (ambulance) within 10 minutes. MRI (Magnetic Resonance Imaging -scan is a noninvasive medical imaging test that uses powerful magnets and radio waves) was obtained. MRI revealed subarachnoid as well as subdural. Patient started on nicardipine (medication used to treat high blood pressure and chest pain) per recommendation of neurosurgery specialist and was expeditiously transferred to (receiving hospital).2.18.2026 at 1:48 PM, Hospital Progress Note documents, in part: Patient with bleed on MRI.2.18.2026 at 5:31 PM, CT Brain without contrast impression documents, in part: No acute intracranial hemorrhage, herniation (abnormal protrusion or displacement of an organ, tissue, or structure through a weakened wall, muscle, or opening) or hydrocephalus (abnormal accumulation of cerebrospinal fluid within the brain's ventricles, causing increased pressure on brain tissue).Surveyor requested facility's fall policy/protocol and received Guidelines for Incidents/Accidents/Falls (dated 6.23.2023). These guidelines document, in part: Policy: It is the policy of the facility to ensure that any incident/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge. After the resident has had immediate attention and their safety is established, a written report will be entered into Risk Management (usually Risk Management section of PCC). The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved. The facility will create a database related to incidents/accidents as part of the QAPI process to enable trending and tracking. This information will be used to implement corrective actions to include any needed training to prevent reoccurrences when possible. 3.5.2026 at 1:43 PM, V2 (DON-Director of Nursing) said, the policy I gave you yesterday (Guidelines for Incidents/Accidents/Falls-undated) is the only fall policy we have.R3's care plan I am at risk for falls related to the following potential/present contributing risk factors: generalized weakness, changes in environment, and adjustment to facility, P. E. (Pulmonary Embolus), HTN (Hypertension), Coronary artery disease, Dementia, Psychosis, anxiety. Date Initiated: 01/22/2026, Revision on: 01/29/2026 documents the following interventions: Ensure that I am wearing appropriate footwear that provide stability and good traction when ambulating or mobilizing in their w/c and during transfers Date Initiated: 01/22/2026 and Upon return from hospital: Ensure that I am wearing appropriate footwear that provide stability and good traction when ambulating or mobilizing in their w/c (wheelchair) and during transfers. Date Initiated: 02/17/2026 Revision on: 02/18/2026

Based upon interview and record review, the facility failed to report an injury of unknown origin to the state surveying agency within regulatory requirements for one (R7) resident. This failure has the potential to affect all 172 residents residing in the facility. Findings include: Findings include: On 01/27/2026 at 2:02PM, Facility Reported Incidents/FRIs were requested from V1 (Administrator) for the past 3 months. V1 provides surveyor with three incident reports via scanned email, that are dated 12/02/25, 12/16/25, and 01/14/2026. V1 states these are the only facility reported incidents that occurred in the facility for the past 3 months. During record review of facility's reported incidents, surveyor observes that they were not submitted to the correct email address. On 01/29/2026 at 2:12PM V1 states she was made aware of R7's incident by V2 (DON). V1 states she reported R7's incident to the state agency via email on 12/16/2025, the same day it was reported to her. V1 is made aware that the state agency is not in receipt of the reported incidents. V1 is asked by surveyor to access her emails electronically and send surveyor email confirmation of the successful submission of the reported incident for R7 to the state agency. V1 states she is unable to access her emails at the current moment and will check for the email confirmation later. On 01/29/2026 at 3:32PM, surveyor receives an email from V1 stating she did not receive email confirmation from the state agency that the reported incident for R7 was received. V1 states the email was kicked back to her email and not sent successfully to the state agency. V1 states R7's reported incident was also sent from V2's email to the state agency. V1 emails surveyor a scanned email documenting a time stamp of an undeliverable blank email to the state agency. V1 also emails surveyor a scanned email documenting a time stamp of a blank email being sent from V2's email to the correct state agency's email. Both scanned emails do not have R7's facility reported incident attached showing proof of submission to the state agency. On 01/29/2026 at 4:07PM, surveyor requests V1 to directly forward surveyor the email that was sent from V2's email to show confirmation of R7's reportable incident that was sent to the state agency. Surveyor asks V1 not to scan the email and send it to surveyor, but to forward the exact email with R7's reportable attached that was sent to the state agency. This email was not provided to surveyor during this survey. On 01/29/2026 at 4:42PM, record review confirms that a facility reported incident for R7 was not received by the state agency from the facility. Further record review documents and confirms that a facility reported incident has not been received by the state agency from the facility since 12/03/2025. On 01/30/2026 at 10:51AM, V1 states that she has been the administrator since 08/2024 and was not aware that she was submitting the facility reported incidents to the incorrect email address. V1 states she never received confirmation that the email was sent to the state agency. V1 states herself and V2 share responsibilities with submitting the facility reported incidents to the state agency. V1 states since being informed by surveyor of using the incorrect email, she has now obtained a fax number to use instead of the email. V1 states the fax number is 708-544-92XX and V1 is made aware by surveyor that this is also an incorrect fax number for communication with the state agency. Surveyor then provides V1 and V2 with the correct fax number to submit reported incidents to the state agency. Surveyor provides V1 and V2 with the fax number 630-645-37XX and V1 successfully repeats the fax number back to surveyor for verification that V1 received the correct fax number. V1 is made aware that the facility not successfully submitting reported incidents to the state agency further puts all residents in the facility at risk for abuse and injuries. V1 states going forward, the facility will now use the fax number provided by surveyor to report facility reported incidents to the state agency. Facility census dated 01/27/2026 documents that a total of 172 residents reside in the facility. Facility policy dated 10/22/2022 titled, Abuse Prevention Program documents in part, All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin. (An injury should be classified as an injury of unknown origin when the source of the injury was not observed or known by any person, and the initial Risk Management investigation could not determine the causeof the injury.

Based on observation, interview, and record review, the facility failed to maintain laundry equipment in good working conditions that provides laundry services to all residents. These failures have the potential to affect all 172 residents living in the facility receiving laundry services. Findings include: On 01/27/2026 at 12:31PM, V16 (Registered Nurse/RN) states she was informed that residents were complaining about their laundry because the facility's washing machine was broken about 2 weeks ago. On 01/27/2026 at 1:18PM, V24 (Licensed Practical Nurse/LPN) states there was a washing machine malfunction that the facility experienced recently. V24 states the facility now has a new washing machine and it is being used to wash linen and resident's clothes. V24 states when the new machine arrived, the facility focused more on washing the facility's linen. V24 states during this time, residents verbalized concerns with their clothing items being washed and returned from the laundry department. Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents in part, You have the right to keep and wear your own clothing. On 01/28/2026 at 10:44 AM, V11 (Housekeeping Director) stated that linens and personal clothes of residents are washed in the facility. V11 stated that clothes and linens were sent to another facility because washing machines needed to be repaired. Three (3) months ago, one washing machine was working and the other one was being repaired. V11 stated that one washing machine is for personal clothes, the other for facility linen. V11 stated that she needs to order linen frequently from outside vendor due to linen not enough. V11 stated that some residents were hoarding linens that facility staff saw linens in resident room after sweeping. V11 stated that currently single washing machines do both linens and personal clothes. With one washing machine we can only do both. There is a lot of difference when both (washing machines) are functioning. It will make a lot of difference. On 01/28/2026 at 11:20 AM with V11 and V15 (Maintenance Director), V15 stated that there are three (3) washing machines and two are not working. Per V15 stated that one washing machine was newly installed because it was not working three (3) months ago. After installation of the new washing machine, the other two (2) washing machines broke and need to be repaired. Both washing machines that need to be repaired were seen in poor condition as to their rust-like structure that has holes. According to V15, parts needed were new motherboard and new bearings. The new washing machine has sixty (60) pounds capacity, two (2) that need to be repaired at 60 pounds and 80 pounds capacity. Middle washer that needs to be repaired still have linens visible inside the washer. V15 stated that it cannot be taken out because the door cannot be opened. Currently, facility has sixty (60) pounds capacity per wash instead of 200 pounds if all three washing machines are working. V15 stated that facility's washing machines that were replaced and need repair were too old and that it was there when he started working in the facility. And does not have manufacturer's information, the only maintenance he does is to grease it. If we cannot repair it, that is the time we replace it. There are three (3) dryers with one (1) dryer that has a paper tape with out of order written. V15 stated that plastic wheel needs to be replaced. V15 was requested to present installation receipt of washing machine. Order of parts to all washing machines and dryer that were found to be not working. V15 stated that he will inform V1 (Administrator). The same requests for documentation were made to V1. Multiple residents including R2, R3, R10 and R11 express concern related to lack of linens. On 01/27/26 at 11:07 AM, R3 stated right now there is no linen, they keep talking about the washer is down, or it was down. R3 said his fitted sheet has not been changed yet because he is still going to finish washing himself up. R3 stated I need to have clean linen because of my bed sores. R3 stated that R3 went to V1 (Administrator) and told her I (R3) don't have any linen, and I have bed sores. R3 stated that V1 said we have some linen coming from another company. And then no linen came. At 12:46PM, R11 states she was recently admitted to the facility but has been hearing about concerns related to the lack of linen in the facility and must wait for linen to be provided. At 12:53PM, R10 is observed with a clean body towel folded on her chest while lying in bed. R10 states she is keeping her towel close to her because if she doesn't, then she will not have a towel to use for her care. R10 states there is not enough linen for residents to use in the facility. On 01/30/2026 at 09:29 AM, R2 stated that he has diarrhea almost every day. A lot of times you ask CNA (Certified Nursing Assistant) for linen they say they don't have it because the washers have broken down. R2 needs to spend money and service his clothes to outside service company. Per sales invoice new washer was shipped on 01/05/2026. Invoice for washer parts are as follows: A blower wheel order dated 11/20/2025 Washer bad computer door lock board part order dated 12/24/2025. Per V15 the old washer that was replaced broke three (3) months ago after installation of the new washer, the two (2) washers broke. Washer parts for current repair were ordered prior to shipment of new washer that shows two (2) dryers that need repair were already not functioning prior to installation of the new washer. Actual installation of new washer receipt was requested but was not provided. Laundry Policies and Procedure not dated: The laundry room equipment and environment will be inspected and serviced by the Maintenance Department following the policies and procedures in the Preventive Maintenance Manual. Laundry daily inspection (document not dated), Environmental Supervisor will follow manufacturer's guidelines on setting of water temperature.

Based on interview and record review, the facility failed to implement a portion of an existing plan related to pressure ulcer care, such as not following treatment/dressing changes as ordered for one (R3) resident out of four reviewed for pressure ulcers in a total sample of 17 residents. However, there has been no evidence of decline or failure to heal. This failure places the resident at risk for more than minimal harm. Findings include:On 01/27/26 at 11:07 AM, R3 stated there have been several days when the wound care treatment was not done. R3 stated I am just wondering why the nurses don't change the wounds. R3 stated my wounds are stage 4 and they are super big and drain a lot, and they are supposed to be changed every day. R3 stated that he didn't call to remind the nurse on duty because R3 stated they can come anytime of the day and I just kept waiting. I am on medications, and I may fall asleep and the day went by.On 01/27/2026 at 12:38 PM, V7 (Wound care coordinator/LPN) stated that R3 has a right Ischium, right trochanter and sacrum pressure ulcer wounds. V7 stated that R3's pressure injuries are documented in R3's comprehensive care plan. V7 stated that when wound care is administered or completed it is documented in the patient's treatment administration record (TAR). Staff nurses are responsible for completing the wound care treatment orders when there is no wound care nurse working. V7 stated that it is important for wound care orders to be followed as ordered to ensure that the wound heals, to follow how the wound is progressing, prevention of decline, no introduction of bacteria or anything to the wound. R3's face sheet documents R3 is a [AGE] year-old individual with diagnoses not limited to: paraplegia, pressure ulcer of sacral region, unspecified stage, pressure ulcer of right hip, stage 4.R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R3 has intact cognitive response.R3's care plan documents in part a pressure ulcer to right trochanter, right ischium, sacrum. Date Initiated: 12/12/2025 Revision on: 12/15/2025. Interventions documents in part Treatment per physician orders Date Initiated: 12/12/2025.R3's treatment administration record for January 2026 documents that R3's wound care treatment was not administered for the following dates 01/05/2026, 01/07/2026, 01/11/2026, 01/12/2026, 01/19/2026, 01/21/2026, 01/22/2026, 01/25/2026.R3's current care plan documents in part, I have a pressure ulcer to right trochanter, right ischium, sacrum. My pressure ulcer will remain free of s/sx (signs and symptoms) of infection and wound will continue to heal without complications daily through next review. Treatment per physician orders.R3's current care plan documents in part, I am at increased risk for impaired skin integrity related to wounds. I will not develop any skin integrity issues thru next review,unless the disease process causes unavoidable deterioration. Administer Wound Care (Treatments) per MD orders (See POS/TAR (physician order set/treatment administration order) for current orders)Facility document not dated titled Guidelines for Prevention/Treatment of Pressure Injuries documents in part it is the intent of the facility to recognize the following and to act on it in such a way as to practice evidence-based recommendations for the prevention/treatment of pressure injuries to the residents who reside in the facility. In accordance with Federal Regulations- and based on resident assessment, the facility will ensure: A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for three (R15, R16) residents in a total sample of 17 residents reviewed. Findings include: On 01/27/2026 at 1:29PM, R15 and R16 observed sitting inside of the second-floor dining room unsupervised and unattended. R15 and R16 were sitting in geri-chairs.On 01/27/2026 at 1:39PM, V4 (Licensed Practical Nurse/LPN) states the Certified Nursing Assistants/CNAs take turns monitoring the residents in the dining room at 30-minute intervals. V4 states residents are monitored to make sure they do not fall, injure themselves, choke, or get into physical altercations with one another. V4 states V12 (CNA) is the person responsible for monitoring the second-floor dining room today from 1:30PM to 2:00PM. Record review of the CNA assignment sheet for the second-floor dining room dated 01/27/2026, documents that V12 is responsible for monitoring the dining room from 1:30PM-2:00PM.R15's fall risk assessment dated [DATE] documents that R15 is at high risk for falls with a fall risk score of 13.R15's care plan documents in part, I have impaired cognition/function or impaired thought process as a history of falling and muscle weakness. loss) Dementia, impaired decision making. Cue, reorient and supervise me as needed. I would like staff to provide me with a safe environment. Observe for fall precautions.R16's fall risk assessment dated [DATE] documents that R16 is at high risk for falls with a fall risk score of 12.R16's care plan documents in part, R16 will have fall interventions in place that will help reduce my risk for falls and injury through the next review. R16 will have a safe environment maintained through next review.Review of the facility's document titled Resident Community Access Tracking Tool was performed for the month of December 2025 and does not show that R7 went out on community pass for the month of December 2025.Facility policy undated, titled Standard Supervision and Monitoring documents in part, The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs.Facility policy undated, titled INCIDENTS/ACCIDENTS/FALLS documents in part, Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place.

Based on interviews and record reviews, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) needs are met in a timely manner for two residents (R4, R8) and medications are being administered as ordered by the physician. The facility's short staffing has the potential to affect all residents residing on the first floor of the facility.Findings include:On 01/25/26 at 10:07 AM, via telephone interview V3 (Staffing Coordinator/Central Supply) stated she does the staffing schedule for all the nurses including RD/LPN and CNAs. V3 stated the nurses do 12 hours shifts 7AM-7PM and 7PM-7AM and the CNAs do 7-3, 3-11 and 7-11 shifts. There are three floors in the building and the second and third floors usually have a higher acuity level than the first floor, so those floors are staffed with more CNAs. V3 stated the first floor is staffed with one nurse depending on the what the census is and V3 will sometimes go up to two nurses. V3 stated when there are 32 residents or more on the first floor that unit will be staffed with two nurses on the 7AM-7PM and 7PM-7AM shifts. V3 stated the first floors runs with three CNAs on the 7-3 and 3-11 shift and two to three CNAs on the 11-7 shift.On 01/25/26 at 10:30 AM, observed one Licensed Practical Nurse (V4) and two Certified Nursing Assistants (V7, V9) working on the first-floor unit. Review of the daily assignment sheet had one nurse (V4) and three CNAs listed on the form. Census not included on the daily assignment sheet.On 01/25/26 at 10:35 AM, facility provided surveyor with document titled, Daily Census dated 01/24/26 which indicated the first floor had 40 residents.On 01/25/26 at 10:45 AM, via telephone interview V3 stated today there is one LPN scheduled to work on the first floor, there were no nursing call outs that is what was scheduled. V3 stated if there are 40 residents on the first floor then it should be staffed with two nurses for continuity of care. V3 stated if the first floor is only staffed with one nurse with the census at 40 there is the potential that there will be an overall delay in care, including the dispensing of medicine which may also be delayed. V3 stated there was a CNA who called out this morning on the first floor, so she found another CNA who agreed to come in to help out.On 01/25/26 at 10:50 AM, V4 (Licensed Practical Nurse) stated they usually have two nurses working on the first floor on the 7AM-7PM shift but today she was the only nurse scheduled. V4 stated she is not aware of any nurse calling out sick she just does not think one was scheduled. V4 stated there is another nurse (V5/LPN) who was working on the 2nd floor who just came downstairs to help because she (V4) is behind with passing morning medications. V4 stated she is getting ready to start passing medications from the second medication cart. V4 stated she has not passed any of her 9 AM medication to those residents yet but she is getting ready to start doing that now.On 01/25/26 at 10:55 AM, V5 (Licensed Practical Nurse) stated today she is assigned to the second floor. V5 stated she was told that the first-floor nurse needed help so when she was done passing her 9AM medications she came down to the first floor at 10:30 AM to help the nurse (V4). V5 stated she has two residents on the first medication cart which still need their medication passed out to them and after that she will be starting to do Accu-Chek readings for the diabetics before lunch is served.On 01/25/26 at 12:07 AM, V4 stated she is still passing out 9 AM medications to the residents. V4 stated the 9 AM medications are late because of staffing. V4 stated she had to pass two carts of medication since it was only her and as a result she fell behind.On 01/25/26 at 12:21 PM, V11 (Certified Nursing Assistant) stated she has been working at the facility since April 2025 and she usually works the 3-11 shift on the first floor. V11 stated V3 Staffing Coordinator/Central Supply) called her this morning and asked her to come in to work early. V11 stated she arrived at the facility at 11:00 AM. V11 stated before she arrived there were two CNAs covering the first-floor unit. V11 stated she is now taking care of 14 residents of which nine residents require total care and two residents require assistance with care. V11 stated she has checked on all her residents and changed three of them and the other CNAs had changed three other residents before she arrived, so she still has five more residents to change. V11 stated on the 7-3 and 3-11 shift the minimum number of CNAs they run the floor with is three with a maximum four CNAs.On 01/25/26 at 12:30 PM, V9 (Certified Nursing Assistant) stated when she arrived there was one other CNA covering the unit with her this morning. V9 stated they are supposed to have at least three CNAs on the first floor. V9 stated she was told there was a CNA who called out. V9 stated because of the call out there were two CNAs to cover 40 residents meaning they each had 20 residents to take care of. V9 stated they usually cover 11-12 residents which is doable based on the resident's level of care. V9 stated it is not realistic for two CNAs to be able to take care of 40 residents. V9 stated the residents that require total care and those that wanted to get up out of bed were complaining this morning because everything took longer to complete which resulted in a delay in care. V9 stated they (V7 and V9) were also the only CNAs passing out breakfast trays, feeding residents that needed to be fed, picking up dirty trays and because of this she could not check and do changes every two hours because there was not enough staff. V9 stated she still needs to give a resident a shower and if they were fully staffed with three CNAs from the beginning of the day she would have gotten to giving the resident the shower already. V9 stated the residents who get up out of bed are usually taken out of bed after breakfast, but they are still getting some of the residents out of bed now. At 12:40 PM, V9 stated V7 (CNA) is in the process of getting R8 out of bed right how.On 01/25/26 at 12:40 PM, surveyor knocked on R8's door. V7 (CNA) stated she is giving R8 care.On 01/25/26 at 12:41 AM, observed R4 lying in bed. R4 stated the staff usually gets her out of bed before breakfast. R4 said, there is not enough staff working here. R4 stated they only have two CNAs working today and they are supposed to have three CNAs. R4 said, if they had 3 CNAs I've be out of bed by now.On 01/25/26 at 1:18 PM, observed R8 sitting in his motorized wheelchair. R8 stated he wanted to get out of bed at 9:30 AM today but when he asked the staff to get him out of bed, they told him they could not do it because there were only two CNAs working the unit. R8 stated he was frustrated that he had to wait and could not get up when he wanted to. R8 stated the CNA got him up out of bed after lunch. R8 stated he's okay now but he would have preferred to get out of bed earlier.On 01/25/26 at 1:06 PM, V7 (Certified Nursing Assistant) stated there are usually three to four CNAs working on the unit per shift. V7 stated this morning when she arrived at the facility it was only herself and V9 cover the unit because there was a call out. V7 stated only having two CNAs to cover the unit made it hectic and chaotic. V7 stated breakfast was our top priority so the two of us had to pass out the breakfast trays, feed the residents that needed to be fed, and collect the dirty trays. V7 stated after breakfast she was able to start on her rounds and giving care to the residents. V7 stated V11 arrived around 10:30-11:00 AM. V7 stated R8 usually get up out of bed at 10:00 AM however there was a delay getting him out of bed today because of the schedule and shortage of staff. V7 stated she got R8 out of bed after lunch around 12:30 PM.On 01/25/26 at 1:34 PM, via telephone interview V2 (Director of Nursing) stated the nursing staff is supposed to pass medication on time (one hour before or one hour after) and medication should be given as prescribed by the physician. V2 stated the number of CNAs assigned to work on a unit is based on census. V2 stated the facility has been assigning three to four CNAs on the first floor. V2 stated if there is a census of 40 residents on the 1st floor there should be three to four CNAs working on the unit. V2 stated if there are less than three to four CNAs on the first floor unit with a census of 40 this could potentially have an impact on resident care specifically it could cause a delay in answering call lights, delay in providing care to residents, and delay in getting residents out of bed. V2 stated if there are any call outs in the building the other staff in the building should be stepping in to assist with giving care to the residents.R4's diagnosis includes but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Dysphagia, Spastic Diplegic Cerebral Palsy, Neuromuscular Dysfunction of Bladder, Limitation Of Activities Due To Disability, Weakness. R4's MDS (Minimum Data Set) dated 12/19/25 indicates R4 requires substantial maximal assistance with ADLs.R8's diagnosis includes but not limited to Fusion of Spine, Cervical Region, Unspecified Pedal Cyclist Injured In Collision with Car, Pick-Up Truck Or Van In Nontraffic Accident, Sequela, Quadriplegia, C1-C4 Incomplete, Acute Respiratory Failure With Hypoxia, Dysphagia, Neuromuscular Dysfunction of Bladder, Chronic Embolism And Thrombosis Of Deep Veins Of Right Upper Extremity,, Muscle Wasting And Atrophy, Limitation Of Activities Due To Disability,, Other Reduced Mobility, Weakness, Emphysema, Unspecified Displaced Fracture Of Seventh Cervical Vertebra, Sequela, Fracture Of Nasal Bones, Sequela, Unspecified Injury At Unspecified Level Of Cervical Spinal Cord, R8's MDS dated [DATE] indicates intact cognition and functional limitations in range of motion to upper and lower extremity to both side and substantial/maximal assistance to dependency for self-care ADLs and mobility.Facility provide Daily Census report dated 01/24/26 which indicates there are 40 residents on the first floor.Facility provided copy of daily assignment for the first-floor days dated 01/25/26 indicating V4 as the only nurse assigned. V7 V9, V11 are listed as the CNAs covering the unit.Per V1 (Administrator) the facility does not have a policy on staffing.Refer to F755 and F558 for additional information.

Based on observation, interview and record review the facility failed to ensure medications were administered as scheduled per physician orders for two (R1, R4) out of three residents reviewed for medication administration.Findings Include:On 1/25/26 at 9:57 AM, R1 was sitting up in bed alert and oriented to person, place, and time. Able to verbalize needs with no difficulty. R1 stated that he did not receive his scheduled morning medications at 6:00 AM today and received it at 8:00 AM instead. R1 also stated that on 1/21/26, he did not receive his scheduled Eliquis, Multivitamin, and Midodrine.1/25/26 at 2:14 PM, a phone interview was conducted with V18 (Registered Nurse) and stated he was R1's nurse on 1/21/26 night shift until 1/22/26 and leaves at 7:30 AM. V18 denied giving R1's Midodrine late on 1/21/26. V18 said that there could be other factors that medications might not be administered either the medication is not available, or it is not ordered.On 1/25/26 at 3:01 PM, a phone interview was conducted with V19 (Registered Nurse) and stated she was the nurse assigned to R1 on 1/21/26 evening. V19 stated R1's Midodrine was on order meaning she had to order more. V19 stated that the Midodrine was not administered to R1 because his BP (Blood Pressure) was high and if needed, the medication is available in the emergency medication dispensing system.R1's face sheet listed diagnoses but not limited to orthostatic hypotension, end staged renal disease, and polyosteoarthritis. R1's Minimum Data Set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) score of 15. R1's Order Review Report and Medication Admin Audit Report printed on 1/25/26 revealed that on 1/21/26, R1 had ordered and scheduled medication of Midodrine 10 mg by mouth every eight hours (Hold if systolic BP is more than 135) to be administered at 10:00 PM but was documented administered on 1/22/26 at 5:19 AM, more than seven hours past the scheduled administration time. R1's progress notes dated 1/21/26 at 5:02 PM documented by V19 reads in part: Midodrine HCl Oral Tablet 10 MG Give 1 tablet by mouth every 8 hours ON ORDER. No documentation of R1's BP readings on 1/21/26 progress notes. R1's blood pressure summary revealed on 1/21/26 at 6:17 AM, R1's BP was 110/68. No other BP readings recorded on 1/21/26.R1's Medication Admin Audit Report printed on 1/26/26 revealed that on 1/25/26, R1 had ordered and scheduled medications of Midodrine 10 mg by mouth every eight hours (Hold if systolic BP is more than 135) to be administered at 6:00 AM but was documented administered at 8:02 AM, Protonix 40 mg one time a day by mouth to be administered at 6:00 AM but was documented administered at 8:03 AM, and Ferrous Sulfate 325 mg by mouth one time a day to be administered at 6:00 AM but was documented administered at 8:02 AM.On 1/25/26 at 11:09 AM, surveyor started the medication administration observation on the first floor with V4 (Licensed Practical Nurse). V4 stated that she documents in the resident's chart that medications were administered after and not before administering medications. V4 stated she signs off the resident's EMAR (Electronic Medication Administration Record) what were administered and the time they were administered will be recorded. V4 stated she is not finished with passing the residents' 9:00 AM medications. V4 said she was by herself when she came in this morning and there are 39 residents to pass medications this morning. V4 said there are supposed to be two nurses working on the first floor, but someone might have called in sick. On 1/25/26 at 11:14 AM, V4 took R4's blood pressure reading and read 136/80 with heart rate of 94 bpm (beats per minute).On 1/25/26 at 11:16 AM, V4 prepared R4's 9:00 AM medications consisted of Aspirin 81 mg (milligrams), Amlodipine 10 mg, and Vitamin D3 125 mcg (microgram) all by mouth.On 1/25/26 at 11:21 AM, R4 took all of her 9:00 AM pills.On 1/25/26 at 1:09 PM, R4 stated that sometimes facility has short staff and would receive her medications late.R4's face sheet listed diagnoses but not limited to cerebrovascular disease and essential hypertension. R4's MDS dated [DATE] shows R4 has cognitive impairment with BIMS of 6. R4's Order Review Report and Medication Admin Audit Report printed on 1/25/26 shows that on 1/25/26, R4 had ordered and scheduled medications of Aspirin 81 mg by mouth one time a day, Amlodipine 10 mg 1 tablet one time a day, and Vitamin D3 125 mcg by mouth one time a day. All to be administered at 9:00 AM but were documented administered at 11:18 AM, more than two hours past the scheduled administration times.On 1/25/26 at 1:33 PM, a phone interview was conducted with V2 (Director of Nursing) and stated that medication administration is done one hour before and one after the scheduled administration times. V2 stated that if the nurses give the medications late, they must call the doctor. V2 stated that after a resident takes their medications, the Nurses are documenting the time they administered the medications in the EMAR. V2 said nurses are supposed to follow policy when administering medications to the residents following the correct resident, right route, right dosage, right medication, and right time. V2 said physician orders are followed for medication administration. V2 stated that it is important to administer all medications to the residents based on the prescription of the doctor to minimize the diagnosis worsening. For example, for hypertensive medications to control hypertension. The facility's 5.1: DRUG ADMINISTRATION--GENERAL GUIDELINES (no date) reads in part: Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administrated precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. The right time: administer drugs as instructed on the MAR and within the time frame established by your facility.

Based on interview and record review, the facility failed to ensure that call lights were answered in a timely manner for one (R1) out of three residents reviewed for accommodation of needs.Findings Include:R1's face sheet listed diagnoses, but not limited to, orthostatic hypotension, end staged renal disease, and polyosteoarthritis. R1's Minimum Data Set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) score of 15.On 1/25/26 at 9:57 AM, R1 was sitting up in bed alert and oriented to person, place, and time. Able to verbalize needs with no difficulty. R1 stated that his call light was on for more than two hours on 1/21/26 around 4:20 PM to get his urinal emptied and get water to drink. R1 said nobody answered his call light until 6:45 PM. R1 said he called the reception four times to send someone, and nobody came. R1 said that the facility is always short on staff.On 1/25/26 at 1:09 PM, R4 was sitting on the side of her bed alert and oriented to person, place, and time with bouts of forgetfulness. R4 said that sometimes staff are delayed in answering call lights and providing showers due to lack of staff.On 1/25/26 at 11:51 AM, a phone interview was conducted with V8 (Receptionist), and she stated she's been working in the facility part time for one and a half year and works 4:00 PM to 8:00 PM. V8 said residents sometimes call the front desk when their call lights are not being answered timely by the floor staff. V8 said she remembers R1 called her sometime last week in the afternoon and told her that R1 had been waiting a while for someone to answer his call light. V8 said R1 did not exactly specify how many hours or minutes he's been waiting. V8 said she went to the floor and found the nurse and informed her about R1's concern. V8 said she does not remember the female nurse's name. V8 said that the nurse said she will send someone in R1's room.On 1/25/26 at 3:01 PM, a phone interview was conducted with V19 (Registered Nurse) and she stated she was the nurse assigned to R1 on 1/21/26 evening. V19 said that when she entered R1's room to give his pain medication, R1 informed her that he was waiting for a while for someone to answer his call light. V19 said R1 said he was waiting for over an hour and his call light was on. V19 said that R1 told her no one was emptying his urinal. V19 said that staff should be answering call light timely and anyone can answer call light. On 1/25/26 at 4:43 PM, a phone interview was conducted with V22 (Certified Nursing Assistant/CNA) and stated she was the CNA assigned with R1 on 1/21/26 evening shift. V22 said that the nurse (does not remember name) informed [V22] that R1's call light was on. V22 said when she entered R1's room, R1 informed her that he's been waiting more than two hours for someone to answer his call light. V22 said that she did not hear and did not see R1's call light because she was sitting at the end of the hallway on the opposite side of R1's room. V22 said R1 needed water, and his urinal emptied. V22 said that anyone can answer the call light and should be attending to the resident's needs.On 1/25/26 at 1:33 PM, a phone interview was conducted with V2 (Director of Nursing) and stated that staff have to answer call lights timely. V2 said anybody can answer call light and they have to answer it in a timely manner no longer than 15 minutes.On 1/25/26 at 12:57 PM, V11 (Certified Nursing Assistant) stated that sometimes facility is short staffed that affects the timelines in providing care to the residents.The facility's CALL LIGHTS (no date) policy reads in part: It is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance and to ensure that the call system is in proper working order. Call lights are to be answered promptly by staff who see that the call light has been activated. Even if you are unable to meet the need of a resident, you can report the need to the appropriate staff member.

Based on observation, interviews and records review the facility failed to follow their policy to ensure one (R2) resident remained free from physical abuse by another resident (R1) in a sample of four reviewed. This failure resulted in R1 hitting R2 with a bottle causing an open wound over R2's left eyebrow. Findings include: R1 is a closed record and was not residing in the facility during this investigation. R1's current face sheet document R1's medical conditions to include but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anxiety disorder, unspecified, depression, unspecified, anxiety disorder, unspecified. MDS (Minimum Data Set) section C dated 04/24/2025, documents R1's Brief Interview for Mental Status (BIMS) as 12/15 indicating R1 has moderate cognitive impairment functional abilities. MDS Section D- Mood documents R1 feels down, depressed, or hopeless 2-7 days (half or more of the days. R2's current face sheet documents her medical conditions to include but not limited to: hemiplegia, unspecified affecting left dominant side, dysarthria and anarthria, cerebrovascular disease, unspecified. MDS (Minimum Data Set) section C dated [DATE], documents R2's Brief Interview for Mental Status (BIMS) as 3/15 indicating R3 has severe impairment. On 06/07/2025, at 10:26 AM, R2 was observed in her room sitting on her bed with wheelchair next to bed. R2 was alert and oriented. R2 stated R1 struck her with a glass bottle on her face while she was in the dining room a while ago. R2 was scared that she would develop seizures. R2 stated since then she has been experiencing headaches. R2 stated, it's too late now to go to the hospital. R2 stated that day she was scared because R1 was taller and bigger than her. R2 thought that R1 might attack her again. R2 stated since then she feels somewhat safe in the facility now. Nursing progress notes dated 5/22/2025, 7:21 PM, documents R1 was involved in verbal altercation with R2 and R1 struck in the face. Police Report Number -JJ264943 dated 4/22/2025 documents R1's name and documents: -Battery; Aggravated: OTHER Dangerous. Form titled Physical Aggression dated 5/22/2025, documents: R1 had an altercation with R2 in the hallway. R1 struck R2 in the face and R2 was noted with open area to left eyebrow. Social Service Note dated 5/22/2025, 4:27 PM, documents R1 was involved in an altercation with R2. R2 displayed increased agitation toward staff. R2 was difficult to re-direct and non-receptive to counseling as she continued to be aggressive and being disruptive on the unit. On 06/07/2025, at 10:39 AM, V6(Certified Nursing Assistant-CNA) was observed sitting in the dining room at a corner adjacent to the nursing station looking through his phone. V6 stated he was supervising residents in the dining room for safety and further stated he can see the residents in front of him. He has turn to see the residents sitting behind him. V6 stated he should be sitting at a place where he can see all residents for resident safety and prevent resident altercations. V6 stated residents are not supposed to fight or have altercations because it can be a form of abuse. On 06/07/2025, at 10:42 AM, V7 (Licensed Practical Nurse-LPN) stated she was R2's nurse on 5/22/2025, when R1 struck R2 on the face outside the door leading to the dining room. She was not on the unit when it happened. V7 stated when she got back to the nursing station, she found V1 (Administrator) and V2 (Director of Nursing) at the nursing station, after being notified of the altercation. V7 further stated she went to R2's room and found the wound nurse cleaning and treating R2's wound in the face, which was bleeding. V7 stated residents are not allowed to hit each other because that's a form of abuse. R1 was sent out to a local hospital for psychiatric evaluation and did not come back to the facility. On 06/07/2025, at 10:24 AM, V5 (Certified Nursing Assistant-CNA) was observed sitting in the dining room at a corner adjacent to the nursing station looking through her phone. Some residents were observed sitting behind V5 playing music. On 06/07/2025, at 10:59 AM, V5 (Certified Nursing Assistant-CNA) stated when the surveyor observed her earlier, sitting in the dining room on her phone, she (V5) was completing her charting on her cell phone and supervising residents for safety in the dining room. V5 stated at the position she was sitting at; she would have to turn to see residents sitting behind her. She should have sat at a position where she could see all the residents in the dining room. V5 stated she worked on 5/22/2025, when R1 was physically aggressive towards R2. R1 was coming out of the dining room and R2 was going into the dining room. V5 stated R1 started becoming aggressive towards R2, swearing at R2, and took something from her wheelchair. R1 hit R2 on the face. V5 stated blood shot out of R2's face and blood went everywhere on R2's face and the floor. V5 stated at that time, all staff ran towards the dining room to see what was happening and separate R1 and R2. V5 stated residents hitting each other is not allowed and it is a form of abuse. On 06/07/2025, at 11:07 AM, V8 (Wound Care Nurse-LPN) V5 and surveyor observed R2 in her room. V8 described R2's scar on the left side of her face as: midline, left eyebrow, 4 centimeters long, width 0.5 centimeters, closed not draining, dark brownish scab on the scar. V8 touched R2's scar. R2 stated she felt pain of 5/10 with 10 being the most pain and the pain was regular in description. On 06/07/2025, at 11:26 AM, V4(Social Services Director) stated on 5/22/2025, there was a physical altercation between R1 and R2. R 1 was the aggressor hitting R2 on the left side of the face with an empty glass perfume bottle, causing R2 to bleed. V4 stated staff separated the residents and attended to R2. V4 stated a glass bottle can be used as a weapon and any form of physical altercation is abuse. Therefore, residents should be monitored for safety, so they don't hit each other. V4 stated R1 has a lot of behavioral issues such as aggression, disrespect, being inappropriate, yelling, and attention seeking behaviors. But R2 does not have these behaviors. V4 stated when residents are in the dining room or in common areas, staff should supervise residents for safety. On 06/07/2025, at 2:04 PM, V9 (Licensed Practical Nurse-LPN) via phone stated on 5/22/2025, at approximately lunch time, she was notified that R2 has a laceration on the face. V9 came to the unit and found R2 in her room sitting on in her wheelchair with a slightly open wound over her left eyebrow, with minimal bleeding. V9 stated R2 did not complain of pain at time but R2 was upset because of the altercation with R1. V9 stated she assessed R2 and called V10 (Physician) who gave a one-time order to cleanse the wound with saline water, apply over the counter antibiotic bacitracin, then cover with strip strips (surgical cape). V9 stated she does not remember if she wrote the orders in R2's Physician Order Sheet (POS) and further stated she is supposed to write the orders to notify other nurses and doctors what has already been given for resident. V9 stated no other orders were given after that and she did not follow up on R2. On 06/07/2025, at 2:28 PM, V10 (Physician) via phone stated he was notified R2 has a lesion on her forehead and was not notified R2 had been hit by another resident. V10 stated V9 had evaluated R2 and informed V10 that the laceration was superficial. Therefore, it was not necessary to send R2 to the hospital. V10 stated he gave orders to V9 to clean the lesion with normal saline, put over the counter antibiotic, and cover with normal dressing. V10 stated nurses are supposed to write all physician orders in the Physician Order Sheet (POS) so the nursing team are aware of which treatments a resident has received for effectiveness. V10 stated residents in the facilities have arguments all the time and hit each other. R2 being hit by R1 is not considered abuse because the laceration R2 sustained was superficial and there was no hematoma of broken bones, but he does not expect residents to hit each other. On 6/7/2025, at 4:20 PM, V2 (Director of Nursing) stated she was informed that two residents on the second floor had an altercation, so she went to the unit to find out what was going on. V2 stated she saw V5 (Certified Nursing Assistant-CNA) with R2 in the hallway holding a gauze on R2's left side of the face, above the eyebrow. V5 informed V2 that R2 was bleeding after being hit by R1. V2 stated the staff told her R2 was sitting outside the dining room adjacent to the nursing station. R1 was coming out of the dining room and as she was passing by. R2 hit her on the face before staff could intervene. V2 stated V1(Administrator) told her R1 used a perfume glass bottle which was in a sock to hit R2 and that is physical assault. V2 stated her expectation is for staff to always monitor residents for safety and staff are not supposed to be on their phones while on the job or use their phones to access residents' medical records to chart. On 06/07/2025, at 5:00 PM, V1(Administrator) stated on 5/22/2025, during lunch time when a staff member (cannot remember who) called the front desk and stated something was wrong on the second floor. V2 ran to the second floor to find out what was going on. V1 stated she found other staff members already on the floor and was told R1 hit R2 with an empty perfume bottle that was in a sock, which R1 had been carrying around tucked under her thigh and wheelchair seat. V1 stated she and V4 brought R1 to V4's office to separate her from R2, as the nurses took care of R2. V1 stated she called the police right away. They came and interviewed R1, R2, and herself. Both residents' doctors were notified of the incident. R1 was sent to the hospital for further evaluation. R2 was treated at the facility to stop her bleeding. V1 stated R1 attacked R2 which is a physical altercation, but V1 does not like calling it physical assault or abuse because calling it that is too harsh. V1 stated residents are not supposed to hit each other. V1 stated she spent some time with R2 that day and R2 told her she was scared. Facility Reported Incident Report dated 5/28/2025, documents: -R1 was verbally aggressive to R1 and stuck R2 when attempting to go into the dining room. Facility Policy titled Standard Supervision and Monitoring, no date documents: Purpose: this guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the residents is an essence part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. Facility Policy Titled: Abuse Prevention Program Abuse And Crime dated 01/19, documents: -Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. -Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. R1's care plan documents: R1 displays manipulative behavior which is disruptive, insensitive and/or disrespectful to staff and peers.

Based on interview and record review, the facility failed to prevent and protect one resident (R1) from resident-to-resident abuse out of four residents reviewed for physical assault. This failure resulted in R1 sustaining a fracture of the left ankle in a total sample of four residents. Findings include: On 04/22/2025, at 11:57 AM, R1 states the altercation between himself and R2 began when he refused to lend his Bluetooth speaker to another female resident. R1 states all parties were located on the first floor of the facility during this time. R1 states R2 inserted himself into the situation and began to try to impress the female resident. R1 states R2 then began calling R1 bit**es and saying he will catch R1 outside. R1 states he and R2 then started a verbal argument and that's when R1 decided to remove himself from the situation. R1 states he began to self-propel himself in the opposite direction from R2. R1 states when he turned his back, R2 rammed him really hard with R2's electric wheelchair, knocked R1 onto the floor, and ran over R1's leg. R1 states R2 then reversed his wheelchair and proceeded to run him over again but that's when staff intervened and stopped R2 from doing so. R1 states staff separated them and R1 went back to his room. R1 states the staff only asked him if he was okay and R1 said yes at the time. R1 states the staff was in the process of trying to change his room when he began feeling pain later. R1 states when staff initially asked was he okay, R1 did not feel any pain. It could have been due to his adrenaline. R1 states he does not know the nurse's name, but he informed the female nurse on duty that he believed something was wrong. R1 states he informed the nurse that he may have broken his foot and that he was now in pain. R1 states staff did not assess him or take his vital signs. Staff moved him to another room located on the second floor. R1 states shortly after being moved to the second floor, he attempted to go to the restroom. R1 states he then felt more pain in his foot as he tried to use the restroom and that's when he fell . R1 states he fell in the restroom due to the pain he felt in his foot. R1 states he then told staff again that his foot was in pain, and he needed to go to the emergency room . R1 states he now has an appointment scheduled on 04/24/2025, with an orthopedic surgeon to have plates and screws placed in his foot. R1 states there have been no consequences for R2 and R2 continues to get community pass privileges. R1 states R2 can also come to the floor where R1 now resides anytime R2 feels like it. On 04/22/2025, at 12:27 PM, R4 states he did not witness the altercation that took place between R1 and R2. R4 states he has witnessed on multiple occasions how R2 is aggressive towards people. R4 states a couple of days ago, while on the smoking patio, R2 was bragging about how he ran over R1's foot and R2 stated to R4 that R2 would do it again. R4 states he also witnessed R2 roll up to R1 and kick R1's Bluetooth speaker onto the floor. R4 states R2 resides on the first floor of the facility but R2 continuously comes to the second floor where R1 is located just to bother R1. R4 states R2 needs to leave R1 alone. On 04/23/2025, at 6:34 PM, V6 (LPN) states upon starting her shift at 7:00 PM, she was given report from the off-going nurse that R1 had recently transferred rooms to the second floor. V6 states she was now responsible for caring for R1. V6 states she was located at the second-floor nurses' station when R1 approached her stating he was having pain in his left ankle. V6 states she assessed R1's left leg at the nurses' station and did not see any swelling or redness. R1's leg was not warm to touch. V6 states R1 told her that he wanted to have an x-ray performed on his left leg. V6 states she then called the doctor, but the doctor did not answer. She left a message and was awaiting a call back for further orders. V6 states approximately 30-40 minutes after complaining of left ankle pain, she was made aware that R1 had fallen while inside of his room. V6 states she called 911 and sent R1 to the hospital. V6 states when R1 returned from the hospital, she was made aware that R1 had a fracture to his left ankle. R1's nursing progress note written by V6 on 04/06/2025, at 8:45 PM, documents While this nurse writer was in the hallway passing meds, cna (certified nursing assistant) informed that R1 fell in the restroom. Upon entering R1's room, R1 was observed lying on his right side on the bathroom floor. Upon assessment, R1 was noted to be unresponsive and diaphoretic with normal vital signs. This writer kept calling R1 until he started to respond. 911 was called. R1 was made comfortable and transferred to bed per facility protocol. All safety precautions were maintained. Neurological assessment initiated. R1's nursing progress note written by V6 on 04/07/2025, at 4:25 AM, documents R1 returned from hospital via stretcher accompanied per 2 ambulance attendants. R1 transferred from stretcher to the bed per ambulance attendants without incident. Upon assessment, R1 was noted with a soft cast to the left ankle. Diagnoses closed bimalleolar fracture of left ankle, initial encounter. R1 is to see orthopedic surgeon. Dr. notified. R1's return and new orders. There is no documentation to show that V6 documented R1's complaint of left ankle pain, assessment of R1's left ankle, and notification to the doctor prior to R1 falling in the facility. R1's abuse care plan documents in part, R1 will be treated w/ respect, dignity & reside in the facility free of mistreatment (i.e., abuse/neglect) (on-going). Facility Designee will complete a Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors within 72-hours of Admission and Quarterly thereafter. Assure the resident that staff members are available to help & department heads maintain an open door policy. R1's aggression assessments dated 02/05/2025 and 04/15/2025 documents R1 has no history of aggression. R1's aggression assessment also documents that R1 scores a 2 which indicates that R1 is at minimal and low risk of aggression. R2's abuse care plan documents in part, My comprehensive assessment reveals a history of suspected abuse and neglect, exploitation, past trauma and/or other factors that may increase my susceptibility to abuse/neglect. R2 demonstrates: Depression, Diagnosis of Mental Illness. R2 had a disagreement with a peer on 8/28/2023. R2 and his roommate had a verbal disagreement on the unit on 10/13/2023 and 11/15/2024. R2 was involved in an alleged incident with staff on 4/11/2024. R2 will be treated w/ respect, dignity & reside in the facility free of mistreatment (i.e., abuse/neglect) (on-going). Facility Designee will complete a Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors within 72-hours of Admission and Quarterly thereafter. R2's behavior care plan documents in part, R2 demonstrates behavioral distress related to verbally abusive behavior when agitated towards and peer. R2 and his roommate had a verbal disagreement on the unit on 08/28/2023, 10/13/2023. Socially inappropriate and disrespectful by using profane languages towards staff members. 01/09/2024,04/24/2024. R2 kick doors instead of asking for assistance from staff 05/13/2024. R2 was socially inappropriate towards peers on 11/7/2024. R2 playing loud music while ambulating with his power-chair 11/20/2024, 11/22/2024. R2 will refrain from verbally and/or physically abusive behavior following staff intervention by: Explain Rules of Conduct and each person's obligation to treat others with dignity & respect at all times. Ask the resident to treat others as he/she would like to be treated. R2's aggression assessment dated [DATE] documents R2 was socially inappropriate towards peers on 11/7/2024. Facility reported incident dated 04/06/2025, documents an altercation between R1 and R2 where R1 became agitated and struck R2. In return R2 bumped his wheelchair into R1's wheelchair. R1's Hospital records dated 04/06/2025, documents that R1 was diagnosed with a closed bimalleolar fracture of the left ankle. Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents in part, You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Facility policy dated 01/2019, titled Abuse Prevention Program documents in part, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based upon interview and record review the facility failed to follow the abuse prevention program, failed to provide supervision, failed to implement preventive interventions, and failed to ensure that two of seven residents (R1, R2) in the sample remained free from abuse. These failures resulted in (8/9/24) physical altercation between R1 and R2. R1 sustained a displaced fracture of the left 5th metacarpal, right shoulder deformity and right eye discoloration. R2 sustained a scratched forehead. Findings include: On (1/10/24) IDPH (Illinois Department of Public Health) received allegations that R1 reported a resident was threatening physical violence (for about 2 weeks) prior to actual assault resulting in R1 sustaining bruises and fractured finger. On 1/27/25 at 10:22am, surveyor inquired if R1 was assaulted by a facility resident, V2 (Director of Nursing) stated (R2's name) was in an altercation with him (R1) several months ago and subsequently affirmed that the incident occurred on 8/9/24. R2's diagnoses include dementia, metabolic encephalopathy, and psychoactive substance abuse. R2's (6/18/24) BIMS (Brief Interview Mental Status) determined a score of 3 (severe impairment). R2's (6/7/24) care plan states resident displays behavioral symptoms related to severe mental illness. Interventions: Intervene when any inappropriate behavior is observed. Refer resident to consulting psychiatrist for a psychiatric evaluation as warranted. R2's progress notes state (7/22/24) Resident wandering down hallway and went into another resident's room. When staff asked resident to come out he became verbally aggressive and began yelling and cursing at staff that this was his house. Staff explained that this was another resident's room, and he had another room. Resident continued to yell and curse. Staff left resident in room and called (V11/Family) from cell phone to get her to speak to resident. Resident yelled and cursed at (V11) as well and refused to leave room. Received an order for IM (Intramuscular) injection of Zyprexa (Antipsychotic) 5mg PRN (as needed) every 8 hours. (7/25/24) Resident confused, leaves room and goes into other resident's rooms walking about the hallway asking where is his room. Resident needs constant redirection. (8/9/24) Resident was engaged in a physical altercation with peer. Resident was difficult to re-direct and non-receptive to Counseling as he continues to be aggressive and being disruptive on the unit. Physician was contacted and ordered the resident to be petitioned to hospital for psychological evaluation. Resident is currently placed on behavior monitoring and supervision until paramedic arrives. Staff will continue to monitor, follow-up and document progress accordingly. Resident transferred to the hospital with petition paperwork. The facility census affirms that R2 was discharged (8/9/24) and did not return to the facility. On 1/29/25 at 12:15pm, surveyor inquired about R2's behaviors, V12 (Social Worker) stated He (R2) was just a wanderer he was confused. Surveyor inquired about the (8/9/24) incident involving R1 and R2, V12 responded (V11) just called for staff to come to the room and by the time I (V12) got there the staff was already breaking them up. I guess they had a fight. Surveyor inquired if R1 reported that R2 threatened physical violence prior to (8/9/24) incident, V12 replied No ma am, not that I'm aware. __ R1's diagnoses include (8/12/24) displaced fracture of base of 5th metacarpal bone, left hand. R1's (12/26/24) BIMS determined a score of 13 (cognition intact). R1's (2/10/24) care plan states resident's medical diagnosis may increase his susceptibility to abuse/neglect. Interventions: observe resident for signs of fear and insecurity during delivery of care. Assure the resident that staff are available to help, and department heads maintain an open-door policy. On 1/27/25 at 11:58am, surveyor inquired about concerns at the facility, R1 stated I was assaulted in August, and I broke my little finger on my left hand. He (referring to R2) asked me what was I doing in his house and before I could understand what he was saying to me, he swung at me. He said everything in here (referring to the room) belonged to him and affirmed that (R2) was his roommate at the time. R1's (8/9/24) progress notes state resident was in an altercation with roommate and was attacked by him causing injuries [nothing was documented from 7/10/24 to 8/8/24 - roughly one month]. The (8/9/24) initial incident report states V11 was in facility to visit (R2). When (V11) entered the room (R2) was sitting in (R1's) wheelchair. (R1) was sitting on the side of his bed slightly leaning forward, (V11) asked if (R1) was alright. (R1) informed (V11) that (R2) had just jumped on him. (V11) attempted to speak with (R2) who became aggressive and defensive. (V11) called for assistance. Staff arrived, immediately separated. NP (Nurse Practitioner) made aware, arrived on the unit for head-to-toe assessment and observed (R1) with right 5th digit and shoulder deformity, and right eye discoloration. (R2) with scratch to left forehead. NP gave orders for transfers to acute care settings for further interventions. The (8/9/24) final incident report states (R1) stated that his roommate (R2) accused him of being in his house and told him (R1) to get out. (R1) stated I tried to defend myself but was overpowered. (R2) was interviewed but could not provide a detailed account of what happened. When asked about the incident, he (R2) only stated that this was his room. After being transferred to the hospital (R1) was examined and noted with a closed displaced fracture of proximal phalanx of left little finger. The (undated) abuse prevention program states it is the policy of this facility to prevent resident abuse. Prevention: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility's concern/grievance procedure. Random rounds will be made throughout facility assessing the safety of the environment. Staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict.

Based on interviews and record reviews the facility [ A] failed to monitor and recognize change in condition for one resident [R3]out of 4 residents with known history of chronic kidney disease fluid volume status, [B] failed review and address diagnostic test results, and [C] failed to follow physician orders to schedule nephrology, cardiology, and pulmonary consultant appointments. These failures resulted in R3 being sent to the emergency department very weak, massive volume overload, worsening kidney function, pulmonary edema, respiratory failure, hypotension, and diagnosed with cardiorenal syndrome, in acute renal failure, admitted to intensive care unit to place line for emergent dialysis. The facility's immediate jeopardy began on [DATE]. On [DATE] at 2:25 PM, the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on [DATE] at 1:59 PM. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings Include: R3's clinical record indicated in part the following: On [DATE], R3 was admitted with medical diagnosis include but not limited to chronic kidney disease, chronic obstructive pulmonary disease, type II diabetes, chronic congestive heart failure, cardiomegaly, essential hypertension, dependence on supplemental oxygen, abnormal gait, mobility, heart failure and atherosclerotic heart disease. R3's care plan dated [DATE] indicate the following in part: R3 has a medical diagnosis of congested heart failure. Interventions are to monitor and document any edema and notify the physician. R3 has a medical diagnosis of heart failure. Interventions are to monitor, document, and report to physician changes in edema and changes in weight. R3 has a medical diagnosis of chronic renal disease stage [3]. Interventions are to monitor lab reports of electrolytes and report to physician if potassium is over 5.5mg/dl. R3's Physician orders: Cardiology Consults Appointments were ordered on [DATE], [DATE]. Pulmonary Consult Appointments were ordered on [DATE], [DATE]. Renal/Nephrology Consult Appointment were ordered on [DATE], [DATE]. R3's progress notes Dated from [DATE] to [DATE], there were eleven documented provider progress notes for multiple consults appointments [Cardiology, Pulmonary, Renal/Nephrology] and a need for a pulmonary function test.] [None of the Consult appointments or test were scheduled] R3's Laboratory results: [DATE] R3 Labs: B-Natriuretic Peptide [BNP] = 1159.2pg/ml [2XXX,d+[DATE]] Blood Urea Nitrogen [BUN] =61mg/dl [,d+[DATE]] Creatinine =1.76mg/dl [0XXX,d+[DATE].32] Glomerular Filtration Rate [GFR] = 45ml/m [ >60] [diagnosed with stage 3 chronic kidney disease.] [DATE] Labs: BUN =71mg/dl [,d+[DATE]] Creatinine = 2.48mg/dl GFR 26 ml/m [ >60] - [There is a trend of deteriorating renal function.] [Stat labs were collected on [DATE] at 21:08 (9:08 pm) and resulted in the facility's dashboard computer system on [DATE] at 21:54 [9:54PM]. Labs was not reviewed until [DATE] at 21:34 [9:34 PM] 4 days later by V9 [Nurse Practitioner]. Labs were not addressed or documented on by V9 or any other physician, nurse practitioner, nor nursing staff in the progress notes.] [DATE] Labs: Potassium 6.0mmol/L BUN=128mg/dl Creatinine= 7.01mg/dl [0XXX,d+[DATE].32] GFR = 7ml/m [>60] BNP= 26,862pg/ml [2XXX,d+[DATE]] [Stat Labs were collected [DATE] at 14:45 (2:45 pm) . Labs resulted on [DATE] at 19:39 [7:39 PM]. Labs was reviewed [DATE] at 11:16 AM by V9 [Nurse Practitioner] approximately 12 hours later, R3's labs were reviewed by V9 [Nurse Practitioner] R3 labs: Elevated potassium at 6.0, BUN at 128, creatinine at 7.0, and an eGFR of 7, indicating critical lab values. [R3 now exhibits lab findings consistent with stage 5 CKD or renal failure.] R3's Progress notes indicates in part: [DATE] at 14:33 R3 noted with right leg edema, physician notified [V17 Medical Director/R3's Physician, no orders were given] R3's [DATE] at 21:57 V18 [Physician] progress note: R3 had no weight change, weight is 219.0 (pounds). Plan is for R3 to have a pulmonary function test, and pulmonary consult with V21 [Pulmonologist]. [V18 also provided V21's phone number in the note]. R3's [DATE] at 17:17 (5:17 pm) progress note documents - R3 noted with right leg edema, physician [V17] notified. (no orders were given) R3's [DATE] at 20:03 (8:03 pm) V18 [Physician] progress note: R3 had no weight change, weight is 219.0. Plan is for R3 to have a pulmonary function test, and pulmonary consult with V21 [Pulmonologist]. [V18] also provided V21's phone number in the note]. R3's [DATE] at 16:25 (4:25 pm) V18 [Physician] progress note documents: Plan is for R3 to have a pulmonary function test, and pulmonary consult with V21 [Pulmonologist]. [V18 also provided V21's phone number in the note]. Cardiologists consult with V23 [Cardiologist]. R3's [DATE] at 10:35 am V10 [ Nurse Practitioner] progress note documents: No weight changes. Weight 219.0. R3's plan-Pulmonary function test, pulmonary consult, and cardiology consult. R3's [DATE] at 18:50 (6:50 pm) V11 [Former Licensed Practical Nurse] progress note: Per V3 [R3's Family Member] R3 has swelling to his abdomen. Upon assessment R3 has distended abdomen that feels ridged and hard. Writer spoke with MD orders for stat x ray (as soon as possible) of R3's abdomen and D5 with ,d+[DATE] normal saline @80 ml/hr. for 48 hours continuous. Orders for stat CBC, BMP. Orders noted and carried out. R3's [DATE] R3's stat abdominal Xray was completed on [DATE]. Resulted on [DATE] at 21:06 (9:06 pm). Findings: Difficult evaluation. [Results was not relay to physician] R3's [DATE] at 9:19 am V10 [Nurse Practitioner] progress note: No weight changes noted. Weight is 236.2 [On [DATE] V10 documented R3's weight 219.0. R3 gained 17.2 pounds in 9 days, however V10 did not notice the weight gain and documented no weight gain] Plan: Pulmonary function test, pulmonary consult, and cardiology consult. R3's [DATE]- V9 [Nurse Practitioner] progress note: The resident is being evaluated today due to reports of abdominal firmness. The onset of the firmness is not clear. According to the nurse on duty, the resident's abdomen is less firm than it was the previous day. The resident reports no pain upon palpation, a complete stat abdominal ultrasound has been ordered. [Stat Ultrasound results was not relayed to V9] R3's [DATE] 13:42 (1:42 pm) Dietary Progress Note documents: NUTRITION: RD Review (Skin, Weight), Weight(s): 236.2 lbs. (,d+[DATE]), 219 lbs. (,d+[DATE]) Weight Change: Up 17.2 lbs. (7.9%) in 1 month. Weight is up in past 1 month. No edema, per provider note, ,d+[DATE]. /Plan: Monitor weight, PO intake, skin updates. RD available, as needed WEIGHT WARNING. [Physician was not notified] R3's [DATE] at 19:05 (7:05 pm) V18 [Physician] progress note documents: No weight changes. R3's weight is 236.2 pounds. [ V18 progress note on [DATE] at 20:03 R3 had no weight change, weight is 219.0. From last visit on [DATE] to [DATE] R3 gained 17.2 pounds]. Plan is for R3 to have a pulmonary function test, and pulmonary consult with V21 [Pulmonologist]. [V18] also provided V21's phone number in the note], nephrology consult, and cardiology consult. [V18 failed to address 17.2-pound weight gain.] R3's abdominal ultrasound was completed on [DATE] , resulted on [DATE] at 21:14 (9:14 pm) . Results were reviewed by V9 [Nurse Practitioner] on [DATE] at 21:14. [V9 stated she went on vacation and did not report the findings to anyone]. Findings: Large amount of ascites. [V9 did not document on R3's ultrasound report findings. No progress note documented the abdominal ultrasound was relay to the physician by nursing staff nor no documentation the test was addressed by any physician, or nurse practitioner]. R3's [DATE] at 13:57 (1:57 pm) V22 [Nurse Practitioner] progress note: No weight changes. R3's weight 219.0 [R3's clinical record document [DATE] weight of 236.2] Pulmonary function test, pulmonary consult, and cardiology consult. [V22 documented the weight gain, failed to address the weight gain] R3's [DATE] at 10:45 am V10 [Nurse Practitioner] progress note: No weight changes noted. Weight is 236.2. Plan: Pulmonary function test, pulmonary consult, and cardiology consult. R3's [DATE] [no time documented] V9 [Nurse Practitioner] progress note stated: On [DATE] The resident is being evaluated for their 30-day follow-up today. They are alert and oriented to both person and place. Vital signs have remained stable. The nurse reports that the patient is compliant with medication and exhibits no new behaviors. Assistance is needed with activities of daily living (ADLs) and mobility. The resident has been stable since the initial assessment, with no falls or new wounds in the past 30 days. They deny experiencing fevers, chills, headaches, dizziness, chest pain, shortness of breath, nausea, vomiting, diarrhea, or constipation. No signs of acute distress are observed. [Upon V9 return back to work, V9 failed to address known, ultrasound results that showed large amount of ascites dated [DATE] that she reviewed while on vacation.] R3's [DATE] 06:21 pm V18 [Physician] progress note documents: No weight changes. R3's weight is 236.2 pounds. Plan is for R3 to have a pulmonary function test, and pulmonary consult with V21 [Pulmonologist]. [V18 also provided V21's phone number in the note], nephrology consult, and cardiology consult. [V18 documented the weight gain and failed to address] R3's [DATE] at 10:25 am V10 [Nurse Practitioner] progress note: No weight changes noted. Weight is 238.2. [V10 note dated [DATE] note R3 weight at 236.2. R3 weight increased by 2 pounds. Plan: Pulmonary function test, pulmonary consult, and cardiology consult. [V10 documented the known weight increase and failed to address] R3's [DATE] 19:42 (7:42 pm) V12 [Registered Dietitian] Dietary Progress Note documents: NUTRITION: RD Review (Skin, Weight) Weight(s): 238.2 lbs. (,d+[DATE]), 236.2 lbs. (,d+[DATE]), 219 lbs. (,d+[DATE]). Weight Change: Up 19.2 lbs. (8.8%) in 2 months. Weight is up in past 2 months No edema, per provider note, ,d+[DATE]. Weight fluctuations may be anticipated with diuretic therapy. R3's [DATE] at 13:59 (1:59 pm) V10 [Nurse Practitioner] progress note documents: No weight changes noted. Weight is 238.2. Plan-Echocardiogram, BNP monthly, cardiology consult, renal ultrasound, Pulmonary function test, and pulmonary consult. [V10 documented a weight increase and failed to address] R3's [DATE] [no time documented] V9 [Nurse Practitioner] progress note stated: Resident is being evaluated today for reports of increased weakness. Resident noted A/Ox2 (Self and location). Resident assessed in privacy of bedroom with [V3/R3's Family Member] at bedside. R3 noted with generalized edema. CBC, CMP, BNP ordered stat. Denies any fevers, chills, headache, dizziness, chest pain, SOB, nausea, vomiting, diarrhea, constipation. No acute distress noted at this time. [Stat Labs were collected [DATE] at 14:45 (2:45 pm) . Labs resulted on [DATE] at 19:39 [7:39 PM]. Labs was reviewed [DATE] at 11:16 AM by V9 [Nurse Practitioner] approximately 12 hours later, R3's labs were reviewed by V9 [Nurse Practitioner] R3 labs: Elevated potassium at 6.0, BUN at 128, creatinine at 7.0, and an eGFR of 7, indicating critical lab values. [R3 now exhibits lab findings consistent with stage 5 CKD or renal failure.] R3 's [DATE] Hospital emergency department record shows: R3 entered the emergency department very weak, massively volume overload, worsening kidney function, pulmonary edema, respiratory failure, and hypotension. Per R3's daughter, R3 has been more confused over the past several days. Left leg edema progressive over the past week. Vital signs with hypotension, bradycardia, and left lower leg edema on arrival. Concern for cardiogenic shock. Nephrology to admit R3 to the intensive care unit and place a line for hemodialysis. admitted to intensive care unit for further care. (R3 was admitted to the hospital on [DATE] at 1:02 pm) Nephrology was consulted and recommended dialysis and admission to the intensive care unit. Likely cardiorenal syndrome in acute renal failure, line to be placed by intensive care unit team for emergent dialysis. Interviews: On [DATE] at 10:13 AM, V3 [R3's Family Member] stated, I noticed around the end of July, prior to R3 being sent out the end of August, that something was wrong, and he had swelling all over his body. I told the V11 [Licensed Practical Nurse] that R3's stomach was hard and swollen. V11 called R3's physician and he ordered labs, stomach x-ray, and intravenous fluids. The nurses told me the R3 was fine, he was dehydrated and needed the fluids. I trusted they were telling me the truth, because R3 had no other symptoms during that time, the end of July. The nursing staff and nurse practitioners kept telling me it was R3's congested heart failure and refused to send him to the hospital. On [DATE], I came to visit R3, and he could not speak, R3 always could talk. He was closing his eyes, and making sounds, but I could not understand one word coming out of his mouth, and he was really swollen in his arms, legs and abdomen area, the edema was worse. I asked V24 [Agency Licensed Practical Nurse] has R3 been like this all day, V24 said yes, and he just thought R3 was very tired. I told V24 this was not R3's normal state, something is wrong with R3, and go get some one that can help. V9 [Nurse Practitioner] came to see R3. V9 told me she would order stat labs and they should be back today to make sure R3 is okay. I asked V9 if R3 should be sent to the hospital, V9 told me she wanted to wait a few hours on the lab results. I explained I was concerned because R3 was very swollen, cannot speak, and keept closing and opening his eye. The nurse practitioner told me she would order labs stat. However, no one called me with the results on [DATE]. The next afternoon on [DATE], V24 nurse called me and said they was sending R3 to the hospital due abnormal labs related to his kidney function. I believe no one followed up on his labs, V9 told me the results would come in a few hours. I feel the facility did not listen to me or cared about R3; they should have done something to help him about four weeks ago when he first started swelling up all over his body. I was the only one who noticed his edema and change in mental status, I am afraid if I did not demand for someone to see him on [DATE], he would have died in the facility. The facility never scheduled any of his important appointments with the Nephrologist, Cardiologist, or Pulmonogist to manage his health conditions, they were responsible to schedule all R3's appointments. R3 arrived in the emergency department and R3 was admitted to the intensive care unit to start a line for emergency hemodialysis. Now R3 needs hemodialysis three times per week, because of the facility's neglect. [R3's family member [V3] noticed change of condition, facility staff did not] On [DATE] at 1:56 PM, V15 [Appointment Scheduler/Central Supply] stated, I knew about R3's appointments and consults that needed to be scheduled. I received R3's first order dated for [DATE] from V33 [Licensed Practical Nurse]. According to my notes, R3 had additional orders for nephrology, pulmonary, cardiology and pulmonary test ordered, the appointments was not scheduled. I did not schedule R3's consult appointments, I believe it was due to his insurance, I am not sure. I did not notify V2 [Director of Nursing] or the any staff nurse that his appointments was not scheduled, I really cannot remember the reason I did not schedule R3 appointments. On [DATE] at 1:04 PM, V11 [Former Licensed Practical Nurse] stated, On [DATE], R3 appeared to look swollen, but he had edema in his legs and arms for a couple of weeks. Other than R3 being swollen he was stable, he was not experiencing any nausea, vomiting, diarrhea, he ate his meals. Around 6PM, R3's family member [V3] was concerned that R3's abdomen was swollen. During my assessment I noted his abdomen was swollen and hard. The swollen abdomen was new that V3 [R3's Family Member] had noticed. I called V2 [Director of Nursing] for V17 [Medical Director] direct phone number, because I was having difficulties getting in contact with V17. V2 gave me his number, and V2 was made aware of R3' swollen abdomen, she did not ask me any questions regarding R3's condition. I spoke with V17 and explained R3 has distended abdomen that feels ridged and hard and have no other symptoms. V17 gave orders for stat x ray of R3's abdomen and intravenous D5.45 normal saline [Dextrose 5% and 0.45% sodium Chloride] @80 ml/hour for 48 hours continuous. Orders also received for stat CBC, BMP. Orders noted and carried out. I did not see the results of the labs because I got off work at 7PM. Once the results are completed the nurse can see the results on the computer system's dashboard and or under the resident's name in the results tab. I gave report to V31 [[Licensed Practical Nurse] to check for R3's labs and test results and to call V17 with the results. V31 said she understood and will call V17. I documented V17 orders, I did obtain nor document any vital signs, V17 did not ask about R3's vital signs because I would have obtained them and documented. R3 seemed to be relaxed and not in distress. [R3's family member [V3] identified R3's change of condition, facility staff did not recognize R3's swelling] On [DATE] at 3:38 PM, V31 [Former Licensed Practical Nurse] stated, I worked with R3 on [DATE], from 7PM to 7:30 AM. I received in report from V11[ Licensed Practical Nurse] earlier that R3 family observed R3 with a hard distended abdomen and V17 [Medical Director/R3's Physician] ordered intravenous fluids, I assumed it was for dehydration, I really did not know the exact reason. Also, R3 was ordered stat labs and stat diagnostic x ray of his abdomen, and for me to call V17 with the results. After report, I logged onto the computer system, the dashboard shows all the labs that needs to be relayed. I checked for R3 labs and abdomen x ray, but they were not posted. I remember, at the start of my shift the IV company came and inserted a picc line in R3's arm, and I started his fluids right away. R3 was alert and oriented x3, speaking to me, he looked stable, I did not take his vital signs. I got busy during my shift and did not check the dashboard or R3's chart [results tab] for his stat lab results. [Family observed R3's change of condition, V31 did not address R3's labs] On [DATE] at 3:14 PM V16 [Licensed Practical Nurse] stated, I worked with R3 on [DATE] for day shift [7am-7pm]. I remember administrating intravenous [IV] fluids to R3 for dehydration. There is usually a nurse practitioner in the facility, and they review and address the labs. The labs are available on the computer system dashboard, and under each resident result tab, but I did not review labs for R3, I did not know he had stat labs ordered on [DATE]. On [DATE] at 3:20 PM, V8 [Registered Nurse] stated, I worked with R3 on [DATE] and [DATE] from 7pm to 7am night shift and I did administer R3 IV fluids for dehydration. All resident labs appear on the computer system dashboard and under each resident chart. I did not check the system dashboard for any labs that was not relayed, because the day shift nurse usually takes care of the labs, not the night nurses. I did not check for R3's labs. On [DATE] at 10:24 AM, V9 [Nurse Practitioner] stated, I been working here through an outside agency, I'm contracted through the facility. R3 was alert and oriented x3, able to make his needs known. R3 was admitted with the diagnosis of chronic kidney disease, congested heart failure, and prostate cancer. On [DATE], V11 [Licensed Practical Nurse] alerted me that she received orders on [DATE] for abdominal Xray and Intravenous fluids Dextrose 0.45% saline at 80ml/hour for 48-hours and now R3's family is concerns that his abdomen is swollen. I do not understand why R3 was ordered intravenous fluids, and he has a diagnosis of chronic kidney disease and congested heart failure, let make it clear, I did not order those fluids. I reviewed the abdominal Xray results showed scattered air in the colon, but difficult to evaluate. Due to the results not giving much information, I ordered a stat abdominal ultrasound, because he had edema in abdominal area and lower extremities. I never received a phone call from the nurses regarding R3's results. On [DATE] I reviewed R3 results remotely, and the results showed large amount out of ascites, marginally enlarged liver without abnormality, and mild dilation of the extrahepatic bile duct. After I reviewed the ultrasound results, on that day I was off and on vacation. I knew R3 was a low sodium diet, diuretics, and awaiting nephrology consult. At the bottom of the ultrasound report, the diagnostic company printed that the results were faxed over to V17 [Medical Director/R3's Physician] office. I did not notify V17 [Medical Director/R3's Physician], V18 [Physician], V10 [Nurse Practitioner], V2 [Director of Nursing] nor any nursing staff, I was out of town and on vacation. However, they all knew I was on vacation. [R3's Family Member [V3] identified R3's change of condition] On [DATE] at 1:44 PM V12 [Registered Dietitian] stated, I am contracted to work with the facility since [DATE]. I usually review the resident's chart online and make adjustments and recommendations based on the resident's clinical chart, I basically work remote. However, there is another dietitian that attends the weekly weight meeting, but we all collaborate on the resident's comprehensive health via phone and or email. During the weight meetings, nursing administration V2 [Director of Nursing] and V14 [Assistant Director of Nursing], are present as well, for any nursing issues that the dietitian is not made aware of or any acute changes that need to be addressed regarding nutrition, wounds or weight. On [DATE], I reviewed R3's chart online remotely, and noted there was a 17-pound weight increase. The oral intake log documented R3 had a good appetite. I also reviewed, V10 [Nurse Practitioner] progress note dated [DATE] at 09:19, V10's assessment notes there was no documentation of concern regarding R3' weight. The note documented no edema. V10 also documented, the weight of 236.0 pounds in her assessment note, with no concerns regarding R3's weight was noted. Once the medical provided did not express any concerns with R3 weight, and documented no edema, just the day before my review and R3 was on a no added salt diet, I did not change or add any new recommendations. The standard of care is that upon all new admissions and re-admissions the residents should be weighted weekly for four weeks then monthly if there's no concerns. R3 was admitted on [DATE] and weighed 219.0 pounds. The facility did not follow their weight protocol, R3's weight was not taken the weeks of [DATE] or [DATE], then R3 was admitted to the hospital on [DATE] and readmitted back on [DATE]. R3 weight was not taken on re-admission ([DATE]) and R3's weight was not taken during the weeks of [DATE], or [DATE]. Then on [DATE] R3's weight was taken at 236.2 pound. The facility nursing administration is made aware of all the weights and any recommendation, it is the nursing responsibility to notify physicians, nurse practitioners and family of weight changes. On [DATE] at 11:11AM, V14 [Assistant Director of Nursing] stated, I been working her since [DATE]. I do not see where the stat labs were addressed. I see that V9 [Nurse Practitioner] reviewed the stat labs on [DATE], because it is documented in the upper left corner of the lab. However, any provider and licensed staff is able to view any labs in the resident electronic chart under the result tab. The weight policy protocol is the restorative aides complete the weights for the facility. The restorative aides obtain the weights, they do not document the weights. Then they give the weights to me, and I review the resident previous weights. If there is a five-pound increase or decrease, in the resident's weight I have the resident re-weighed. Once the resident weight is confirmed, I would review the resident's medical diagnosis and call their physician and dietitian. R3's weight upon admission was 219.0 lbs. ([DATE]) [pounds], on [DATE] R3's weight was [236.2 pounds] verified on [DATE] [236.2 pounds]. R3's other weights were [DATE] [236.0 pounds], [DATE] [238.2 pounds], and on [DATE] [238.2 pounds]. I entered R3's weight for [DATE] and [DATE], but I did not look back at his previous weight, that was an oversight. V2 [Director of Nursing] was overseeing the resident's weight monitoring, I was only entering the weights into the resident's chart. When the physician or nurse practitioner give an order to monitor vital signs that mean blood pressure, heart rate, pulse, oxygen saturation percentage, respirations, and temperature. When there is a picc line inserted and intravenous fluids ordered, the nurses should closely monitor the resident condition, all vital signs, the picc line site, signs and symptoms of fluid overload and document in the resident progress notes. Any change in condition such as a change in vital signs, edema noted, or mental status change the physician or nurse practitioner should be notified immediately and documented in the resident's progress note. On [DATE] at 11:34 AM V2 [Director of Nursing] stated, R3's physician orders for needed appointments with nephrology, cardiology, and pulmonary, should've been scheduled, I am not sure. R3 went back to the hospital at the end of June to beginning of July. V15 [Appointment Scheduler/Central Supply] would know if the appointments were scheduled. My expectation is that soon as an order is placed for a consult or needed appointment, that V15 need to schedule the appointment soon as possible. The process to schedule an appointment is when the provider writes an order for a needed appointment, the nurse will place in the order and notify V15. I have not received any concerns from physicians or nurse practitioners that the orders for consult appointments was not being scheduled. If medical consult appointments are not scheduled, that does not mean a delay in treatment, because the resident is being managed here in the facility. I was not overseeing the resident weight. The former restorative nurse[V32] was responsible to oversee the weights. Weekly, the restorative nurse, [V32] dietician, assistant director of nursing, and I would meet and reviewed the weights, wounds, and gastric tube feeders which were the facility's nutritional at risk residents. I would write down any recommendations from the dietitian. If the dietician does not give any recommendation, then, there is nothing to report to the physician. The physicians and nurse practitioners are able to access the resident's complete chart while in the facility and remotely. All physicians and nurse practitioners are responsible to review the residents chart including the weights, I don't remember if R3 had a significant weight gain. All weights are documented in the resident's chart under the weight tab. If the dietitian did not have any recommendation for us to pass on to the physician, then it was nothing for us to report. If the dietician report recommendation for a significant weight increase or decrease, then the physician will be notified. I will check our significant weight change policy to see who is responsible for notifying the physician. I did not receive any information from nursing staff, providers or R3s' family that R3 was swollen all over his body. On [DATE], V11 [Former Licensed Practical Nurse] contacted me about R3's abdomen was only swollen and wanted V17 [Medical Director/R3's Physician] phone number. I did not discuss R3's weight gain with V11, I cannot remember every resident's weight. Again, the physician can access the resident's complete chart, and can review the dietician notes. My expectation of the staff nurses that receive an order for a stat labs or diagnostic test are to relay the results to the ordering provider soon as possible. The staff nurses should be on the lookout for the labs results to post on the facility's system dashboard. Again, the physicians or nurse practitioners should also follow up on their resident's stat orders they as well can check the dashboard remotely at any time. [Surveyor requested a copy of the facility's weight management policy] On [DATE] at 12:51 PM, V2 [Director of Nursing attended V30's interview] V30 [Restorative Aide] stated, I been working here for six months. I go around the facility and obtain the resident's weights, then I gave the weights to V32 [Former Restorative Nurse], and she would place them in the resident's electronic chart. I just found this paper with some of R3's weights written down. R3 was admitted on [DATE] and I took his weights on [DATE] R3 weighed 223.6 pounds, [DATE], 223.4 pounds, [DATE] 223.4 pounds, and on [DATE], R3 weighed 221.6 pounds. R3 came back from the hospital in July with the weight gain. I forgot to document all those weights in R3's electronic chart from June and [DATE]. Surveyor asked about R3's weight in the computer system documented his weight on [DATE], R3 weight was 219.0 pounds. V30 stated, I am not sure how R3 weighed 219.0 pounds on [DATE]. Surveyor asked V30 how she obtained R3's weight on [DATE], because he was still in the hospital, and R3 did not readmitted back into the facility until [DATE]. V30 stated, I don't know, I'm done, this is too much. V2 [Director of Nursing] stated, Give me the paper back. [Surveyor declined V2's request] V2 [Director of Nursing] stated, I spoke to fast, per my nurse consultant, the facility no longer have a policy on weight management, weight protocol, or significant weight loss. On [DATE] at 4:22 PM V32 [Former Restorative Nurse] stated, I worked at the facility for about six weeks. My last day was [DATE]. I was a part of the weight team. The facility weight policy was to weight the admissions weekly for four weeks then monthly. Most of the time that did not occur. Residents were not weighed weekly for four weeks. If a resident's weight showed a five-pound increase or decrease the restorative aide would re-weight the resident to make sure the weight was accurate. The restorative aids were not allowed to place in a resident's weight into the computer system. V2 [Director of Nursing], V14 [Assistant Director of Nursing], and I documented the weights in the resident's electronic chart. Weight was not kept or stored on sheets of paper. I attended the weekly weight meetings. The director of nursing [V2], assistant director of nursing, dietitian and I would attend the meeting. I remember R3, had a significant weight increase, review his weights, and notice R3's weight was taken a few times in just a few days to verify R3's weight. During the meetings V2 [Director of Nursing] would take notes on all the weight gains and weight loss. V2 was responsible to notify the physician of the resident's weight gain or loss, I was not responsible. On [DATE] t 12:15 PM, V10 [Nurse Practitioner] stated, When I exam any resident I first review the resident's chart, such as labs and test results as a standard practice. I had a visit with R3 on [DATE], R3 seemed to be doing well. I ordered for R3 to be scheduled to see Pulmonogist and to complete a pulmonary function test due to him having chronic obstructive pulmonary disease. On [DATE] I reordered the R3 to be scheduled to see Pulmonogist and to complete a pulmonary function test, because I did not see that the test or appointment was completed. I do not recall ordering the intravenous fluids for R3, I do not remember. If I order IV fluids, I would have documented as such. On [DATE] visit I documented no weight change and current weight was 219.0, on ,d+[DATE] I documented no weight change, and current weight was 219.0, on [DATE] I documented no weight change, and I documented in the same note R3's current weight wa [TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to follow their skin condition assessment policy to ensure three [R1, R2, R3] of three residents wound dressings were checked for placement, and cleanliness, and failed to complete wound care as prescribed for one [R1] resident. These failures resulted in R1 developing a stage II pressure wound on his left rear thigh, R2's wound increased in size, and R3 developed moisture associated dermatitis. Findings Include, R1's clinical record indicates in part; R1 was admitted with the medical diagnosis of heart failure, chronic obstructive pulmonary disease, schizoaffective disorder, reduced mobility, abnormal gait and mobility, lack of coordination, acquired absence of left leg below knee, and muscle weakness. R1's Minimum Data Set, dated dated dated [DATE], R1 is cognitively intact [scored 15], alert and oriented x3. R1's Weekly Skin Assessments document in part: Left back thigh facility acquired stage II pressure ulcer noted on 6/6/24. 6/6/24 measured 2.0 x 0.5 x 0.2 cm. 6/12/24 measured 1.7 x 0.5 x 0.1 cm. 6/19/24 left back thigh was healed. R1's Left back thigh re-opened back up on 8/7/24 measured 4.0 x 3.0 x 0.1 cm [centimeter]. On 8/14/24 measured 3.0 x 5.0 x 0.5 cm [wound size increased]. R1's Physician order: 8/28/24- Lt thigh rear: cleanse with normal saline. Apply collagen to site. cover with 4x4 foam dry. Three times per week and as needed. Everyday shift on Monday, Wednesday, and Friday. R1's ETAR [electronic treatment administration record] documented on 9/6/24, V5 [Wound care Nurse] documented [9- see nurse note]. No PRN [change as needed] order signed out from 9/4/24 to 9/9/24. R1's Progress note: Type: Skin/Wound Note 9/6/2024 11:06:44 Writer [V5] attempted to treat [R1]'s wound, (R1) begins to talk aggressive to writer, resident was not easily redirected and did not allow writer to do tx [wound care treatment] all parties made aware of refusal current plan of care on going. R1's ETAR (treatment record) indicated his wound care was completed on 9/4/24 [Wednesday]. R1's next treatment was due on 9/6/24 [Friday], wound care was not complete, nor on 9/7/24 [Saturday], and 9/8/4 [Sunday]. On 9/9/24 R1's ETAR indicates his wound care was completed. [R1 did not receive wound care for four [4] days] On 9/10/24 at 11:22 AM, V6 [Facility's Ombudsman] stated, I am the Ombudsman for this facility. On 9/9/24, R1 called my work cell phone early morning and asked me to please help him, that no one has changed his wound dressing since 9/4/24. R1 said he is supposed to receive wound care on every Monday, Wednesday, and Friday's, and he thinks his wound is infected. R1 said he had someone take a picture of his wound, and it looks horribly infected. R1 said that V5 [Wound Care Nurse] came to change his wound on 9/6/24 but had a very disrespectful mouth and they both had words. R1 said that V5 told him that he would not get his wound care. On 9/6/24, 9/7/24, and 9/8/24, R1 said he been asking the nursing to change his wound dressing, they all said no, the wound care nurse will change your dressing it's not my job and told him he is not due for a dressing change until Monday. I called the facility several times on 9/9/24, I was told V2 was unavailable due to her being in meetings. On 9/10/24, I continued to call V2 and did not receive any phone call back. Then I started emailing V2, with no respond back until this morning, after you [IDPH Surveyor] walked into the facility. I had to email the facility's corporate nurse for assistance. Today when I saw V2, I asked her, if she spoken to R1 regarding his wound care and V2, told me no. V2 said I did not have time because we have a surveyor in the facility. On 9/11/24 at 9:18 AM, R1 stated, I was supposed to receive wound care on every Monday, Wednesday, and Friday's, and my wound is infected. I had someone takes a picture of my wound, and it looks terrible. V5 [Wound Care Nurse] came to change my wound on 9/6/24 but she was disrespectful, with a big mouth running off with her words. Then I told V5 back off, so V5 told me that I would not get wound care. On 9/6/24, 9/7/24, and 9/8/24, I been asking the nursing to change my wound dressing, they all said no, the wound care nurse would change your dressing, it's not my job and told me it was not due for a dressing change until Monday. Whenever my dressing come off, I cannot get no one to put another dressing back on. The staff nurse will not touch my wound, they all say it is the wound care nurse's job, and I have to wait until the wound care nurse come in. Even when the wound care nurse come in the next day, the wound care nurse still doesn't come to place a dressing or help me, I been told I have to wait until the next time the dressing is due to be changed. I have to move around with an open wound on the back of my leg, leaking fluid and causing me pain, all the time. My wound only gets changed or a dressing placed three times per week. On 9/11/24 at 9:42 AM, surveyor observed R1's wound care with V28 [Wound Nurse Practitioner]. R1 did not have a dressing on his wound. R1 stated, The dressing has been off since yesterday evening. R1's wound was beefy red, no drainage, no four odors noted. V5 [Wound Care Nurse] was present during wound care. On 9/11/24 at 9:55 AM, V5 [Wound Care Nurse] stated, I will change the order from three times per week to daily wound change. When I tried to change R1's wound dressing on 9/6/24, he started speaking disrespectful to me, I told the staff nurse I did not complete his dressing change. I did not make any other attempts to complete R1 wound care. I did not notify the director of nursing or R1's physician. R2's Weekly Skin Assessment document in part: R2's clinical record indicates he is cognitively intact. Sacrum stage four wound, R2 was admitted with sacrum wound on 5/2023. 5/2023 measured 1.8 x 1.5x x 3.2 cm. 6/26/24 measured 1.5 x 1.0 x 2.4 cm 7/3/24 measured 1.5 x 1.0 x 2.4 cm 7/31/24 measured 2.0 x 1.0 x 2.0 cm 8/7/24 measured 2.0 x 1.0 x 2.2 cm [R2's wound size increased] R2's Physician order: 1/3/24-Sacral wound cleanse with normal saline medihoney then cover with calcium alginate then cover with dry dressing only use metro cream for contamination daily and as needed for wound care. On 9/11/24 at 8:10 AM, R2 stated, I have not been changed all night. I am soaked with urine and feces; and this happens all the time. I have a wound on my butt, and my wound needs to stay covered and cleaned. My dressing came off and none of the nurses would clean my wound a put another dressing on me, they all told me to wait until the treatment nurse come in today. The urine and feces burn like hell in my wound. I had this wound for years since I been here, this is why my wound will not heal. On 9/11/24 at 8:15 AM, surveyor observed V26 [Certified Nurse Assistant] complete incontinence care for R2's. V26 and surveyor observed R2's under brief soak with urine that leaked out on to the fitted sheet. Once V26 turned R2 over his buttocks area wound was uncovered. There was not wound dressing on the wound, in the under brief, or bed. There was an open wound hole with white crumbs all over his buttocks and inside his wound. V26 stated, The white crumbs are the under brief disintegrating from being soaked with urine for so long the under brief is falling apart. I have to go to the laundry department for more towels and linen, I'll be back in a few minutes. On 9/11/24 at 8:20 AM, surveyor observed R2's wound care with V28 [Wound Nurse Practitioner. V28 cleaned the area and also applied metro cream. V28 stated, The metro cream to help prevent the wound from being contaminated with urine and feces to help prevent infection. R2 tells me his dressing comes off at times due to feces and urine, so the metro cream will help the wound from developing an infection. R3's Weekly Skin Assessment document in part: R3's clinical record indicates he is cognitively intact. 9/11/24-perineal, scrotum, bilateral inner thighs have moisture associated dermatitis, redness and excoriation with red patches [no measurements] Sacrum unstageable wound measures 1.0 x 1.0 x 0.4 [This assessment was completed 9/11/24 at 16:19, surveyor observed resident in bowel movement at 7:45 AM] R3's clinical record Minimum data set, brief interview mental status indicates R3 is alert and oriented X3, he is cognitively intact. On 9/11/24 at 7:22AM, surveyor heard R3 yelling out for help. Surveyor entered R3's room and observed R3 resting in bed, alert and orientated. R3 stated, Help me, no one have cleaned me up all night long and this bowel movement is eating me up all over my a**, it is itching and burning so bad. On 9/11/24 at 7:38 AM, V7 [Certified Nurse Assistant] and surveyor observed R3's incontinence care. Observed R3's under brief filled with feces and urine. The feces and urine were leaking out onto the incontinence pad with four brown colored circle rings. Observed R3 with redden small open superficial arear to peri area, groin, and buttocks. V7 stated, I will go get the night nurse, R3 was not changed at all last night, the night nurse needs to see this. On 9/11/24 at 7:45 AM, V8 [Registered Nurse] stated, I saw the night certified assistant enter into this room to clean R3 up. The night certified assistant did not touch him at all. I am going to discipline her. I am so sorry. I am not sure why R3 do not have a dressing on his wound. I will replace the dressing. V7 stated, I will clean R3 up right now, I need to go get more bath towel to soak off the dried feces. R3's progress note dated 9/11/24 at 16:19 V20 [Wound Nurse] document in part: R3 is alert and orientedx3. With open areas to the sacrum, moisture associated dermatitis to perineal area, scrotum, and bilateral thighs. [Noted after 7:45 AM observation] On 9/17/24 at 1:03 PM, V4 [Wound Care Coordinator] stated, Moister associated dermatitis is causes by excessive moisture, from being wet too long. If a resident is not provided timely incontinent care, it could potentially cause moister associated dermatitis. R3 was admitted on [DATE] and his skin admission assessment did not note any moister associated dermatitis on R3's peri area. On 9/11/24, R3's skin assessment was completed by the wound team and moister associated dermatitis was noted. On 9/10/24 at 3:00 PM V4 [Wound Care Coordinator] stated, I have been the wound care coordinator her for three years. The Wound Detail report information is inputted by the wound care nurse practitioner. Under the subtitle 'Acquired at Facility' means the wound developed while the resident was in the facility. I see on the report the answer is 'no' for all resident on the report. I am not sure why the report reflexes 'no' for all residents. There are some residents that did in fact acquire or develop a wound while in the facility. I did not notice that when I gave you the report, the report is not accurate. On the report I provided, I wrote (FA) which means facility acquired, (A) which means the resident was admitted to the facility with the wound. There are two other treatment nurses, we are here daily to complete wound care. After we leave for the day, the staff nurse is capable of changing a wound dressing as needed. The wound team stagger the schedule, so we have a wound nurse in the facility on the weekends as well. Whenever a wound dressing comes off the staff floor nurse should replace the dressing to promote healing and prevent infection. On 9/6/24 when R1 and V4 was not getting along, and V4 told the staff nurses that R1's dressing was not completed. Then the floor staff nurses should have made attempts to change his dressing and document the attempts. If a dressing is not clean, changed or the dressing is not replaced, it could potentially cause a wound infection or worsening of the wound. On 9/11/24 at 11:10 AM, V28 [Wound Care Nurse Practitioner] stated, If the resident does not receive wound care treatments as ordered, it could potentially cause an infection, worsen the wound, or could stop the healing process. If the resident is not receiving timely proper incontinence care, it could potentially cause skin excoriation from the moisture, cause a wound, make a wound worse or cause an infection. All wound treatment orders also have a change wound dressing as needed order, so any licensed nurse should be able to apply the wound dressing to protect the wound. On 9/12/24 at 4:20 PM, V14 [Assistant Director of Nursing] stated, I have not received any concerns that R1 concerns that his wound was infected. I recently seen R1's wound, because he needed a dressing change. I saw the wound, and the wound was not infected no odor, and discharge, he had no signs or symptoms of infection was noted. If a wound dressing comes off or need changing the staff floor nurse should complete wound care and sign it out on the electronic treatment administration record [ETAR] immediately after completing the treatment. If there is no signature in the ETAR, then the treatment was not completed. If a resident refuses a wound care treatment, the staff nurse should make multiple attempts, if not successful then call the physician to receive new orders. Also, the nurse can educate the resident the importance of wound care. If a bandage is not change or covered as prescribed, it could potentially cause an infection, or the wound could worsen. On 9/12/24 at 4:38 PM, V2 [Director of Nursing] stated, If a resident refused his wound care, it is his right to refuse, we cannot make him. It is not the other staff nurse's responsibility to complete wound care, after it was already offered, V5 offered R1 wound care on Friday, and he refused. I do not expect the other weekend nurses assigned to R1 to complete his wound care from Friday. R1 can not expect his wound treatment to be completed whenever he decides he wants it. R1 received wound care on Monday, 9/10/24 which was his scheduled next day for wound care. I did not receive any emails from V6 [Ombudsman] regarding R1 until this morning, and I responded. The other staff nurses did not have to make attempts to change R1's wound. The staff nurses said that R1 did not ask for a wound change over the weekend. If there is no signature on the electronic treatment record, it does not mean the treatment was not completed, it just means the nurse forgot to sign out the treatment, as nurses we have the right to forget to document. The standard of care is once you administer medication or a treatment the nurse should sign out on the resident's electronic mediation or treatment administration record at that time, but the nurse has the right to forget to sign. I have not found any nurse that worked the weekend say they completed R1's wound care. If a wound is not changed as ordered or a dressing is not on the wound, it could or could not make the wound worsen. R1's wound is not infected according to the wound care nurse practitioner notes, and there is not documentation from the wound care team that states R1 wound is or was infected. Policy documented in part: Skin Condition Assessment and Monitoring -Pressure and Non-Pressure dated 2/14/23. -Assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions, and assuring interventions are implemented. -Each resident will be observed for skin breakdown daily during care from the certified nurse assistant and unit nurse. -Dressings which are applied to pressure ulcers, skin tears, wound lesions or incisions shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness, and signs of infection. -Physician ordered treatments shall be initialed by the staff on the electronic treatment administration record after each administration. -A licensed nurse shall observe the condition of wound daily or with dressing changes as ordered.

Based on observations, interviews, and record reviews the facility failed to provide ADL (Activity of Daily Living) care to residents who are dependent on staff assistance with ADL's. This failure affected 3 [R2, R3, R4] of three residents reviewed for incontinence care and personal hygiene. This failure resulted in R2 feeling the urine and feces burning in R2's wound, R3 feeling itching and burning due to delayed care and R4 not receiving incontinence care for 12 hours and which resulted in R4 itching and scratching all night from urine. Findings Include, R2's clinical record indicates in part; R2's medical diagnosis was muscle wasting, paraplegia, and major depressive disorder. Minimum Data set [MDS] Section [C] dated 8/6/24, Brief interview mental status scored [15], indicates R2 is cognitively intact. MDS section GG dated 8/6/24 indicates R2 is dependent for activities of daily living [ADL] care, toileting, bathing, and transferring. R2's care plan dated 6/13/22, document in part, R2 has a self-care deficit and require total assistance with for activities of daily living [ADL] care. On 9/11/24 at 8:10 AM, R2 stated, I have not been changed all night. I am soaked with urine and feces; and this happens all the time. I have a wound on my butt, and my wound needs to stay clean, the urine and feces burn like hell in my wound. I had this wound for years since I been here, this is why my wound will not heal because I sit in urine and feces. On 9/11/24 at 8:15 AM, surveyor observed V26 [Certified Nurse Assistant] complete incontinence care for R2's. V26 and surveyor observed R2's under brief soaked with urine that leaked out on to the fitted sheet. There were crumbs all over his buttocks. V26 stated, The white crumbs are the under brief disintegrating from being soaked with urine for so long the under brief is falling apart. On 9/11/24 at 8:20 AM, surveyor observed R2's wound care with V28 [Wound Nurse Practitioner. V28 cleaned the area and also applied metro cream. V28 stated, The metro cream to help prevent the wound from being contaminated with urine and feces to help prevent infection. R2 tells me his dressing comes off at times due to feces and urine, so the metro cream will help the wound from developing an infection. Incontinence care need to be provided timely to prevent contamination. R4's clinical record indicates in part; R4 was admitted with hemiplegia and hemiparesis, flaccid hemiplegia affective left side, and essential hypertension. MDS section [C] dated 7/22/24, Brief interview mental status scored [13], indicates R4 is cognitively intact. MDS section GG dated 7/22/24, indicates R4 is dependent for activities of daily living [ADL] care, toileting, bathing, and transferring. R4's care plan dated 7/22/24, document in part, R4 has a self-care deficit and require total assistance with for activities of daily living [ADL] care. On 9/11/24 at 8:40 AM, R4 stated, I am soaked with urine. I have not been changed since yesterday around 9PM. My fingernails are nasty, because I been itching and scratching all night from the urine eating at my skin. I am so nasty. I been asking to get a shower for the last couple of days. I'm treated like a dog. R3's clinical record indicates in part; R3 was admitted with medical diagnosis of weakness, reduced mobility, abnormal gait and mobility, essential hypertension, and limitation of activities due to disability. MDS section [C] dated 7/17/24, Brief interview mental status scored [8], indicates R3 is mildly cognitively impaired MDS section GG dated 7/17/24, indicates R3 is dependent for activities of daily living [ADL] care, toileting, bathing, and transferring. On 9/11/24 at 7:22AM, surveyor heard R3 yelling out for help. Surveyor entered R3's room and observed R3 resting in bed, alert and orientated. R3 stated, Help me, no one has cleaned me up all night long and this bowel movement is eating me up all over my a**, it is itching and burning so bad. On 9/11/24 at 7:38 AM, V7 [Certified Nurse Assistant] and surveyor observed R3's incontinence care. Observed R3's under brief filled with feces and urine. The feces and urine were leaking out onto the incontinence pad with four brown colored circle rings. V7 stated, I will go get the night nurse, R3 was not changed at all last night, the night nurse needs to see this. On 9/11/24 at 7:45 AM, V8 [Registered Nurse] stated, I saw the night certified assistant enter into this room to clean R3 up. The night certified assistant did not touch him at all. I am going to discipline her. I am so sorry. On 9/12/24 at 3:33 PM, V14 [Assisted Director of Nursing] stated, I started in serving nursing staff on ADL care, and once they come on the floor to complete rounds and if anyone is soiled the certified nurse assistant from the previous shift will be disciplined. Incontinence care rounds should at least be made every two hours. On 9/12/24 at 4:05 PM, V2 [Director of Nursing] stated, All nursing staff should make rounds every two hours to provide incontinence care. The nurse should make rounds to ensure incontinent care is being provided. If incontinent care is not being provided timely, it could potentially cause skin issues and infection. Reviewed Facility's resident council: 4/9/24- Resident said she was sitting in feces for over two hours. 4/26/24- Family member concerned that resident was not receiving proper incontinent care throughout night shift. 4/13/24 Resident complaint, she did not have her call light for two hours, could not call for assistance. Reviewed Facility's resident council minutes: 8/18/24 resident said they have to wait a long time for call light response to receive assistance. Policy documents in part: Guidelines for incontinence care date 9/21/23 -Ensure that residents received as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care. Frequent minimal every two hours checks as well as care planning.

Based on interview and record review, the facility failed to prevent a fall by not implementing effective fall interventions for residents (R5, R6) who were at risk for fall and with history of falling and failed to supervise (R16) from smoking while oxygen is in use. The facility failed to ensure that resident (R7) was assessed by nurse before moving / transferring back to bed, facility failed to follow facility policy and procedutes and failied to follow residents care plans. These failures resulted in (R5) sustaining an lumbar compression fracture, (R6) sustaining acute subdural hematoma. These failures affected 4 (R5, R6, R7,R16) out of 4 residents reviewed for resident safety / falls/supervision. Findings include: 1. R5 health record documented initial admitted [DATE] with diagnosis not limited to Fracture of nasal bones, End stage renal disease, Unspecified systolic (congestive) heart failure, Weakness, Unspecified abnormalities of gait and mobility, Unspecified dementia, Other lack of coordination, Cerebral infarction, Hypoglycemia, Unspecified atrial fibrillation, Anemia, Essential (primary) hypertension, Low vision left eye, Hyperparathyroidism. On 11/29/23 at 10:35 am Observed R5 sitting up on wheelchair by her bed, appears comfortable, well groomed, alert, and oriented to time, place, person, and situation, verbally responsive. R5 able to recall the fall incident on 10/5/23, stated that she got up from bed to go to the bathroom. Stated that she called the staff using the call light, but nobody was answering and wanted to urinate badly, so she got up and went to the bathroom. Stated that after using the bathroom she walked back to her room but slid and next thing she knew she was sitting on the floor. Stated that she used to ambulate, she was not wearing non-skid footwear and she was barefooted at the time of the fall incident. Stated that in the hospital it was found out that she had a fracture in the lumbar area / tailbone. Stated that she is still having on and off pain especially when she is sitting for a long period of time. On 11/30/23 at 9:41 am V27 (R5's Nurse Practitioner) stated that he recalled R5 fall incident on 10/5/23. Stated that the nurse called him regarding the incident. Stated that R5 had refused to go to the hospital after the fall incident but the next day she agreed to be transferred to the hospital due to severe back pain. Stated that R5 Compression fracture was most likely from the fall. Stated that R5 is not totally immobile and is able to get out from bed. Stated that R5 was not wearing a non-skid footwear / barefooted at the time of the fall incident can be a contributing factor of the fall. Stated not able to rule out the cause of the fall as it was an unwitnessed incident. At 12:32 pm V31 (LPN, former employee) was interviewed via phone and said that around 1st week of November she left the facility. Stated that she knew R5 and was able to remember the fall incident on 10/5/23. Stated that R5 got up from bed without calling for assistance. Stated that R5 wanted to go to the bathroom. Stated that R5 was identified as a fall risk. Stated that fall could have been prevented if R5 room was closer to the nurse's station, frequent rounding and more number of staff in the facility to closely check or monitor R5 whereabouts and to attend to R5 needs. Stated unable to remember if R5 was wearing a non-skid footwear or barefooted on 10/5/23 fall incident. R5 nursing Progress Note dated 10/5/2023 documented in part: Resident was observed on hallway floor outside of room. R5 Fall Risk Review assessment with signed date of 10/9/23 documented in part: Score: 12 (High Risk for Falls). Assessment showed that R5 had a history of fall in the last 3 months. R5 fall risk assessment dated [DATE] indicated a total score of 19 (high risk for falls). R5 Physician Progress Note dated 10/16/2023 documented in part: a long-term resident of the facility was sent to hospital with a fall. The patient was evaluated in the ER. X-ray to lumbar spine showed L1 compression fracture. R5 Care plan dated 10/6/23 documented in part: R5 has had an actual fall related to unsteady gait. Care plan interventions included but not limited to: Ensure non-skid footwear is in place and available. Monitor whereabouts and provide redirection/education as needed. MDS (Minimum Data Set) dated 7/14/2023 showed that R5's cognition was moderately impaired. R5 needed extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, personal hygiene, toilet use; Supervision with eating, walk in room and corridor. MDS showed that R5 used walker. MDS indicated that R5 was frequently incontinent of bowel and bladder. 2. R6 health record documented initial admitted [DATE] with diagnosis not limited to Nontraumatic subdural hemorrhage, Paranoid schizophrenia, Other lack of coordination, Parkinsonism, Depression, Hypoxemia, Primary osteoarthritis, Dysphagia oropharyngeal phase, Acute kidney failure, Metabolic encephalopathy, Unspecified abnormalities of gait and mobility, Insomnia, Weakness, Respiratory failure, Unspecified injury of head, History of falling, Syncope and collapse, Difficulty in walking, not elsewhere classified, Bilateral primary osteoarthritis of first carpometacarpal joints, Muscle weakness (generalized), Dysphagia oral phase, Gastro-esophageal reflux disease without esophagitis, Other secondary, hypertension, Dementia in other diseases classified elsewhere, Schizophrenia. On 11/28/23 at 11:01am Observed R6 sitting up on wheelchair in the dining / day room, Alert and verbally responsive with confusion. R6 unable to recall / verbalize any fall incident. At 9:57 am V28 (CNA) said that she remembered R6 fall incident on 9/10/23. Stated that R6 was found sitting on the floor in another resident's room. Stated that R6 used to ambulate with walker and roam around the unit or another resident's room. Stated that she was not aware that R6 was a fall risk. Stated no fall preventions implemented prior to R6 fall incident on 9/10/23 because R6 was not a fall risk. Stated that if R6 was identified as a fall risk, closely monitoring and frequent redirection could have been done. Stated that R6 could have a 1:1 but staff is also busy attending with other residents and providing care. R6 Fall Risk Review assessment with signed date of 9/10/23 documented in part: Score: 11 (High Risk for Falls). Fall Risk Review assessment dated [DATE] indicated a total score of 10 (High Risk for Falls). R6 Nursing Progress Notes dated 9/10/2023 documented in part: resident was found sitting on the floor in another resident's room. R6 escorted to her room, observed little laceration to upper right eye, bleeding noted. R6 hospital records dated 9/10/23 (Hospitalist History and Physical) documented in part: Patient is a nursing home resident where she tripped and had a fall hitting her head on the ground. Patient has a small laceration on her right eyebrow no active bleeding. CT (computerized tomography) head revealed small acute subdural hematoma overlying the left lobe and left frontal and anterior temporal areas up to 5 mm (millimeter) in thickness. R6 Physician Progress Note dated 9/25/2023 documented in part: long term resident of the facility. The patient was sent to Hospital ER (emergency room ) on 09/10/2023 for evaluation due to an unwitnessed fall. CT of head revealed small acute subdural hematoma overlying the left lobe and left frontal and anterior temple area up to 5 mm in thickness with no evidence of mass effect or midline shift. R6 Care plan dated 06/28/22 documented in part: At Risk for Falls. Care plan interventions included but not limited to: Frequent rounding on resident for safety. Nursing Staff will complete a Fall Risk Assessment per Facility Fall Protocol. Follow the facility Fall Protocol. MDS dated [DATE] showed that R6's cognition was severely impaired. R6 needed extensive assistance with bed mobility, transfer, walk in room and corridor, locomotion on unit, dressing, toilet use and personal hygiene; Limited assistance with locomotion off unit, eating. MDS showed that R6 used wheelchair. MDS indicated that R6 was always incontinent of bowel and bladder. 3. R7 health record documented initial admitted [DATE] with diagnosis not limited to Muscle wasting and atrophy, Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Heart failure, Congestive heart failure, Weakness, Personal history of covid-19, Contracture, Other specified anemias, Vitamin d deficiency, Essential (primary) hypertension, Type 2 diabetes mellitus without complications, Atherosclerotic heart disease of native coronary artery without angina pectoris, Hyperlipidemia, Major depressive disorder, Benign prostatic hyperplasia without lower urinary tract symptoms. At 12:03 pm V23 (LPN/Licensed Practical Nurse) stated that she was able to remember R7 fall incident on 9/28/23. Stated that when did her rounding, saw 2 CNAs attending R7 in bed. Stated that one of the CNAs said that resident fell on the floor and was transferred back to bed without informing her. Stated that she told the CNAs that they are not supposed to move the resident until seen or assessed by the nurse. Stated that she was very upset with the CNAs because R7 was transferred back to bed without informing the nurse to assess R7. Stated that she informed the DON about the incident and CNAs were in serviced or educated to never move a resident until a nurse assesses the resident after a fall incident. At 12:17 pm V24 (CNA/Certified Nursing Assistant) stated that she was the assigned CNA to R7 on 9/28/23 fall incident. Stated that during making rounds, R7 was on the side of the bed in sitting position with another CNA (V29). Stated that they both assisted R7 back to bed x 2 staff assist. Stated that she was not the one who first saw R7 sitting on the floor. Stated that she did not initiate the transfer of the resident. Stated that she was not aware that V29 did not inform the nurse yet about the fall incident. Stated that facility's fall protocol is to leave the resident and call the nurse to check / assess on the resident before moving / transferring the resident. Stated that she was disciplined / written up because of the fall incident. Stated that if resident was moved / transferred after a fall incident without informing the nurse first, the resident could have a broken bone or injury that CNA don't know of, and it could trigger another injury or worsen the injury. Stated that the best thing to do is to call the nurse before touching or moving the resident. At 1:27 pm V29 (CNA) said she was able to recall R7 fall incident on 9/28/23. Stated she saw the resident sitting on the floor. Stated that she went to nurse's station and nurse was doing medication pass. Stated that she went back R7 room and picked up / transferred R7 back to bed with another CNA (V24). Stated that they transferred R7 to the bed and the nurse was not aware of the fall incident. Stated that staff were instructed not to move the resident without informing the nurse first to assess the resident after a fall incident. Stated I know it was wrong, but I was trying to help the resident. Stated that after a fall incident, if resident was not assessed first by the nurse and was moved / transferred, resident could have broken bone, can cause more injury or worsen the injury. At 12:26pm Observed R7 sitting up on wheelchair in the dining room, alert and verbally responsive with forgetfulness. Stated that he fell on the floor after rolling over from bed, unable to recall date and time. Stated he was assisted back to bed by 2 staff. R7 Nursing Progress Note dated 9/28/2023 documented in part: the resident was noted on the floor in a sitting position with his back was towards the bed. Received resident in bed alert verbally responsive. R7 Fall Risk Review assessment with signed date of 9/28/23 showed score of 14 (High Risk for Falls). MDS dated [DATE] showed R7's cognition was severely impaired. R7 needed extensive assistance with bed mobility, transfer dressing, toilet use and personal hygiene; Dependent / total assistance with locomotion on and off unit; Limited assistance with eating. MDS showed that R7 used wheelchair. MDS indicated that R7 was always incontinent of bowel and bladder. At 1:40pm V3 (Restorative Director, LPN/Licensed Practical Nurse) said that in the event of fall incident, CNA should inform the nurse immediately before moving the resident. Stated that nurse is expected to do full body assessment to check for any injury. Stated that if resident was identified as a fall risk, fall prevention interventions should be implemented for resident's safety. Reviewed R6's electronic health record with V3 and stated that if R6 was closely monitored, fall could have been prevented. Stated that R5, R6 and R7 were identified as a fall risk. Stated that Fall risk assessment is done by nurse on duty upon admission, quarterly and every after-fall incident. Facility's fall prevention program policy dated 1/25/23 documented in part: - The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. - A fall risk assessment will be performed after any fall incident - Safety interventions will be implemented for each resident identified at risk. - Nursing personnel will be informed of residents who are at risk of falling. - Resident at risk of falling will be assisted with toileting needs. - Footwear will be monitored to ensure the resident has proper fitting shoes and / or footwear is non-skid. Facility policy and procedures for Resident Supervision / Monitoring dated 7/2023 documented in part: - All staff are responsible for monitoring residents' locations, to ensure resident safety at all times. - Staff must immediately provide supervision/monitoring, as deemed appropriate to ensure the safety of the at-risk resident(s), i.e. reduced cognition, impaired physical mobility, etc. 4. On 11.29.2023 at 11:40 AM, R14 said he observed R16 in her doorway, smoking marijuana. R14 said he is concerned about the safety of residents residing in the facility as R16 uses oxygen. R14 said he reported his concern to V15 (Social Service Director). On 11.30.2023 at 10:58 AM, V15 (Social Service Director) said, what happened with R16, the nurse said she (R16) was smoking. When I talked to her, she denied smoking in her room. I counseled her that she can't smoke with oxygen. She doesn't go out; I don't know how she gets the contraband. We counsel her, call her family to inform of situation, we do random room checks. We found marijuana and marijuana butts. She will not tell how or from whom she got the marijuana. Smoking while using oxygen is a danger to R16, other residents, and staff because an explosion could happen. 11.29.2023 at 12:00 PM, R16 was observed awake, alert, neat, clean, sitting up in bed, watching television. An oxygen concentrator was observed at bedside; the concentrator was on, however, R16 was not using oxygen. R16 said she dons/doffs her oxygen cannula. R16 said she is a former marijuana smoker/smoker; stopped a while ago. 12.1.2023 at 12:58 PM, V53 (Former Licensed Practical Nurse) said via telephone interview, that she never saw R16 smoking marijuana, but did on several occasions smelled an odor of marijuana in R16's room. V53 said R16 did not have a roommate on those occasions. V53 said R16 denied smoking marijuana each time. V53 said she counselled R16 about the dangers of smoking oxygen while using oxygen, telling R16 it was dangerous and R16 could catch fire, blow herself up, and die. V53 said she did confiscate smoking paraphernalia including a cigarette lighter and what appeared to be marijuana cigarettes; resident was referred to Social Service, paraphernalia was turned over to Social Service. On 11.30.2023 at 10:58 AM, V15 (Social Service Director) said the nurse said she (R16) was smoking. when I talk to her, she denies smoking in her room. I counseled her, that she can't smoke with oxygen. We do random room checks; we found marijuana and marijuana butts in her room. R16 will not tell us how or from whom she got the marijuana. V15 said it's a danger to R16, other residents, and staff because she's on oxygen an explosion could happen. V15 said R16 was told at the end of Otober, if she continues to smoke in the facility she will be discharged . 9.30.2023 at 3:51 AM, Nursing Progress Note documents: Upon rounds staff smelled marijuana. Writer went into resident room asked resident was she smoking or smoked marijuana resident stated no. Resident currently receiving O2 @ 2L/NC continuously. Resident has history of having contraband materials in/on the facility premises. During the room search, smoking materials was found in resident's room/possession. All contrabands were confiscated from the resident. Resident was re-educated on the facility smoking and substance abuse policy and advised to adhere to them at all times. Resident was also educated on the negative impact of marijuana along with her prescribed medication with the use of oxygen may cause health/bodily harm to her. IDT to be made aware of resident's behavior. 10.18.2023 at 6:29 PM Social Service Note documents: Staff conducted a random room search for contrabands with resident's presence. Resident has a history of having contraband materials in the facility premises. During the room search, smoking materials was found in the resident's room/possession. All contrabands were confiscated from the resident. Resident was re-educated on the facility smoking and substance abuse policy and advised to adhere to them at all times. Resident was also educated on the negative impact of marijuana along with her prescribed medication may cause to her health. IDT made aware of resident's behavior. Staff will continue to follow up and document accordingly. Facility's Resident Smoking Policy and Procedure (2023) documents: the Facility will maintain an environment that remains as free from accident hazards as is possible, and the Facility will ensure that each resident receives adequate supervision and assistance to prevent accidents. Residents are not permitted to have any smoking paraphernalia in their room or on their person. Residents with medical oxygen are not permitted to smoke or enter a designated smoking area. Per Smoking and Home Oxygen: What You Need to Know ([NAME] County, MD undated fact sheet): While oxygen itself is not flammable, an oxygen-rich environment can cause materials to ignite easier and burn quickly. Never smoke inside a home where supplemental oxygen is in use. Smoking while on oxygen increases the risk of fire. Once ignited, fires burn hotter and more rapidly in oxygen-rich surroundings. 15301

Based on interviews and record reviews, the facility failed to protect R110's right to be free from physical abuse by a resident. This failure resulted in R132 hitting R110 on the face. R110 was sent to acute hospital and showed R110 sustained a nasal fracture and dental injury. Findings Include: On 6/06/23 at 11:22 AM, an interview conducted with R110. R110 stated that another resident (R132) who's room was right across R110's room had hit R110 on the face. R110 stated that R132 came in R110's room, woke R110 and started hitting R110. R110 stated, The resident hit me on my nose bridge and my mouth. It was another resident. His name was [R132] he was right next door across the hall. It was around 2 o'clock in the morning. I don't remember the exact date. It was last week Tuesday. I was sleeping he was waking me up then he hit me on the face. I yelled and the female CNA [Certified Nursing Assistant] came right away. R110 stated R110 went to the hospital because R110's mouth was bleeding and had a broken nose. R110 stated R110 felt scared after the incident happened. On 6/7/23 at 7:36 AM, a phone interview conducted with V23 (Certified Nursing Assistant). V23 stated that last week around 2 in the morning, V23 heard R110 hollering for help. V23 ran in R110's room and saw R132 standing over R110's bed. V23 stated R110 said that R132 had hit R110. V23 stated R132 tried to hit R110 again and also tried to hit V23. V23 stated that the bottom of R110's mouth was bleeding and was saying R110's tooth was loose. V23 stated R110 also said that R110 was frightened. At 7:46 AM, a phone interview conducted with V24 (Registered Nurse). V24 stated that V24 was alerted to R110's room because R110 was screaming for help. V24 stated that when V24 got to R110's room two CNAs were already in R110's room and found R132 standing next to R110. V24 stated V24 and the other two CNAs removed R132 from R110's room and V24 instructed the CNAs to monitor R132 in R132's room. V24 stated V24 saw R110 bleeding in R110's mouth and was told that R110 was woken up by R132 and started beating R110. V24 stated V24 provided first aid kit to R110 and was sent to the hospital via 911. V24 stated that R110 came back the same day from the hospital and R110 sustained a nasal fracture based on the Computed Tomography (CT) Scan. R110's clinical record shows an initial admitted [DATE] with listed diagnoses not limited to Cerebral Infarction, Type 2 Diabetes Mellitus, and Epilepsy. R110's Minimum Data Set (MDS) dated [DATE] shows R110 is cognitively intact. The facility's incident final report shows incident date of 6/2/23 with brief description of incident that reads in part: R110 yelled out as [R110] awoke in [R110] bed, as the resident [R132] was hitting R110. CNA was at the nurses station and heard [R110] yell out. Both the CNA and Nurse immediately went to [R110] room, at which time [R132] standing at the bedside. [R132] was removed from the room immediately by the nurse. The nurse completed a total body assessment, contacted MD and sent [R110] put to the hospital. [R132] was petitioned out to the hospital. The conclusion of this final report reads in part: Investigation was completed and allegations were substantiated. [R110] was sent to the hospital and has returned with a nasal bone fracture and dental injury. R110's hospital records dated 6/2/23 shows that R110 had CT scan of the face with conclusion that reads: Slightly depressed bilateral nasal bone fracture and Very poor dentition with multiple missing and loose teeth, widespread dental caries and signs of chronic dental infection. The facility's policy titled; ABUSE PREVENTION PROGRAM with revision date of 1/2019 reads on part: Prevention The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. The facility's RESIDENTS' RIGHTS for People in Long-Term Care Facilities reads in part: Your rights to safety You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually.

Based on observations, interviews and record reviews, the facility failed to follow their Fall Prevention and Management Program by (a) not implementing a comprehensive resident centered care plan with goals and interventions to prevent falls, (b) not providing supervision for a wandering resident, and (c) not providing fall prevention interventions for 5 (R7, R8, R15, R16, R11) of 5 in a sample of 28 residents reviewed for falls. These failures resulted in R11 sustaining a right femoral neck fracture. These failures also resulted in R15 falling on the floor directly on her face and sustaining a nasal bone fracture. R7 sustained a left hip (femur) fracture. R8 sustained a scalp hematoma, forehead laceration that required stitching, and multiple acute pelvic and sacral fractures. Findings Include: On [DATE] at 2:48 pm, an interview conducted with R15. When asked about the incident that happened on [DATE], R15 stated, I used to be on the 3rd floor. There was this resident (R16) who walks around and goes to other rooms. I was lying in bed I looked up and saw that resident (R16) in my room. She (R16) was reaching something in my dresser. She (R16) was by herself. There was no staff watching her (R16). I got up and when I got up I guess I moved so fast I lost my balance and fell . I fell on the floor. I was between the dresser and the bed. I felt blood coming from my nose. I never got to touch her (R16). I was going to get her out of there but did not get a chance to because I fell and then she (R16) just left and walked out. That's what she (R16) does she (R16) goes to room to room. On [DATE] at approximately 9:45 am to 10:00 am, surveyor observed R16 wandered around the 3rd floor unit. Surveyor did not observe any staff re-directed R16 at that time period. On [DATE] at 1:52 pm, V21 (Certified Nurse Aide) stated, V21 worked on [DATE] day shift but did not witness R15's fall. V21 was doing patient care with another resident. V21 stated, R16 is confused and wanders around the unit by herself. V21 stated staff should be re-directing R16. At 1:59 pm, interviewed V22 (Certified Nurse Aide) and stated worked on [DATE] day shift but did not witness R15's fall. V22 stated, V22 was doing patient care with another resident. V22 stated R16 wanders to other residents' rooms and staff should be re-directing R16 back to the dining room or where staff can supervise R16. At 2:06 pm, interviewed V14 (Contract Licensed Practical Nurse) who stated, V14 was not the nurse in-charge of R15 on the day of R15 and R16's incident. V14 stated, V14 did not witness R15 falling. V14 stated, R16 wanders in the unit and sometimes to other residents' rooms. V14 stated, R16 should always be supervised when wandering. On [DATE] at 11:22 am, interviewed V10 (Social Service Director) and stated that staff should always be re-directing R16 when wandering. V10 stated, If (R16) walks inside another resident's room they have to re-direct. On [DATE] at 9:42 am, a phone interview conducted with V55 (Certified Nurse Aide). V55 stated was in-charge of R15 when R15 and R16's incident happened but did not witness the incident. V55 stated, V55 went downstairs and was not in the unit when the incident happened. V55 stated V55 was not in-charge of R16 that time but V55 saw R16 walking around the unit. V55 stated R15 walks independently, gets up by herself (R15), and toilets independently. V55 stated R15 does not need assistance with transferring or when walking. Surveyor attempted to contact V25 (Agency Registered Nurse) multiple times and left messages to call back to no avail. V25 was in-charge of R15 on [DATE] day shift. R15's clinical records indicate an admitted [DATE] with listed diagnoses not limited to Alzheimer's disease, hypertension, weakness, and other lack of coordination. R15's Quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of [DATE] shows R15 has impaired cognition and requires limited one person assistance with activities of daily living and is unsteady with balance during transitions and walking. R15's progress notes dated [DATE] at 10:15 am documented by V25 indicates V25 observed R15 sitting on the side of R15's bed with trails of blood on the floor and R15's arms. R15's reported pain on R15's left arm. R15 reported that R15 was trying to get another resident out of R15's room. R15 fell on the floor directly on R15's face. R15 was transferred to the hospital. R15's hospital records show a computed tomography scan of facial bone was performed on [DATE] at 1:00 pm with findings that shows displaced fracture at the base of the right nasal bone. R16's clinical records indicate an initial admitted [DATE] with listed diagnoses not limited to dementia, disorientation, and anxiety disorder. R16's Annual MDS assessment with ARD of [DATE] shows R16 requires supervision one staff assistance with transfer and walking. R16's comprehensive care plan with date initiated on [DATE] shows R16 has a diagnosis of dementia and wanders in and out of peer's rooms. One intervention shows to re-direct R16 when R16 goes to other peer's room. R11's progress notes dated [DATE] documented by V26 (Agency Registered Nurse) reads at 4:00pm, staff heard (R11) calling out for help. Staff responded to (R11's) call immediately. Staff observed (R11) lying on the floor right side of bed. This note also documents R11 did not know what happened, was sleeping and woke up on the floor. This note also documents R11 stated R11 hit R11's head and was sent out to acute hospital via 911. Facility's final incident reporting on R11's fall reads in part: Based on a thorough review of (R11's) medical record, the incident was determined to be contributed by (R11) attempting to ambulate out of bed without staff assistance. (R11) was treated at the hospital for the Dx: Right Hip Fracture. R11's hospital records dated [DATE] shows X-ray of right femur performed on [DATE] at 5:57 pm with conclusion that reads in part, 1. There is evidence of an age-indeterminate fracture of the right femoral neck, possibly acute. R11's clinical record shows an [DATE] with listed diagnoses not limited to cerebral infarction, heart failure, dementia, weakness, abnormalities of gait and mobility, diabetes mellitus, and hypertension. R11's Quarterly Minimum Data Set (MDS) assessment with ARD of [DATE] shows R11 was cognitively impaired and requires extensive 2 staff assist requires for bed mobility, toileting, transfer. Unsteady with balance during transitions and walking. R11's Restorative Nursing Review dated [DATE] shows R11 was not steady with balance during transitions. R11's Fall Risk Review dated [DATE] shows R11 was at risk for falls. R11's comprehensive care plan shows R11's fall care plan was not initiated until [DATE], which was after the fall. On [DATE] at 2:26 pm, interviewed V23 (Certified Nurse Aide) and stated did not witness R11's fall. V23 stated R11 needed limited with one staff assistance with transfer, bed mobility, and toileting. V23 stated R11 was at risk for falls. On [DATE] at 10:04 am, an interview conducted with V34 (Restorative Director). V34 stated V34 is in-charge of the fall program in the facility. V34 stated R11 fell on [DATE] at around 4:47 PM. R11 slipped off the bed and woke up on the floor. V34 stated R11 required extensive 2 staff assistance with bed mobility, transfer, and was incontinent of bowel and bladder. V34 stated R11 was cognitively impaired with diagnosis of dementia psychotic disturbances. V34 stated R11's fall care plan was initiated on [DATE] right after the fall. V34 stated prior to R11's fall, R11 had no fall care plan. V34 stated R11 was at risk for falling based on the fall risk assessment dated [DATE]. V34 stated that if fall care plan is not implemented repeated falls could potentially happen. V34 stated that the fall care plan should be implemented upon admission and updated quarterly, annually, significant changes, or after a fall. V34 stated that fall care plan should have the residents' updated and personalized goals and updated personalized interventions. V34 stated that the purpose of the fall care is to keep the residents safe and to keep the interventions in place to prevent residents from falling. Facility's policy titled; Fall Prevention and Management version 080317 reads in part: Fall Prevention Protocol III. Fall Prevention A. Identify risk factors B. Implements individualized approaches/interventions based upon resident risk 1. The Fall Prevention Strategies/Interventions list may be used to identify appropriate interventions 2. Approaches/interventions should focus on risk factors identified V. Care plan A. Interdisciplinary care plan is implemented for residents at risk and may include 1. Interventions to prevent falls B. Evaluations of the interventions is completed 1. Quarterly 2. Post fall 3. Interventions are modified as indicated based upon evaluated efficacy of the interventions Facility's policy titled; Standard Supervision and Monitoring not dated, reads in part: Procedure: 1. When a resident has been assessed either by the staff nurse of Psychosocial staff to have stable physical and psychosocial needs regular rounds will be maitnained to ensure that all of the resident's needs are met. 40061 Findings include: R8's face sheet documents in part diagnoses that include but are not limited to difficulty in walking, weakness, abnormalities of gait and mobility, cognitive communication deficit, history of falling, and Alzheimer's disease. R8's [DATE] Admission Minimum Data Set (MDS) Assessment documents in part that R8 requires supervision and one-person physical assist for locomotion on the unit. R8's Fall Risk Review dated [DATE] documents in part that R8 is a high risk for fall. R8's comprehensive care plan contains a focus initiated on [DATE]. It documents in part that R8 is at high risk for falls related to behavioral concerns and history of falls prior to admission. V7's (Registered Nurse) progress note dated [DATE] 02:33 AM documents in part: Patient [R8] was observed on the floor in the dining area. Patient informed the writer that [R8] slept in [R8's] wheelchair and fell face down from [R8's] wheelchair. R8 had a laceration to forehead. Facility sent R8 to the hospital for evaluation. During a telephone interview on [DATE] at 7:45 AM, V7 stated R8 fell in the dining room on [DATE] around 2:00 AM. V7 stated R8 was sitting up in a wheelchair in front of the television. V7 stated R8 fell asleep and fell from the wheelchair. V7 stated to my recollection no one was there with her. V7 stated R8 with behaviors of going to the dining room at night without telling staff. V7 stated we don't tell [R8] nothing. [R8] will fight you to the moon on that. Whatever and whenever [R8] wants to do it, [R8] does it. This was not reflected on R8's comprehensive care plan. V7 stated last seeing R8 in the bedroom about an hour prior to the fall. On [DATE] at 9:59 AM, V1 (Administrator) stated all dining rooms should be supervised when there are residents present. V1 stated this goes for all shifts including night shift. On [DATE] at 12:10 PM, V2 (Director of Nursing) stated a staff member must always be supervising in the dining room when residents are present. V2 stated during night shift staff should be doing rounds at least hourly to make sure everyone is in bed and that no one is on the floor. R8's hospital records from the [DATE] admission documents in part that R8 sustained a +4-centimeter laceration to the forehead which required stitching. R8 also sustained multiple pelvic fractures and a sacral fracture which required hospital overnight stay with orthopedic consult. Facility's undated Standard Supervision and Monitoring policy documents in part: The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. If the resident cannot be guided, supervised, or redirected during regular intervals of rounds, the resident may require 30-minute, 15-minute or 1:1 supervision. Facility's Fall Prevention and Management Program policy version 080317 documents in part: Through an interdisciplinary approach, this facility will provide fall prevention assessment, implement interventions to prevent falls as much as possible, and manage post-fall treatment. 41356 Findings include: R7 was [AGE] years old, initial admitted [DATE] and discharged date [DATE]. R7 brief interview for mental status dated [DATE] scored at 7 that means R7 has impaired cognition. Under functional status bed mobility, ambulation, walk in room and corridor all 1-person limited assistance. On [DATE] at 11:18 AM. V12 (R7's Sister) stated that because of the fall on [DATE], R7 went to hospital on [DATE] and had a hip surgery on [DATE]. After R7 left the hospital, he was transferred to a different Long-Term Care facility where he expired on [DATE]. Per R7's notes dated [DATE] (04:12 AM) by V8 (Licensed Practical Nurse), in part reads: Approximately 4:00 AM this morning, R7 was found out of bed. And prior to the incident, R7 was found not acting as usual. Per R7's notes dated [DATE] (01:26 PM) by V8 (Licensed Practical Nurse), in part reads: R7 was observed kneeling by the side of the bed. On [DATE] at 09:56 AM, V8 said that she cannot remember anything to all the questions that were asked by the surveyor. On [DATE] at 09:07 AM, V52 (Former Director of Nursing) stated that she is the nursing consultant for the company and was acting as the DON (Director of Nursing) during that time. V52 said, I am sorry I cannot remember. I can hardly remember R7 vaguely. And I cannot account to what resident condition at that time. R7's notes dated [DATE] by V6 (Licensed Practical Nurse), documents in part: R7 was unresponsive with oxygen saturation of 78% with labored breathing. 911 was called and R7 was transported to the hospital. On [DATE] at 09:43 AM, V6 said, I am an agency nurse, but I remember sending R7 out to the hospital on [DATE]. I was called by a CNA (Certified Nursing Assistant) who told me that R7 was not responsive. And when I checked R7 oxygen saturation it was low. I took care of R7 in the past beside the time when I sent him (R7) out of the hospital. R7 has altered mental status. And yes, he was walking or ambulating by himself. V6 was informed that per R7's assessment he (R7) needs 1-person to assisting when walking. V6 said, Was I the one who made that assessment? R7 was walking by himself, he (R7) walks independently. Facility Incident Report Form dated [DATE] marked as initial report, in part reads: Under description of occurrence, documentation reads: Received update from hospital regarding R7's status of left femur fracture. Full investigation initiated. No description was provided as to occurrence of the incident. On [DATE] at 2:34 PM. V2 (Director of Nursing) stated related to R7's report, that there should have been detailed description of the event. V2 said, the present documentation does not account as complete. V2 said after reading (Description of Occurrence), No that is not complete. It does not amount to complete description. R7's notes dated [DATE] by V5 (Licensed Practical Nurse), documents in part reads: She (V5) spoke with a nurse that R7 was admitted with left femur fracture. R7's notes dated [DATE] by V61 (Physician), in part reads: R7 seen and examined today for follow visit. R7 has reported behaviors at times including attempts to elope. Requires redirection from staff. Care plan for elopement was initiated on [DATE] and was never reviewed. On [DATE] at 09:56 AM. V2 (Director of Nursing) said, Yes, I don't think that R7 has an updated Fall Risk Assessment before the fall. I will check if R7 has any current fall assessment. But of course, if he does not have any, I cannot give it to you. Yes, care plan for fall must be updated quarterly. After the fall, there must be a head-to-toe assessment done, pain assessment needs to be done related to the fall that must be comprehensive to make sure that R7 has no pain. R7 BIMS score is at 7 that means he is cognitively impaired and may not verbalized how he felt. Fall Assessment and care plan is needed to have interventions help prevent falls. R7 most recent Fall Assessment was done on [DATE]. Fall care plan was initiated on [DATE]. Fall interventions for the care plan were also dated on [DATE] and was never reviewed. Per R7's notes dated [DATE], R7 has history of fall that was not care planned. Since fall care plan was only initiated on [DATE]. Fall Prevention and Management Program not dated, in part reads: The facility is committed to safety and maximizing each resident's physical, mental, and psychosocial well-being. The purpose of our Fall Prevention and Management Program is to: Provide our residents with an interdisciplinary approach to assess risk of falls Provide appropriate interventions to prevent falls Ensure that in the event a fall occurs, the fall will be investigated, appropriate emergency treatment will be provided, additional interventions will be implemented to prevent another fall from occurring as much as possible. Fall Prevention Protocol not dated, in part reads: Fall Risk Assessment is completed quarterly. Care Plan: Evaluation of the interventions is completed. Review will be done quarterly. Interventions are modified as indicated based upon evaluated efficacy of the interventions.

Based on interviews and record reviews, the facility failed to maintain R1's pain levels for 1 of 5 residents reviewed for medications. This failure resulted in R1 being hospitalized due to pain and experiencing pain of 11 on a scale of 1 to 10. Findings include: On 3/1/23 at 9:01 am, R1 said he was in terrible pain during his stay at the facility. R1 said, his pain was 11 on a pain scale of 1 to 10. R1 said, he got no pain medications during his stay and he was withdrawing from opioid as he got no pain treatment at the facility. R1 said, his pain felt like I want to saw my leg off, I also felt insignificant. R1 said, whenever he would press the call light and staff would come in, they would inform him they already know what he needs (referring to pain medications). R1's face sheet documents in part diagnoses including but not limited to monkeypox, rash and other nonspecific skin eruption. R1's 'Pain Review' dated 12/01/2022 9:37 PM documents in part that R1 experienced pain occasionally in the last 5 days. R1 described it as moderate pain. R1's care plan initiated 12/02/2022 documents in part that R1 has an alteration in comfort secondary to pain related to an alteration in skin integrity. Interventions initiated 12/02/2022 include Give medications as ordered. Keep the physician informed of the resident's progress. R1's physician order sheets and Medication Administration Record (MAR) document in part orders for ibuprofen, hydrocodone-acetaminophen, and morphine sulfate for pain as needed (PRN). R1's MAR documents in part that R1 did not receive any pain medications PRN. On 02/21/2023 at 3:25 PM, V18 (Facility's Customer Service Representative) stated R1 called V18 on 12/02/2022 complaining about not receiving pain medication. On 02/22/2023 at 10:55 AM, V31 (Nurse) stated R1 complained of being in pain on 12/03/2022. R1 called V77 (R1's Outside of Facility Physician) repeatedly to report the pain and not receiving medication. V31 stated the doctor called me and said if you guys aren't able to keep pain down, just send [R1] out. V31 stated [R1] wasn't saying what [R1's] pain was at from 0-10 but [R1] was saying that [R1] was in excruciating pain. [R1] just said [R1] was in pain 'I'm in pain.' I remember his mood was not stable. V31 stated there was an order in the computer for hydrocodone-acetaminophen and morphine sulfate PRN but pharmacy could not dispense it without a prescription faxed to them. Surveyor asked if there was any documentation that the facility attempted to get a prescription for the medications or if staff followed-up with V69 (Nurse Practitioner) or V70 (R1's Physician) regarding R1's pain. V31 reviewed electronic medical records and stated could not find it. V31's (Nurse) progress note dated 12/03/2022 5:18 PM documents in part R1 does not have any PRN pain medication. R1 sent to the hospital for pain. When V31 asked V77 (R1's Outside of Facility Physician) what the diagnosis was for hospital evaluation, V77 stated pain because its Saturday and its not much I can truly do for [R1]. On 02/23/2023 at 12:10 PM, V2 (Director of Nursing) stated during admission, the nurse has to reconcile the medications with the doctor and get clarifications. V2 stated They have to ask the doctor whether to continue the narcotics. If we don't have a script, the doctor has to give us the script or they contact the pharmacy themselves. V2 stated nurses are supposed to document this conversation with the doctor whether the facility is waiting for the prescription or the doctor is going to call the pharmacy. During a telephone interview on 02/23/2023 at 1:03 PM, V69 (Nurse Practitioner) stated [V69] was not aware of a resident that was admitted to the facility with monkey pox. V69 stated if a resident with monkey pox has open wounds, a provider would be at the facility within 24-48 hours to assess. V69 stated so we did not get a call. So that was definitely three days of miscommunication. Someone like [R1] would definitely need something more for pain. V69 stated if a resident is reporting pain and requesting stronger medications, the providers would order a pain consult as soon as possible. R1's physician order sheets did not read an order for pain consult. Facility's undated Management of Pain policy documents in part: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. Policy documents in part that the facility with achieve these goals through promptly and accurately assessing and diagnosing pain, monitoring treatment efficacy and side effects, and Using pain medication judiciously to balance the resident's desired level of pain relief with avoidance of unacceptable adverse consequences.

Based on interview and record review, the facility failed to protect residents right to be free from abuse. This deficient practice affected 4 residents (R5, R6, R21, and R22) in a sample of 28 residents reviewed for abuse. This failure resulted in R5 feeling intimidated and R6 feeling threatened by the facility administrator and R21 and R22 receiving unwanted touching by a facility staff member. Findings include, Facility's Final Incident Investigation Report dated (12/09/22) regarding incident which occurred on 12/05/22 involving R5, R6 and the facility administrator (V43) documents in part: V43 spoke inappropriately and aggressively toward R5 and R6 using profanity. R5 has diagnosis not limited to Unspecified Injury of Face, Subsequent Encounter Assault by Strike Baseball Bat, Insomnia, Major Depressive Disorder, Lack of Coordination, Muscle Weakness, Acquired Absence of Other Specified Parts of Digestive Tract. R5's Brief Mental Status Interview (BIMS) dated 02/03/23 documents that R5's cognition is intact. R5's MDS dated [DATE] section GG documents in part R5 uses a wheelchair and/or scooter. R5's document titled, Screening Assessment for Indicators of Agressive (Aggressive) and/or Harmful Behavior dated 12/05/22 documents in part total score = 1 with recommendations and outcome that R5 potentially able to integrate into the peer community, minimal risk for aggression. R5's care plans reviewed. R5 does not have a care plan for abuse or history of aggression. R6 has diagnosis not limited to Driver of Heavy Transport Vehicle Injured in Collision with Two or Three-Wheeled Motor Vehicle in Traffic Accident, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Quadriplegia, Muscle Weakness, History of Falling, Muscle Spasm, Contracture, Major Depressive Disorder, Hyperlipidemia, Retention of Urine, Anemia, Idiopathic Peripheral Autonomic Neuropathy. R6's Brief Mental Status Interview (BIMS) dated 12/01/22 documents that R6's cognition is intact. R6's MDS section G (Functional Status) dated 12/02/22 document in part R6 requires extensive assistance with two+ persons physical assist with bed mobility, transfer, dressing, toilet use, and personal hygiene. Activity of walking in room and walking in corridor did not occur, R6 uses wheelchair. R6's care plan dated 06/01/22 documents in part R6's medical and psychiatric diagnosis may increase resident's susceptibility to abuse/neglect. R6's care plan dated 06/01/22 documents in part R6 displays socially inappropriate and behavior. R6's care plan dated 06/01/22 documents in part R6 was socially inappropriate by using profane language towards staff members. R6's assessment titled, Screening Assessment for Indicators of Agression (Aggression) and/or Harmful Behavior dated 12/05/22 documents R6 has a history of verbal aggression towards staff/peer, resident was involved in an altercation with staff on 12/05/22. R6's score of 4 for recommendations and outcome potentially able to integrate into the peer community, minimal risk for aggression. On 02/21/23 at 1:36 PM, R5 stated that the previous administrator (V43) lashed out at R5 one day by the 1st floor elevator. R5 stated that R5 did not remember what led up to the altercation but that V43 got hostile with R5 by raising V43's voice and pointing V43's finger in R5's face. R5 stated that R5 was sitting in R5's wheelchair and V43 was standing over R5 looking down at him. R5 stated, he (V43) just snapped! R5 denies any issues with V43 prior to this. R5 does not remember specifically what V43 said to R5 but R5 stated that V43 was cursing at R5 a few times. R5 stated that R5 felt disrespected and intimidated. R5 stated that, I felt like I was going to have to defend myself and fight. R5 stated that the staff intervened and put V43 in the Social Service Director's office to calm down but then when V43 came out of the office got into it with R6 by the 1st floor elevator. R5 stated that at that point V43 was told to leave the building. On 02/21/23 at 2:01 PM, R6 stated the R6 was sitting in R6's electric wheelchair by the 1st floor elevator and R6 heard V43 and R5 having words. R6 stated R5 and V43 were cussing each other out and that V43 was standing over R5 (who was in a wheelchair) pointing V43's finger in R5's face. R6 stated that V43 went into the Social Service Director's office and then when V43 came out of the office V43 tried to fist pump (daps) R6. R6 stated that R6 did not return V43's fist pump because R6 was upset at the way V43 had spoken to R5. R6 stated, I told him to get out of my face. R6 stated that V43 raised V43's voice, got into R6's face and yelled at R6, what do you want to do? you can't do sh**. R6 stated that V43 was standing over R6 and aggressively pointing V43's finger in R6's face. R6 stated that this made R6 feel threatened and intimidated. R6 stated, I didn't know what he (V43) was going to do to me. R6 stated that the Social Service Director told R6 to go back to R6's room but that V43 refused to get out of R6's face and yelled, yeah, mother fuc**** what do you want to do? R6 stated at this time the staff intervened and physically removed V43 from the situation and soon afterwards V43 was escorted out of the building. On 02/21/23 at 3:50 PM, surveyor conducted interview via phone with V43 (Former Administrator) who stated that R5 was a gang member and participating in organized gang-like activities such as trying to sell drugs in the facility and acting inappropriately to female staff. V43 stated R5 was playing the system to stay in the nursing home by claiming that he (R5) has a psych problem. V43 stated, everyone was scared of him. V43 stated that on 12/05/22 R5 threatened my personal safety by R5 telling V43, I'll take you out. V43 stated that at this point V43 and R5 went into the Social Service Director's office to allow R5 to explain himself. V43 stated that R5 said, you're not my father and you cannot tell me what to do. V43 stated that R5 tried to stand up from R5's wheelchair so that R5 could punch or fight with V43. V43 stated, the way he (R5) threatened me rattled me and I lost my cool. I should have known better. V43 stated that when V43 left the Social Service Office R6 was by the office and V43 tried to engage in a conversation with R6. V43 stated that R6 likes to play gangster music and is friends with R5. V43 stated that R6 said to V43, F*** you! V43 stated that V43 has no memory of swearing back at R6 however other staff said that V43 did do this. V43 stated that the building director (V44) called and told V43 to leave the building. V43 has not been back to the facility since this date. V43 stated, I knew this was going to be written as an abuse case. On 02/22/23 at 11:15 AM, V1 (Administrator) stated that V1 has been the Administrator for the facility since Monday, 02/20/23 and is the Abuse Coordinator for the building. V1 stated that staff should never have any verbal or physical altercation with a resident because that is considered to be abuse and harmful to the resident as it goes against the rights of the resident as a person. V1 stated that the goal of the facility is for residents to feel safe, that their needs are being met, and that they are cared for and happy. V1 stated that the residents should feel that this is their home. On 02/22/23 at 12:15 PM, V10 (Social Service Director) stated that V10 has been working at the facility for 3 years. V10 stated that if an abuse is reported, V10 would immediately inform the Abuse Coordinator who is the Administrator and that once the Abuse Coordinator is informed then V10 and staff make sure the residents are separate physically and by floor if needed. V10 stated, we don't want any escalation of aggression. V10 stated that the social service staff get the residents statement and then do an Aggressive Assessment and document what occurred in a behavior note and update the care plan with the date and modify the interventions. V10 stated that abuse training is done monthly and V10 provide the following examples of abuse: physical, neglect, exploitation. V10 stated that V10 was present on 12/05/22 and in V10's office when V10 heard loud voices by the elevator and went out to check out the situation. V10 stated that based on V10's observations on 12/05/22, R5 and R6 were both victims of verbal abuse. On 02/22/23 at 1:34 PM, V13 (Admissions Director) stated that V13 was in V13's office and V13 heard loud talking from V10's office and toward the elevator on the 1st floor. V13 stated that V43 was being very loud, and confrontational with 2 of the residents (R5 and R6). V13 stated that one of the residents said something sarcastic to V43 and V43 responded with an inappropriate comment back. V13 stated that heard everyone (R5, R6, V43) using profanity. V13 stated that V43 keep talking loudly to the residents (R5, R6) and these residents were saying for V43 to leave them alone yet V43 keep it up saying something like, you don't talk to me like that! who do you think you are? Hu? Who do you think you are? V13 stated that it seemed like V43 was goading R5 and R6 to get more of a response from them. V13 stated that V43 was in the position of authority, and the Abuse Coordinator and it was not appropriate for V43 to talk like that to anyone but especially a resident. V13 stated that this is the residents' home, and they should feel safe and comfortable here. On 02/24/23 at 10:45 AM, surveyor conducted interview via phone with V76 (Psychiatric Nurse Practitioner) who stated that V76 is familiar with R6 but has not seen R5. V76 stated that V76 saw R6 on 12/16/22 and was never made aware of the altercation between R6 and the former administrator on 12/5/22. V76 stated that V76 or the psychiatrist should have been called or notified. V76 stated that it is staff responsibility to calm residents down in a non-threatening manner to help diffuse situation, not fuel it. V76 stated that V43 was the professional and should not have come down to the level of the resident. V76 stated that now R6 may feel R6 cannot trust R6's surroundings, where R6 lives, and this is a safety concern. V76 stated, who do they turn to for help? and that it is creating a hostile environment coming from a person in a position of power and authority. Policy: Abuse Prevention Program - Policy undated, documents in part, it is the policy of the facility to prevent resident abuse, neglect, mistreatment and misappropriation of property. Facility policy titled, Resident Rights undated, documents in part, residents have the right to be free from verbal, sexual, physical or mental abuse and the facility must implement procedures that protect (you) from abuse, neglect or mistreatment. 39779 R21 has diagnosis not limited to Spondylosis with Myelopathy Cervical Region; Epilepsy; Nicotine Dependence; Low Back Pain; Fusion of Spine; Mastodynia; ETOH (Alcohol) Abuse; Thrombocytopenia; Hyperlipidemia; Overactive Bladder; Problem related to Care Provider Dependency; History of Falls. R21 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. On 02/22/23 at 09:15 AM R21 using a rollator walker, approached the surveyor while standing at the second-floor nurse station and stated V1 (Administrator) put her hands on me. V1 grabbed my arms with both her hand and put me in the line while I was standing and waiting to go on smoke break. I was off balance. No worker is supposed to put their hands on residents. It happened at 07:45 this morning. V1 want every resident in line outside to smoke on the patio. The whole line and the worker in the red uniform that was passing out cigarettes saw the incident. On 02/22/23 at 09:21 AM surveyor called receptionist and requested that V1 (Administrator) come to the second-floor nurse station. On 02/22/23 at 09:31 AM V39 (Activity Aide) stated When I was passing cigarettes at 7:45 AM I grabbed the cigarette cart and material to go to the patio pass out and light cigarettes for the residents. V1 wanted the residents to stand in a straight line. This morning there was lot of confusion, and this was the new administrator first time being here to see cigarette break time. The residents are not always in a straight line so some of them were out of line. V1 (Administrator) was trying to put them in a straight line and trying to tell them to get in a straight line. The administrator put R21 in the line by touching her, I think on her arms. R21 told her that she is not supposed to be touching the residents. R22 hollered you don't have to push me. On 02/22/23 at 09:40 AM V1 (Administrator) arrived on the second-floor nurse station and the incident that R21 reported to the surveyor was reported to the administrator. V1 (Administrator) responded I am going to have to call my boss so that she can come into the facility. On 02/22/23 at 09:55 AM V1 (Administrator) stated I was in the first-floor dining room during smoke break observing. I don't know the time; the dining room light was off. V39 (Activity Aide) came in with the smoking cart and was inside the dining room passing cigarettes. I told V39 (Activity Aide) that I need for you to be outside with the residents. V39 (Activity Aide) was upset, and people were jammed up. I was touching the residents as they walked out the door. I said you have to be outside to supervise the residents. The whole room smelled like smoke. I told the residents to line up outside and get cigarettes. I said we are going to line up and go out the door. I was touching people as they went out the door. R21 said don't touch me. The housekeeping supervisor was there. While the residents were standing outside, I touched a lot of people. I touched several people because I am a touchy-feely person. I can't say I was assisting R21 in anyway. I don't remember any other person saying you don't have to touch me. The housekeeping director was also there. I called my boss so they can come in and take over. V39 (Activity Aide) was upset with me for having her go outside to pass the cigarettes. I told the residents that we were going to paint and strip floors. It is going to take 24 hours and I would give the residents a couple days' notice because the room will be closed down. On 02/22/23 at 10:30 AM V65 (Housekeeping Supervisor) stated I was standing in the first-floor dining room. I cut the lights on and walked over to where the smokers were. V1 (Administrator) was talking about the floors being done and the walls painted. V39 (Activity Aide) came with the cigarette cart in the dining room and V1 (Administrator) said she did not want the residents in the dining room. V1 (Administrator) wanted the residents outside and wanted V39 (Activity Aide) to stand outside. I did not see V1 (Administrator) touching the residents. R22 has diagnosis not limited to Epilepsy; Metabolic Encephalopathy; Non-traumatic Subdural Hemorrhage; Muscle Wasting and Atrophy; Difficulty in Walking; Lack of Coordination; ETOH (Alcohol) Abuse; Cognitive Communication Deficit; Hypokalemia; Weakness; Pancytopenia. R22 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. On 02/22/23 at 01:17 PM R22 stated the administrator was aggressively grabbing people in the smoke break line and saying the line is this way outside. V1 (Administrator) put her hands on my wheelchair. My hands were on the wheels and could have gotten caught in the wheels. I asked V1 can you get your hands off of my wheelchair. V1 aggressively put her hands on R21 and could have knocked her to the ground. I was in my wheelchair behind R21. Initial Reportable dated 02/22/23 document in part: Facility received report from an IDPH (Illinois Department of Public Health) Surveyor on 02/22/23 at approximately 9:00 a.m. that R21 alleged that V1 (Administrator) grabbed/pushed her while resident attended a scheduled smoking break. During initial/preliminary investigation of the alleged incident, it was reported that V1 grabbed R22's wheelchair and pushed R22 chair without permission and bumping the chair into R21 leg. V1 (Administrator) denies the allegation made against her. V1 (Administrator) immediately removed herself from resident contact and has been suspended pending investigation of the alleged incident. Investigation was initiated. Policy: Policy titled Abuse Prevention Program revised 01/19 document in part: it is the policy of this facility to prohibit and prevent resident abuse. 1. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being.

Based on observation, interview and record review the facility failed to ensure wound care was provided for 2 (R4, R13) of 3 residents reviewed for wound care. The facility also failed to turn and reposition R4 while in bed. This failure resulted in the decline of R4 wounds with exposed bone to the left lower extremity. Findings Include: On 02/21/23 at 03:19 PM V9 (Wound Care Coordinator) stated R4 has one pressure wound underneath the buttocks to the sacral conjoined, tunneled one to the other and both heels. Both knees lateral side are venous ulcers and both side of the upper and lower leg are venous ulcers. R4 wounds looked bad, and I have seen a significant improvement in the wounds since I started. R4 has diagnosis not limited to Spondylosis with Radiculopathy, Thoracolumbar Region, Paraplegia, Neuromuscular Dysfunction of Bladder, Type 2 Diabetes Mellitus, Methicillin Resistant Staphylococcus Aureus Infection, Reduce Mobility, Limitation of Activities Due to Disability, Lack of Coordination. Pressure Ulcer of Right Buttocks, Stage 4, Non-Pressure Ulcer of Right Calf with Fat Layer Exposed, Non-Pressure Ulcer of Other Part of Right Lower Leg, Non-Pressure Ulcer of Other Part of Left Lower Leg , Osteomyelitis, Weakness, Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity, Muscle Wasting and Atrophy, Acute Kidney Failure, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity, Major Depressive Disorder, Osteoarthritis, and Essential (Primary) Hypertension. R4 Care plan document in part: R4 is at increased risk for alteration in skin integrity related to incontinence of bladder, incontinence of bowel and impaired mobility status. Interventions: Precautions for prevention of pressure ulcers will be completed: good peri care and drying of the skin. Apply protective barrier cream. Reposition resident frequently when in bed /chair/Geri chair and or wheelchair. Administer Wound Care (Treatment) per MD (Medical Doctor) orders. R4 Treatment Administration Record dated 09/01/22 -09/30/22 document in part: Collagen- Antimicrobial Sheet Apply to Left Lateral Leg every day has 16 out of 31 days with no documented treatments. Collagen- Antimicrobial Sheet Apply to Right Lateral Leg every day has 16 out of 31 days with no documented treatments. Foam Dressing Pad apply to Right Lateral Lower Leg every Tuesday, Thursday, Saturday has 5 out of 13 days with no documented treatments. Gentamicin Sulfate Ointment 0.1 % Apply to Right Gluteal fold topically every day shift has 7 out of 15 days with no documented treatments. Medi honey gel apply to right gluteal fold has 9 out of 12 days with no documented treatments. Left Lateral Lower Leg: Cleanse with NSS (Normal Saline) apply collagen sheet cover with foam dressing every day shift has 2 out of 4 days with no documented treatments. Right Gluteal Ischial cleanse with 1/2 Dakin's every day shift has 2 out of 4 days with no documented treatments. Right Lateral Lower Leg: Cleanse with NSS every shift has 2 out of 4 days with no documented treatments. R4 Treatment Administration Record dated 10/01/22 - 10/31/22 document in part: Calcium Alginate Miscellaneous Apply to Left Lower Extremity and Right Lower Extremity every day has 10 out of 25 days with no documented treatments. Collagen-Antimicrobial sheet apply to left lateral leg every day has 5 out of 6 days with no documented treatments. Collagen-Antimicrobial sheet apply to right lateral knee every Monday, Wednesday, Friday has 4 out 11 days with no documented treatments. Collagen-Antimicrobial sheet apply to right lateral leg every day has 5 out of 6 days with no documented treatments. Foam Dressing pad apply to right lateral lower leg Tuesday, Thursday, Saturday has 7 out of 13 days with no documented treatments. Medi honey Apply to Left Lower Extremity & Right Lower Extremity topically every day has 10 out of 25 days with no documented treatments. Left Lateral lower leg: cleanse with NSS apply Medi honey and Calcium Alginate every day has 10 out of 25 days with no documented treatments. Left Lateral Lower Leg: cleanse with NSS apply collagen sheet every day has 5 out of 6 days with no documented treatments. Right Gluteal Ischial Cleanse with 1/2 Dakin's every day has 5 out of 6 days with no documented treatments. Right Lateral Knee: Cleanse with NSS apply collagen sheet or calcium alginate Monday, Wednesday Friday has 4 out of 10 days with no documented treatments. Right Lateral Lower Leg: Cleanse with NSS apply collagen sheet every day has 5 out of 6 days with no documented treatments. Right Lateral Lower Leg: Cleanse with NSS apply Medi honey and Calcium Alginate has 10 out of 25 days with no documented treatments. Dakin's 1/2 strength 0.25 % sodium hypochlorite apply to right gluteal fold every day and night shift has 22 out of 50 wound changes with no documented treatments. Right Gluteal Ischial: Cleanse with Dakin's 1/2 strength, moisten and loosely insert, every day and night shift have 22 out of 50 wound changes with no documented treatments. R4 Treatment Administration Record dated 11/01/22 - 11/30/22 document in part: Collagen-Antimicrobial Sheet Apply to Right lateral knee topically every day has 5 out of 13 wound changes with no documented treatments. Foam Dressing pad apply to right lateral lower leg Tuesday, Thursday, Saturday has 4 out of 13 days with no documented treatments. Medi honey Apply to Left Lower Extremity & Right Lower Extremity topically every day has 9 out of 30 days with no documented treatments. Left Lateral lower leg: cleanse with NSS apply Medi honey and Calcium Alginate every day has 9 out of 30 days with no documented treatments. Right Lateral Knee: Cleanse with NSS, pat dry, apply adaptic, cover with foam dressing Monday, Wednesday Friday has 4 out of 9 days with no documented treatments. Right Lateral Lower Leg: Cleanse with NSS, apply Medi honey and Calcium Alginate every day has 9 out of 30 days with no documented treatments. Dakin's 1/2 strength 0.25 % sodium hypochlorite apply to right gluteal fold every day and night shift has 14 out of 60 wound changes with no documented treatments. Right Gluteal Ischial: Cleanse with Dakin's 1/2 strength, moisten and loosely insert, every day and night shift have 3 out of 19 wound changes with no documented treatments. Right Gluteal Ischial: Cleanse with Dakin's 1/2 strength, pack loosely with iodoform gauze, every day and night shift have 12 out of 41 days with no documented treatments. R4 Treatment Administration Record dated 12/01/22 - 12/31/22 document in part: Calcium Alginate apply to Left Lower Extremity and Right Lower Extremity topically every day has 2 out of 4 days with no documented treatments. Foam Dressing pad apply to right lateral lower leg Tuesday, Thursday, Saturday has 2 out of 4 days with no documented treatments. Gentamicin Sulfate Ointment 0.1 % Apply to Left Lateral lower leg everyday Cleanse with 1/2 Dakin's apply gentamycin ointment daily and PRN (as needed) day has 9 out of 14 days with no documented treatments. Gentamicin Sulfate Ointment 0.1 % Apply to Left Lateral lower leg everyday Cleanse with 1/2 Dakin's has 3 out of 10 days with no documented treatments. Medi honey Apply to Left Lower Extremity & Right Lower Extremity topically every day has 2 out of 4 days with no documented treatments. Left Lateral lower leg: cleanse with NSS apply calcium alginate daily and prn has 9 out of 13 days with no documented treatments. Left Lateral lower leg Cleanse with Dakin's 1/2 strength apply gentamycin every day has 3 out of 9 days with no documented treatments. Left Lateral lower leg Cleanse with NSS apply Medi honey and calcium alginate every day has 2 out of 7 days with no documented treatments. Right Lateral Knee Cleanse with NSS Monday, Wednesday, Friday has 1 out of 7 days with no documented treatments. Right Lateral Lower Leg: Cleanse with NSS, apply Xeroform Monday, Wednesday, Friday has 5 out of 10 days with no documented treatments. Right Lateral Lower Leg: Cleanse with NSS, apply Medi honey and calcium alginate every day has 14 out of 31 days with no documented treatments. Apply Xeroform over any exposed bone, wet to dry with Dakin's solution twice a day has 13 out of 33 wound changes with no documented treatments. Dakin's 1/2 strength 0.25 % sodium hypochlorite apply to right gluteal fold every day and night shift has 3 out of 7 wound changes with no documented treatments. Gentamicin Sulfate Ointment 0.1 % Apply right gluteal ischial topically every day and night shift for wound care Cleanse with 1/2 strength Dakin's apply gentamicin ointment with calcium alginate Twice a day and prn have 14 out of 29 wound changes with no documented treatments. Right gluteal ischial Cleanse with Dakin's 1/2 strength pack loosely with iodoform gauze every day and night shift have 9 out of 33 wound changes with no documented treatments. R4 Treatment Administration Record dated 01/01/23 - 01/31/23 document in part: Gentamicin Sulfate Ointment 0.1 % Apply to Left Lateral lower leg topically every day shift Clean with 1/2 Dakin's apply gentamicin ointment daily and PRN shift has 15 out of 18 days with no documented treatments. Santyl ointment 250 unit/gm (gram) apply to left heel every day has 2 out of 2 days with no documented treatments. Santyl ointment 250 unit/gm (gram) apply to left knee every day has 4 out of 6 days with no documented treatments. Santyl ointment 250 unit/gm (gram) apply to left lateral lower leg cleanse with 1/2 strength Dakin's every day has 2 out of 4 days with no documented treatments. Santyl ointment 250 unit/gm (gram) apply to left lateral lower leg cleanse with NSS apply calcium alginate daily and prn has 4 out of 9 days with no documented treatments. Left Heel cleanse with NSS apply Xeroform Monday, Wednesday, Friday has 7 out of 8 days with no documented treatments. Left lateral knee cleanse with NSS paint with betadine every day has 14 out of 18 days with no documented treatments. Right Heel cleanse with NSS apply Xeroform Monday, Wednesday, Friday has 8 out of 9 days with no documented treatments. Right Lateral Lower Leg: Cleanse with NSS, apply Xeroform Monday, Wednesday, Friday has 7 out of 8 days with no documented treatments. Right Lateral Lower Leg: Cleanse with NSS, apply Medi honey and Calcium alginate every day has 14 out of 18 days with no documented treatments. Gentamicin Sulfate Ointment 0.1 % Apply right gluteal ischial topically every day and night shift for wound care Cleanse with 1/2 strength Dakin's apply gentamicin ointment with calcium alginate Twice a day and prn have 26 out of 36 wound changes with no documented treatments. R4 Wound Care Note dated 10/20/22 document in part: Left Lateral Lower Leg non-pressure Size in cm (centimeters) 7.4x3.4x0.4. Right Gluteal Ischial Pressure Size in cm (centimeters) 1.5x2.2x3.7. Right Lateral Lower Leg non-pressure Size in cm (centimeters) 11.6x3.5x0.3. Right Lateral Knee non-pressure Size in cm (centimeters) 0.8x0.8x0.1. R4 Wound Care Note dated 11/10/22 document in part: Left Lateral Lower Leg non-pressure Size in cm (centimeters) 8.5x4.2x0.4. Right Gluteal Ischial Pressure Size in cm (centimeters) 2x1.8x2.3. Right Lateral Knee non-pressure Size in cm (centimeters) 1x0.4x0.1. R4 Wound Care Note dated 11/17/22 document in part: Left Lateral Lower Leg non-pressure Size in cm (centimeters) 9x4.5x0.5. Right Gluteal Ischial Pressure Size in cm (centimeters) 2x2x2.8. Right Lateral Lower Leg non-pressure Size in cm (centimeters) 12x3x0.4. R4 Wound Care Note dated 12/01/22 document in part: Left Lateral Lower Leg non-pressure Size in cm (centimeters) 14x5x1.3. Right Lateral Lower Leg non-pressure Size in cm (centimeters) 14x5x1.2. Left Lateral Knee Size in cm (centimeters) 0.8x0.4x0.1. R4 Wound Care Note dated 12/07/22 document in part: Left Lateral Lower Leg non-pressure Size in cm (centimeters) 16x8.5x1.3. Right Lateral Lower Leg-Proximal Reopen non-pressure Size in cm (centimeters) 1.2x0.8x0.1. R4 Wound Care Note dated 12/21/22 document in part: Left Lateral Lower Leg non-pressure Size in cm (centimeters) 17.3x7.5x1.2. Right Gluteal Ischial Pressure Size in cm (centimeters) 2x3.2x2.5. Right Lateral Knee non-pressure Size in cm (centimeters) 3.2x4x0.1. Right Heel pressure Size in cm (centimeters) 3.5x3x0. Left Heel pressure Size in cm (centimeters) 2.5x3.5x0. R4 Wound Care Note dated 01/18/23 document in part: Right Gluteal Ischial Pressure Size in cm (centimeters) 8x7.8x2.4. Right Lateral Lower Leg non-pressure Size in cm (centimeters) 15.5x4.2x1.2. Left Lateral Knee non-pressure Size in cm (centimeters) 3.5x3.8x0. Right Heel pressure Size in cm (centimeters) 7x7.4x0.2. Left Heel pressure Size in cm (centimeters) 3.5x7x01. Left Post Knee Size in cm (centimeters) 2x3.7x0.1. Left Anterior Knee Size in cm (centimeters) 2x2x0.1. R4 Wound Care Note dated 02/08/23 document in part: Right Gluteal Ischial Pressure Size in cm (centimeters) 8x7.4x2.8. R4 Hospital Record dated 11/27/22 document in part; Final Hospital Diagnosis: Chronic osteomyelitis of fibula, Pyogenic arthritis of left knee joint, Decubitus ulcer of right perineal ischial region, stage 4. R4 presented to the hospital due to newer wounds on bilateral lower extremities with exposed bone. Initially started as superficial wounds about 2 months prior. R4 came to the hospital from the nursing home facility due to worsening of wounds on both legs. admitted [DATE] with chronic bilateral fibulas (and likely tibial) osteomyelitis with worsening bilateral lower extremity wounds and sacral decubitus ulcer. Wounds on bilateral lower extremities, red granulation tissue with exposed bone. Imaging: X-ray Lower Leg/Tibia-Fibula Bilateral 2 views. Final Result: 1. Soft tissue wounds along the distal bilateral lower extremities, greater on left. Periosteal reaction involving the adjacent bilateral fibula concerning for chronic osteomyelitis. With respect to R4 new bilateral lower extremity wounds, has new findings of chronic appearing lateral ulcerative changes with bone exposure (fistula). This is likely also in the setting of chronic pressure. On 02/22/23 at 08:37 AM the surveyor entered R4 room. R4 was observed lying in a supine position with a pillow under the lower extremities. R4 stated the old wound care team walked out when the facility was making its transition and they had no one to do wound care. The old Director of nursing told V41 (Former Wound Care Nurse) that the residents don't have to have wound care every day, and they can miss a day. I still do not get my wound care done daily. The facility tried to make the floor nurses do the wound care, but they don't know how to do it or what medicine go on each leg. My legs got worse. V41 came in and started doing wounds but it was not an everyday thing. V38 (Nurse Consultant) said the facility was getting a wound care team coming in but about the time they came you could see the bone in my leg, and I was sent out to the hospital to get my legs checked out. The Certified Nurse assistant came in at 2 AM this morning to give me some ice water and I have not seen a Certified Nurse Assistant since then. I have never been turned every 2 hours. I have been laying on my back all night. On 02/22/23 at 10:25 AM V9 (Wound Care Coordinator) stated R4 has daily dressing changes to the buttock and Bilateral lower extremities. R4 has a low air loss mattress, and we recommend and encourage R4 to off load, turn and reposition. R4 is alert and oriented x4 and is compliant sometimes. If a resident is not turned and repositioned it can cause pressure, worsening of the wounds and drainage. I will update the care plan to include turning and repositioning R4 every 2 hours. On 02/22/23 at 10:34 AM the surveyor entered R4 room with V9 (Wound Care Coordinator). V42 (Certified Nurse Assistant) had R4 turned on his (R4) right side performing incontinent care. V42 (Certified Nurse Assistant) stated R4 had a bowel movement. R4 was noted with 4 plus pitting edema to the left lower extremity with a large indentation observed to the left lower extremity. V42 (Certified Nurse Assistant) stated R4 had a pillow under the left leg, under the knee area. A moderate amount of serosanguinous drainage was observed to the left lower extremity dressing and the edge of the dressing near the buttocks was soiled with stool. Dressing and packing to right buttocks was removed by V9. The entire buttocks appeared dark with scattered areas of light pink tissue. V9 cleaned the gluteal wound, applied Santyl/gentamycin, and packed the wound with calcium alginate. V9 stated the gluteal wound has improved since I started doing the wound care. A small open area was observed to the scrotum. V9 stated I saw the open area to the scrotum yesterday. R4 left lower extremity outer lateral area was observed with a large open area red in color with slough tissue observe to the top edge of the wound. V9 stated it was much larger, deeper, wider with a lot of slough tissue, green and yellow drainage. The surgical site to the left knee turned into a wound and has gotten worse. The right outer heel and upper ankle were observed with eschar tissue. The right lower outer lateral leg was observed with a large wound. The wound bed appeared red in color with slough tissue observed to the top area of the wound. A small open area was observed to the right ankle. The wound observed to the right lateral knee area appeared red in color with slough tissue. Open area observed to the right outer heel with eschar tissue. A total of six open areas were observed to the right lower extremity. V9 (Wound Care Coordinator) stated the right heel wound was facility acquired. On 02/22/23 at 10:56 AM V40 (Certified Nurse Assistant) knocked on R4 door while V9 (Wound Care Coordinator) was performing wound care. On 02/22/23 at 11:01 AM V42 (Certified Nurse Assistant) stated the whole wound care department left in September 2022 and the floor nurses would have to do their own wound care. R4 aide has not been in here yet. In September R4 did not have the wounds to the heels and the wounds to the lower extremities were much thinner. R4 had the one wound to the gluteal fold but the area above the gluteal fold that had to get the most packing is the newer wound. On 02/22/23 at 11:55 AM V40 (Certified Nurse Assistant) entered R4 room to perform AM care. R4 was transferred to the wheelchair using the sit to stand with three assistances. On 02/22/23 at 11:59 AM V66 (Licensed Practical Nurse) stated I saw R4 once at the beginning of the shift. It was after 8 AM when I went in to take R4 blood pressure. No one else has been in R4 room to my knowledge. On 02/22/23 at 12:40 PM V40 (Certified Nurse Assistant) exited R4 room. V40 stated This is my first day. When they were doing wound care and I knocked on the door, that was the first time that I attempted to see R4. When I start my shift, I do a view of my patients to make sure they are okay. The residents are turned and repositioned at least twice a shift and every 10 - 15 minutes. When I came over it was time for R4 to get up. Before I came over here, I am sure whoever had R4 turned R4. On 02/22/23 at 1:21 PM V38 (Nursing Consultant) stated I would have to look at R4 initial assessments. I am not a wound nurse or wound coordinator. R4 has wounds to the bilateral legs and buttocks. On 02/15/23 it is documented R4 left lateral lower leg full thickness, right gluteal ischial stage 4 pressure, left lateral knee non pressure. The facility had a wound care team coordinator, treatment nurse and the Certified Nurse Assistant that rounded with the team. The wound care team did not want to work with the new company that took over in August 2022 and the wound team exited the facility the first part of September. At that time, I would round with the wound doctor until we found a treatment nurse. The wound care doctor come to the facility on ce a week and the floor nurses did the wounds 6 days a week. I really don't want to describe R4 wounds because it would be based on my memory. R4 was seen by the nurse practitioner on 11/17/22. I reviewed the assessment, and I observed the wounds referred back to the assessment versus what I was objectively assessing with my visual assessment there was a decline in R4 wounds. At that time the orders were daily and prn (as needed). R4 likes to use pillows under the knees that causes pressure. You cannot make the resident do anything; you can care plan. On 01/12/23 R4 most recent BIMS score is 15. R4 is alert oriented to person, place, time, and situation. All we can do is educate preventive measure for the wound care. Pressure is detrimental to the healing of R4 wounds. R13 has diagnosis not limited to Cellulitis, Lack of Coordination, Dysphagia, Non-Pressure Chronic Ulcer of Other Part of Right Lower Leg with Fat Layer Exposed, Non-Pressure Chronic Ulcer of Other Part of Left Lower Leg with Fat Layer Exposed, Sepsis, Pressure Ulcer of Contiguous Site of Back, Buttock, and Hip, Stage2, Pressure Ulcer of Sacral Region, Stage 4, Weakness, Limited Activities Due to Disability, Reduced Mobility and is no longer a resident at the facility. R13 Braden Scale for Predicting Pressure Sore Risk dated 12/13/22 document in part: 3. Activity: 1. Bedfast. 4. Mobility: Completely immobile. R13 Wound Care Note dated 12/21/22 document in part: Right leg and foot non-pressure size in cm (centimeters) 58x30x0.3. Left leg and foot non-pressure size in cm (centimeters) 59x30x0.3. Back/Buttock/Hip Pressure size in cm (centimeters) 4.5x1.5x0.2. Midback with no documented measurements. R13 Wound Care Note dated 12/29/22 document in part: Midback size in centimeters 3x2x0.2. R13 Wound Care Note dated 01/04/23 document in part: Midback 4x2x0.2. Sacral Pressure reopened size in centimeters 2x2x0.1. R13 Wound Care Note dated 01/11/23 document in part: Sacral Pressure size in centimeters 4x4x0.1. R13 Wound Care Note dated 01/18/23 document in part: Midback 5x1.8x0.2. Sacral Pressure size in centimeters 5x8x0.1. R13 Treatment Administration Record dated 12/01/22 - 12/31/22 document in part: Left leg and foot cleanse with Hibiclens apply gentamycin, collagen, Unna boot every Monday, Wednesday, Friday has 0 out of 3 scheduled dressing change dates with no documented treatment. Right Hallux and 2nd and 3rd toes cleanse with Hibiclens apply gentamycin, collagen every Monday, Wednesday, Friday has 0 out of 3 scheduled dressing change dates with no documented treatment. Right leg and foot cleanse with Hibiclens apply gentamycin, collagen, Unna boot every Monday, Wednesday, Friday has 0 out of 3 scheduled dressing change dates with no documented treatment. R13 Treatment Administration Record dated 01/01/23 - 01/31/23 document in part: Gentamicin Sulfate 0.1 % (Gentamicin Sulfate (Topical)) Apply to Left leg and foot topically everyday shift for wound care cleanse with 1/2 strength Dakin's apply gentamycin ointment + adaptic cover with abd pad wrap with kerlix and ace wrap daily and PRN (as needed) has 9 out of 31 days with no documented treatments. Gentamicin Sulfate 0.1 % (Gentamicin Sulfate (Topical)) Apply to Right and Left hallux and 2nd to topically everyday shift for wound care cleanse with 1/2 strength Dakin's apply gentamycin ointment + adaptic cover with abd pad wrap with kerlix and ace wrap start date 01/13/23 has nine out of 19 days with no documented treatments. Gentamicin Sulfate 0.1 % (Gentamicin Sulfate (Topical)) Apply to Right leg and foot topically everyday shift for wound care cleanse with 1/2 strength Dakin's apply gentamycin ointment adaptic abd pad wrap with kerlix and ace wrap -Start Date- 01/13/23 has nine out of 19 days with no documented treatments. Santyl External Ointment 250 UNIT/GM (Gram) Apply to sacral topically everyday shift for wound care cleanse with 1/2 strength Dakin's apply Santyl calcium alginate cover with foam dressing daily and PRN -Start Date- 01/26/23 with 3 out of 6 with no documented treatments. Santyl Ointment 250 UNIT/GM Apply to mid back topically everyday shift for wound care cleanse with NSS (Normal Saline) apply Santyl/adaptic and foam dressing daily, and PRN has 13 out of 31 days with no documented treatments. Left Buttocks cleanse with NSS apply zinc oxide cover with foam dressing daily and prn -Start Date- 01/26/23 has 4 out of 6 days with no documented treatments. Left leg and foot cleanse with 1/2 strength Dakin's apply adaptic abd pad and kerlix and ace wrap everyday shift for wound care -Start Date- 01/01/23 -D/C (Discontinue) Date- 01/12/23 has 4 out of 12 days with no documented treatments. Right and Left Hallux and 2nd toes cleanse with 1/2 strength Dakin's apply adaptic abd kerlix wrap and ace wrap daily and PRN -Start Date- 01/01/23 -D/C Date- 01/12/23 has 4 out of 12 days with no documented treatments. Right Leg and foot cleanse with 1/2 strength Dakin's apply adaptic abd cover with kerlix ace wrap daily and prn -Start Date- 01/01/23 -D/C Date- 01/12/23 has 4 out of 12 days with no documented treatments. Right upper buttocks cleanse with NSS apply Medi honey calcium alginate cover with foam dressing everyday shift -Start Date- 01/26/23 has 4 out of 6 days with no documented treatments. Right upper buttocks-site cleanse with NSS apply adaptic cover with foam dressing 3/week and PRN every Monday, Wednesday, Friday has 6 out of 11 scheduled dressing change dates with no documented treatment. Mid Back cleanse with NSS apply Medi honey calcium alginate cover with foam dressing daily and PRN -Start Date- 01/26/23 has 4 out of 6 days with no documented treatments. On 02/22/23 at 05:22 PM V2 (Director of Nursing) stated R13 was one of the wound patients. I started here on 01/09/23 and V41 (Former Wound Care Nurse) walked out within the first week of me being here. The staff should make rounds on shift arrival to make sure the residents are alive and not on the floor. R4 is alert and oriented x4 and makes his needs and complaints known. The residents should be repositioned in bed. R4 is on a pressure reducing mattress. The purpose for turning and repositioning is to offload the areas to reduce pressure. If the treatment administration record is not signed or documented, it is not done. If it is not signed, we cannot verify that the treatments were done. R4 wounds were bad when I first started but they are getting better since the new wound coordinator. On 02/23/23 at 10:25 AM V33 (Nurse Practitioner/Infectious Disease) stated R13 has Chronic wound care following vascular issues preventing the wounds from healing. R13 has been treated for bacteria. I know at the facility I have heard from other residents about the sporadic wound care. At one point not long ago, the wound nurse was not working there anymore. I tried to follow what wound care providers was providing. We want wound care to be done as ordered. If wound care is not done for chronic and slow healing wounds, that does not help the issue and is not in the best interest because it could cause the wounds to get worst. We are trying to keep the wounds from getting infected and to heal. The wound care should be done as frequently as wound care recommend. R4 was the resident I had to discuss with the Director of nursing. When R4 came back from the hospital, wound care was ordered twice daily. If the wound care is not being done and especially if there are pictures and the measurements show that the wounds were getting worse then that is evidence that the lack of wound care is why the wounds got worse. On 02/23/23 at 12:50 PM V64 (Former Wound Care Coordinator) stated R13 was admitted with a sacral wound that closed and bilateral lower extremity vascular wounds that were chronic. The dressings were changed as order. R4 had a stage 4 pressure wound to the right gluteal fold that was facility acquired. The Bilateral Lower Extremity vascular wound were improving. The bottom part lateral left leg was larger than right lateral leg wound and was kind of wide. There were no wounds to R4 heels. I left the facility the second week of September. They were cutting staff and wanted the wound nurses to work the floor and wanted the staff nurses to do the wounds. On 02/23/23 at 01:02 PM V41 (Licensed Practical Nurse) stated R13 bilateral lower extremity wounds were improving to the point where R13 had start growing skin. There was granulation to the lower part of the wound. I was not receiving any assistance from anyone for wound care. There was no wound nurse for a couple of weeks after the wound care team left in September 2022 and the resident wounds were not getting done. V38 (Nurse Consultant) was trying to do the wounds and they wanted the nurses to do the wounds. When the wound doctor came, we could not do the whole building in one day on the wound care rounds. I became the only wound care nurse and they had no one to replace the wound care coordinator. I took a day off on a Monday, it was a couple nurses that did wound care, but they did not touch anyone on that Monday. When I returned to worked on Tuesday, I could tell by R4 bandages that R4 wound care was not done that Monday. In one day, the wound was all the way to R4 bone. I called V38 (Nurse Consultant) to witness R4 wounds. V38 told R4 it is not that bad I see a little bone I don't see any green drainage. I told R4 it was bad your bone is showing and there was green drainage. R4 was sent to the hospital and came back with orders for dressing changes twice a day. I quit because of the lack of help. R4 had wounds to both lower extremities on the lateral sides, 2 on the knees because they were not turning R4 and another wound on the gluteal fold that was facility acquired. On 02/23/23 at 03:57 V67 (Wound Care Nurse Practitioner) stated there was a couple of wound care nurses at the facility that quit. R4 has multiple wounds. When I started R4 had one small gluteal wound and it deteriorated from R4 sitting in wheelchair and going out. R4 has multiple wounds on the legs. The wounds to the legs became septic and were not improving. R4 went to hospital because of the septic arthritis. There is a potential for infection, bacterial growth and the wound bed will get worst, deteriorate, and increase in size if the dressings are not changed as ordered. R13 legs were deteriorating. Document titled Job Description undated document in part: The Certified Nurse Assistant for the Special Care Unit provides each assigned resident with routine daily nursing care and services in accordance with the resident's assessment and care plan. Policy: Titled Preventive Skin Care undated document in part It is the intent of the facility that the facility provides preventive skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well groomed, and free from pressure sores. Procedure: 4. Residents identified as being high risk for potential breakdown shall be turned and repositioned frequently to prevent redness that does not fade or blanche. Titled Activities of Daily Living undated document in part: ADL (Activities of Daily Living) care is provided throughout the day, evening and night as care planned and/or as needed. ADL care of the resident includes Assisting with movement and ambulation and ROM (Range of Motion) as indicated and care planned. Titled Turning/Repositioning Guideline undated document in part: If the resident cannot change position without the help of other(s) or cannot change position due to a splint or brace or other device the risk for skin breakdown is increased.

Based on interview and record review the facility failed to assess residents' (R4 and R6) concerns for safety in a sample of 3 residents reviewed for psychosocial concerns. This failure resulted in R4 and R6 living in fear with R6 stating the needs to sleep with one eye open affecting R6's sleep pattern due to fear that R3, who is R6's current roommate, will attack R6. Finding Include: R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITH STATUS EPILEPTICUS, HYPERLIPIDEMIA, UNSPECIFIED, INSOMNIA, UNSPECIFIED, BIPOLAR DISORDER, UNSPECIFIED, SCHIZOPHRENIA, UNSPECIFIED, SCHIZOAFFECTIVE DISORDER, UNSPECIFIED, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, ESSENTIAL (PRIMARY) HYPERTENSION(I10), UNSTEADINESS ON FEET. Facility's Final Reportable (10/21/22) regarding R3 and R4 documents in part: Based on interviews conducted, review of the resident's record, interview with the housekeeper, Social Service Worker and R4 who alleged that R3 was playing his television too loudly and he asked him to turn it down. R4 stated that they exchanged words then R3 came over to his side of the room and knocked over a basin of water used to clean himself, and said 'what you gonna do about it, you're in a wheelchair', He then balled his fist to hit me, I ducked, but he managed to graze my left eye. Staff intervened immediately but R3 had returned to his side of the room. Nurse assessed R4 for pain and bruises. R4 expressed that he was not in pain and that his eye does not hurt and feels safe in the facility. However, as per protocol, R3 was ordered out to H. P. Hospital for psych evaluation. Both Resident's care plan and assessment will be updated as appropriate. Families, MD made aware of the outcome of this investigation. Behavior Care plan (initiated 07/11/2022) notes R3 demonstrates cognitive impairment and displays behavioral symptoms related to diagnosis of severe mental illness. Behavior Care plan (initiated 10/21/2022) notes R3 has a history of aggressive behavior including verbal/physical aggression. Minimum Data Set Section G (MDS) (dated 11/24/2022) scored R3 as (2) requiring one- person physical assistance for bed mobility. M.D.S (dated 11/24/2022) scored R3 as (2) requiring one-person physical assistance for transfers. R4's Face Sheet documents resident is a [AGE] year old with diagnoses including but not limited to: PULMONARY HYPERTENSION, UNSPECIFIED, EPILEPSY, UNSPECIFIED, INTRACTABLE, WITH STATUS EPILEPTICUS, METABOLIC ENCEPHALOPATHY, NONTRAUMATIC SUBDURAL HEMORRHAGE, UNSPECIFIED, MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED, OTHER ABNORMALITIES OF GAIT AND MOBILITY, MUSCLE WASTING AND ATROPHY. Minimum Data Set Section G (MDS) (dated 11/14/2022) scored R4 as (3) extensive assistance requiring 2-person physical assistance for bed mobility. M.D.S (dated 11/14/2022) scored R4 as (3) extensive assistance requiring one-person physical assistance for transfers. R6's Face Sheet documents resident is a [AGE] year old with diagnoses including but not limited to: DISORDER OF CARTILAGE, UNSPECIFIED, GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS, MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE, OTHER ABNORMALITIES OF GAIT AND MOBILITY, OTHER LACK OF COORDINATION, UNSPECIFIED LACK OF COORDINATION, UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY , UNSTEADINESS ON FEET. R6's Minimum Data Set Section C (MDS) (dated 08/25/2022) documents R6 with a Brief Interview for Mental Statues (BIMS) score of 15. On 11/29/2022 at 12:32pm, R3 stated, I don't remember anything about that. On 11/29/2022 at 12:45pm, R6 stated, I have a concern with my roommate. I have a problem with R3, and I told the social service director many times that I don't feel safe with R3 being my roommate and all he does is listen to me and nothing is being done about my concerns and R3 is still here with me as my roommate. I have a problem with R3's behavior. R3 talks to himself all night long and I can't sleep, R3 keeps me up all night. R3 plays his television really loud all night and it prevents me from getting a good night sleep. I have to constantly keep one eye open when I sleep because R3 has severe mental illness, and I don't feel safe sleeping in the same room as R3. He does not flush the toilette after he uses it. R3 is aggressive and gets into other resident's faces. R3 gets aggressive with staff too. R3 is a bit unpredictable. I talked to the social worker, and I expressed concern to the social worker. When I try to sleep at night, I have to sleep with one eye open because of R3's behavior, his severe mental illness and the fact that R3 has physically attacked 2 residents in this facility and continues to get into resident's and staff faces in an aggressive manner. I don't know what R3 is going to do so I keep my eye on R3 at all times because I don't feel safe as he is very unpredictable. All the residents in this building know R3 and they are scared of him. On 11/29/2022 at 1:02pm, R4 stated, On 10/21/2022, I remember that day that the incident occurred between me and R3. I came into my room one day and R3 and I were roommates at the time. It was in the afternoon, R3 had his tv up real loud. I asked R3 to please turn the tv down because I had a headache. When I asked R3 to turn the tv down politely, R3 ignored me. I asked R3 to turn the tv down for the second time and R3 said to me, I used to be a boxer and I will knock you out. I don't know what triggered R3 to get up and come to my wheelchair and R3 got aggressive. R3 swung on me, and I tried to block myself, however, R3 was still able to hit me, and he gave me a black eye. I am wheelchair bound and he came to me aggressively and I tried to block it, but he was able to punch me and give me a black eye. When R3 came to my wheelchair in an aggressive manner, R3 knocked my water over with his hand. The water was standing on my bedside table and R3 knocked my water over on purpose with his hand which resulted in the water spilling on the floor. R3 had an incident on the 3rd floor as well where R3 tossed down nurses to the floor. R3 is very aggressive, and he has a mental problem, and I am wheelchair bound and I have a physical problem so R3 posed as a direct threat to me. Why is R3 still in this facility. R3 is not appropriate to be in this facility he is very aggressive and dangerous. R3 can be dangerous at times to other residents. With R3 you never know what R3 can do or what he is capable of because R3 has mental problems, and I don't feel safe with R3 at all. They moved R3 out of my room, but he's still in the building and I know for a fact that other residents fear R3 because R3 gets into resident's faces aggressively all the time. I don't feel safe with R3 in this building because he is severely mentally ill, and he is dangerous and aggressive towards others. On 11/30/2022 at 11:04am V8 (social service director) stated, On 10/21/2022 I was called by my psych tech to inform me that an altercation between R3 and R4 occurred. The nurse was there and performed a skin assessment after the altercation and R3 was not able to be redirected. R3 was aggressive and not accepting direction and loud with everything and we had to put R3 on a 1 to 1 supervision after the altercation occurred. The psychiatrist ordered to send R3 to the hospital for psychiatrist evaluation. R3 and R4 were roommates at the time the altercation occurred. R3 has mental issues and is often loud and aggressive toward staff and other residents. At times R3 cannot hold conversation and exhibits a lot of aggressive behaviors. R3 has had physical contact with another resident prior to the physical altercation with R4. It occurred with a different resident in a dining room, where R3 was aggressive and touched another resident so we had to send R3 out for psychiatric evaluation. R4 is not the only resident that was physically assaulted by R3, there have been another resident. R3 is a resident with severe mental health issues and there have been many instances where R3 verbally assaulted staff and other residents. We sent R3 to the hospital for psychiatric evaluation many times. R3 was on each resident floor, and we keep moving R3 around. R3 had incidents with other residents on each floor so we had to move R3 many times. Based on R3's behaviors, R3 is not suitable for this facility. Based on R3's behavior R3 is not appropriate for this facility. R3 is a threat to other residents. R3 is a threat to the safety of other residents and staff as well. We tried to send R3 out to other facilities, however, other facilities did not want to accept R3 back. Any times we send a resident out for psych evaluation, we send the resident with a petition and R3 was sent back to this facility stating that R3 is stable and good to return. We did indicate that R3 is a danger to self and other residents. R3 is not appropriate to have a roommat because most of the time, the roommates that share a room with R3 complain about R3. At this time, R3 is not appropriate to have a roommate because already, R3 current roommate (R6) is complaining about R3. R6 is complaining about R3 and asked me to move R3 out of the room. Since R3 has not made any physical contact with R6, I feel that it is ok for R3 and R6 to share a room. Since R3 did not physically attack R6, I feel at this time it is safe for R3 and R6 to share a room. We did not give R3 a private room because a private room is given to a resident on isolation and since R3 is not on isolation precautions, we did not place R3 in a private room. The last time R6 came to me and expressed concern pertaining to R3, R6 stated that R3 watches television really loud and late at night and R6 cannot sleep. R6 also expressed to me that R3 talks to self and R6 expressed some concerns with R3's behavior. R6 requested that we remove R3 from his room. R6 expressed concerns with R3 and requested for R3 to be moved out of R6's room. R6 did express to me that R3 watches television loudly in the late hour. I explained the rules to R6 that if a resident complains about their roommate, then the resident who is complaining is the one who will be moved out. I said to R6 that if he is complaining about R3 that I have to look for a room for R6 and move R6 instead of moving R3. R6 was residing in that room first, before R3. R6 stated that R6 did not want to be moved. R6 wanted us to move R3 out. One of the staff members complained that R3 aggressively got into their face and was not able to be redirected. On 12/01/2022 at 10:21am V1 (administrator) stated, I am the abuse coordinator. The facility policy is that all staff have to report any kind of abuse and all staff have to watch and monitor for any kind of resident abuse. It is mandatory for staff to report any form of abuse to the administrator. If any kind of abuse is reported, we investigate. We have cameras and we do a full investigation into abuse allegations. Any kind of abuse such as resident to resident or staff to resident is investigated and we have to report it to the state agency anything regarding any sort of harm allegation that was reported we have to report it to the state. Depending on the type of abuse that is reported, we investigate, and we also report it to the resident's physician. If there is an abuse allegation which involves resident to resident, we immediately separate the residents. If the abuse allegation is between 2 roommates, we separate them and move them to different locations and we assess the residents for injuries. The aggressor is sent out and also if there are injuries involved, we send the resident out. If there is a issues between 2 roommates and the 2 roommates are not getting along, we try to accommodate the needs and desires of the existing roommate that was there in that particular room. If we move a new roommate into the room of an existing resident residing in that room and if there is a problem between the 2 roommates, then we accommodate the needs of the existing roommate, unless the existing roommate that was there first is the one that causes the problems and issues. Typically, if the new roommate that was moved into the room of another roommate is the one causing issues, we move that resident out of that room. I started working at this facility on November 8 and I am not familiar with what occurred between R3 and R4. I am not aware that R6 is having problems with his current roommate, R3. I am not aware that R6 fears R3 so I will talk to the social service director. If R6 is having issues with R3 and he is afraid of R3, then we have to accommodate R6's wishes and we have to move R3. R6 is the original roommate in that room, so we will move R3 out of that room to accommodate R6 and make sure that R6 feels safe. I was not made aware by the social service director that R6 is afraid of R3. I was not made aware by social service director that there are existing issues between R3 and R6 and that R6 cannot sleep and is afraid to sleep. That should never occur no resident should live in fear, and I am taking action immediately to move R3 out and we will place R3 into a room by himself. R6 is our guest and R6 and any other resident should never have to be afraid to sleep and fear their roommate. R3 should have been in the room by himself and not placed into a room with any other resident if R3 is constantly aggressive towards other residents and staff, but I was not made aware of this at all. I had no knowledge that R6 is having issues with R3 and if I was made aware by social service, then R3 would have been placed in a room by himself. I will move R3 into a private room immediately. I will also look into possibly finding R3 a more suitable facility which can accommodate R3's severe mental health issues. It is not original occupant of the room, so the original occupant should be accommodated, unless the original occupant of that room is the one causing the issue. On 12/01/2022 at 6:48pm, V36 (psychiatrist) stated The incident between R3 and R4 happened on 10/21/2022 and after the incident, R3 was sent out to the hospital for psychiatric and R3 was admitted . R3 was admitted for a while and then sent back to the facility. I was informed from a nurse at the nursing home that when R3 came back to the facility, R3 is more calm and more compliant with medications and more manageable. So far there has been no aggression from R3 toward other resident. At this time R3 is more manageable due to R3's last psych admission. I told the nursing facility that R3 does not get along with his current roommate and has issues with any roommate R3 has and R3 should be in a room by himself. I told the social service director that R3 should be in a room by himself because R3 does not get along with any resident because of R3's severe mental illness. R3 is a man of his own mind and suffers from severe mental illness and R3 should be in a room by himself for safety of other residents. R3's Progress Note (10/21/2022) documents, Made aware by co-staff of resident in his room with physical aggression towards his roommate. Both immediately separated and placed 1:1 with staff. Remains verbally aggressive and refused writer to assess him. Facial scratches observed refuse writer to cleanse and dress area. doctor called and made aware. New order to transfer to hospital noted and carried out. Admin and DON made aware. Report given and hospital states okay to transfer to ED (emergency department). Ambulance made aware with ETA 40 mins. State Guardian office call and made aware. All necessary paperwork completed. R3's Social Service Behavior Note (dated 10/21/2022) documents, Per report, resident was involved in an altercation with his roommate. Resident was difficult to re-direct and non-receptive to counseling as he continues to be disruptive on the unit. Resident's physician was contacted and ordered the resident to be petitioned Hospital for a psyche evaluation. Resident is currently placed on 1:1 behavior monitoring and supervision until paramedic arrives. Staff will continue to monitor, follow up and document progress accordingly. R4's Progress Note (dated 10/21/2022) documents, Alert to resident roommate being physically aggressive toward him. Staff separated them and placed 1:1. Head to toe assessment reveals no injuries. Denies pain or discomfort. No bruising or redness noted. Admin and DON made aware. Doctor called and made aware. POA made aware and thanked writer. Resident instructed to notify the nurse with any concerns/issues. Staff to monitor psychosocial wellbeing. Able to verbalize all needs. Petition for Involuntary/ Judicial Admission (dated 10/21/2021) documents that R3 has displayed physical aggression toward R4 a male peer with harm and is recommended for immediate hospitalization for evaluation. Resident Rights Policy (undated) states: You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. Room Changes-Resident Rights Policy (undated) states: Resident/Responsible party will be informed of their right to refuse to transfer to another room in the facility. Abuse Prevention Policy (undated) states: It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. This facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other.

Based on observation, interview, and record review, facility failed to follow their policy to ensure initial fall risk assessments and fall prevention interventions are completed for 1 (R14) out of 3 residents reviewed for accident and prevention. This failure resulted in R14 sustaining a fall, being transferred for hospital evaluation and requiring stitches to the forehead. Findings include: On 11/30/2022 at 2:17 PM, V2 (Director of Nursing) stated she (V2) has been working here 8 weeks. V2 stated, Upon admission you have to do an initial fall risk assessment. This is important because if you know the resident has an unsteady gait you can aid preventing falls by providing them with the necessary interventions. Once somebody falls, we do initial the fall risk assessment and do the follow up as a team. There were no initial fall risk assessments done for R14. V2 stated, R14 fell on [DATE]. R14 fell again on 10/11/2022. When R14 fell on [DATE], he had a laceration on his head. V2 stated, I am not sure if R14 had any initial fall interventions in place. I don't think they did an initial fall risk assessment. I just started around that time and hadn't gotten my full bearings yet. V2 stated the purpose of the care plan is to keep up with the patient's treatment plan. V2 also stated that if there is change of status whether the interventions were working or not, the care plan would be updated. The initial fall risk assessment could have helped to appropriately monitor the resident and provide him (R14) with the necessary fall prevention interventions to prevent him from falling and injuring himself. R14's progress note by LPN (10/10/2022) documents in part: R14 observed on the floor sitting on buttocks with wheelchair near unlocked and no socks on his (R14) feet. R14 stated he (R14) was attempting to go to the bathroom and fell . Head to toe assessment obtained and no abnormal findings noted. No deviation from mental/physical baseline. R14's progress note by LPN (10/12/2022) documents in part: Nurse assessed R14 since R14 is a re-admission back to facility post fall. R14 is alert and oriented x1. R14 has stitches in middle of forehead, right leg wound and wound on right heel, wound on left heal and wound on right elbow. R14's Physician progress note (12/24/2022) documents in part: R14 was sent to outside hospital on 10/11/2022 due to fall. R14 hit his head. R14 received stitches to the forehead. Facility's Reported Incident for R14's fall incident (10/11/2022): On 10/11/2022, R14 sustained fall incident with head injury. 10/11/2022 - Full assessment completed. Ice pack applied. Area cleansed with normal saline solution with pressure dressing applied. Pain assessed. 911 notified. MD notified. Family notified. Transported to emergency department for evaluation and treatment. On 10/12/2022 at 7:38 PM, R14 returned to facility. Full assessment completed. Sutures noted to forehead. Pain management in place. Based on a thorough review of R14's medical record, staff, and resident interview, the incident was determined to be contributed by R14 attempting to ambulate out of bed without staff assistance. Sutures to forehead remain intact with follow up appointment scheduled for removal of sutures. Reviewed R14's Electronic Medical Record. No documentation of initial fall risk assessment. Reviewed R14's care plan. No documentation of fall prevention interventions prior to 10/10/2022. Facility's Fall Prevention Protocol documents in part: Fall risk assessment is completed upon admission and readmission. Implement individualized approaches/interventions based on resident's risk. The Fall Prevention Strategies/Interventions list are used to identify appropriate interventions. Interdisciplinary care plan should be implemented for residents at risk and interventions to prevent falls.

Based on interviews and record reviews, the facility failed to keep residents (R1, R2, R4, R10, and R11) free from abuse for 5 of 9 residents reviewed for abuse. This failure resulted in R3 and R4 having an altercation, resulting in R3 punching R4 in the eye and R4 sustaining a bruised right eye and R4 feeling unsafe around R3. This failure also resulted in being attacked by R11 and R18 and R10 sustaining an orbital fracture. Findings include: R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITH STATUS EPILEPTICUS, HYPERLIPIDEMIA, UNSPECIFIED, INSOMNIA, UNSPECIFIED, BIPOLAR DISORDER, UNSPECIFIED, SCHIZOPHRENIA, UNSPECIFIED, SCHIZOAFFECTIVE DISORDER, UNSPECIFIED, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, ESSENTIAL (PRIMARY) HYPERTENSION(I10), UNSTEADINESS ON FEET. Facility's Final Reportable (10/21/22) regarding R3 and R4 documents in part: Based on interviews conducted, review of the resident's record, interview with the housekeeper, Social Service Worker and R4 who alleged that R3 was playing his television too loudly and he asked him to turn it down. R4 stated that they exchanged words then R3 came over to his side of the room and knocked over a basin of water used to clean himself, and said 'what you gonna do about it, you're in a wheelchair', He then balled his fist to hit me, I ducked, but he managed to graze my left eye. Staff intervened immediately but R3 had returned to his side of the room. Nurse assessed R4 for pain and bruises. R4 expressed that he was not in pain and that his eye does not hurt and feels safe in the facility. However, as per protocol, R3 was ordered out to H. P. Hospital for psych evaluation. Both Resident's care plan and assessment will be updated as appropriate. Families, MD made aware of the outcome of this investigation. Behavior Care plan (initiated 07/11/2022) notes R3 demonstrates cognitive impairment and displays behavioral symptoms related to diagnosis of severe mental illness. Behavior Care plan (initiated 10/21/2022) notes R3 has a history of aggressive behavior including verbal/physical aggression. Minimum Data Set Section G (MDS) (dated 11/24/2022) scored R3 as (2) requiring one- person physical assistance for bed mobility. M.D.S (dated 11/24/2022) scored R3 as (2) requiring one-person physical assistance for transfers. R4's Face Sheet documents resident is a [AGE] year old with diagnoses including but not limited to: PULMONARY HYPERTENSION, UNSPECIFIED, EPILEPSY, UNSPECIFIED, INTRACTABLE, WITH STATUS EPILEPTICUS, METABOLIC ENCEPHALOPATHY, NONTRAUMATIC SUBDURAL HEMORRHAGE, UNSPECIFIED, MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED, OTHER ABNORMALITIES OF GAIT AND MOBILITY, MUSCLE WASTING AND ATROPHY. Minimum Data Set Section G (MDS) (dated 11/14/2022) scored R4 as (3) extensive assistance requiring 2-person physical assistance for bed mobility. M.D.S (dated 11/14/2022) scored R4 as (3) extensive assistance requiring one-person physical assistance for transfers. On 11/29/2022 at 12:32pm, R3 stated, I don't remember anything about that. On 11/29/2022 at 1:02pm, R4 stated, On 10/21/2022, I remember that day that the incident occurred between me and R3. I came into my room one day and R3 and I were roommates at the time. It was in the afternoon, R3 had his tv up real loud. I asked R3 to please turn the tv down because I had a headache. When I asked R3 to turn the tv down politely, R3 ignored me. I asked R3 to turn the tv down for the second time and R3 said to me, I used to be a boxer and I will knock you out. I don't know what triggered R3 to get up and come to my wheelchair and R3 got aggressive. R3 swung on me, and I tried to block myself, however, R3 was still able to hit me, and he gave me a black eye. I am wheelchair bound and he came to me aggressively and I tried to block it, but he was able to punch me and give me a black eye. When R3 came to my wheelchair in an aggressive manner, R3 knocked my water over with his hand. The water was standing on my bedside table and R3 knocked my water over on purpose with his hand which resulted in the water spilling on the floor. R3 had an incident on the 3rd floor as well where R3 tossed down nurses to the floor. R3 is very aggressive, and he has a mental problem, and I am wheelchair bound and I have a physical problem so R3 posed as a direct threat to me. Why is R3 still in this facility. R3 is not appropriate to be in this facility he is very aggressive and dangerous. R3 can be dangerous at times to other residents. With R3 you never know what R3 can do or what he is capable of because R3 has mental problems, and I don't feel safe with R3 at all. They moved R3 out of my room, but he's still in the building and I know for a fact that other residents fear R3 because R3 gets into resident's faces aggressively all the time. I don't feel safe with R3 in this building because he is severely mentally ill, and he is dangerous and aggressive towards others. On 11/30/2022 at 11:04am V8 (social service director) stated, On 10/21/2022 I was called by my psych tech to inform me that an altercation between R3 and R4 occurred. The nurse was there and performed a skin assessment after the altercation and R3 was not able to be redirected. R3 was aggressive and not accepting direction and loud with everything and we had to put R3 on a 1 to 1 supervision after the altercation occurred. The psychiatrist ordered to send R3 to the hospital for psychiatrist evaluation. R3 and R4 were roommates at the time the altercation occurred. R3 has mental issues and is often loud and aggressive toward staff and other residents. At times R3 cannot hold conversation and exhibits a lot of aggressive behaviors. R3 has had physical contact with another resident prior to the physical altercation with R4. It occurred with a different resident in a dining room, where R3 was aggressive and touched another resident so we had to send R3 out for psychiatric evaluation. R4 is not the only resident that was physically assaulted by R3, there have been another resident. R3 is a resident with severe mental health issues and there have been many instances where R3 verbally assaulted staff and other residents. We sent R3 to the hospital for psychiatric evaluation many times. R3 was on each resident floor, and we keep moving R3 around. R3 had incidents with other residents on each floor so we had to move R3 many times. Based on R3's behaviors, R3 is not suitable for this facility, R3 is not appropriate for this facility. R3 is a threat to other residents. R3 is a threat to the safety of other residents and staff as well. Any times we send a resident out for psych evaluation, we send the resident with a petition and R3 was sent back to this facility and were told by hospital nurse that R3 is stable and good to return. We did indicate that R3 is a danger to self and other residents. R3 is not appropriate to have a roommate because most of the time, the roommates that share a room with R3 complain about R3. At this time, R3 is not appropriate to have a roommate because R3's current roommate (R6) is complaining about R3. One of the staff members complained that R3 aggressively got into their face and was not able to be redirected. On 12/01/2022 at 10:21am V1 (administrator) stated, I am the abuse coordinator. The facility policy is that all staff have to report any kind of abuse and all staff have to watch and monitor for any kind of resident abuse. It is mandatory for staff to report any form of abuse to the administrator. If any kind of abuse is reported, we investigate. We have cameras and we do a full investigation into abuse allegations. Any kind of abuse such as resident to resident or staff to resident is investigated and we have to report it to the state agency anything regarding any sort of harm allegation that was reported we have to report it to the state. Depending on the type of abuse that is reported, we investigate, and we also report it to the resident's physician. If there is an abuse allegation which involves resident to resident, we immediately separate the residents. If the abuse allegation is between 2 roommates, we separate them and move them to different locations and we assess the residents for injuries. The aggressor is sent out and also if there are injuries involved, we send the resident out. If there is an issue between 2 roommates and the 2 roommates are not getting along, we try to accommodate the needs and desires of the existing roommate that was there in that particular room. If we move a new roommate into the room of an existing resident residing in that room and if there is a problem between the 2 roommates, then we accommodate the needs of the existing roommate, unless the existing roommate that was there first is the one that causes the problems and issues. Typically, if the new roommate that was moved into the room of another roommate is the one causing issues, we move that resident out of that room. I started working at this facility on November 8 and I am not familiar with what occurred between R3 and R4. R3 should have been in the room by himself and not placed into a room with any other resident if R3 is constantly aggressive towards other residents and staff, but I was not made aware of this at all. I will move R3 into a private room immediately. I will also look into possibly finding R3 a more suitable facility which can accommodate R3's severe mental health issues. On 12/01/2022 at 6:48pm, V36 (psychiatrist) stated The incident between R3 and R4 happened on 10/21/2022 and after the incident, R3 was sent out to the hospital for psychiatric and R3 was admitted . R3 was admitted for a while and then sent back to the facility. I was informed from a nurse at the nursing home that when R3 came back to the facility, R3 is more calm and more compliant with medications and more manageable. So far there has been no aggression from R3 toward other resident. At this time R3 is more manageable due to R3's last psych admission. I told the nursing facility that R3 does not get along with his current roommate and has issues with any roommate R3 has and R3 should be in a room by himself. I told the social service director that R3 should be in a room by himself because R3 does not get along with any resident because of R3's severe mental illness. R3 is a man of his own mind and suffers from severe mental illness and R3 should be in a room by himself for safety of other residents. R3's Progress Note (10/21/2022) documents, Made aware by co-staff of resident in his room with physical aggression towards his roommate. Both immediately separated and placed 1:1 with staff. Remains verbally aggressive and refused writer to assess him. Facial scratches observed refuse writer to cleanse and dress area. Doctor called and made aware. New order to transfer to hospital noted and carried out. Admin and DON made aware. Report given to hospital and states okay to transfer to ED (emergency room ) ambulance made aware with ETA (estimated time of arrival) 40 mins. State Guardian office call and made aware. All necessary paperwork completed. R3's Social Service Behavior Note (dated 10/21/2022) documents, Per report, resident was involved in an altercation with his roommate. Resident was difficult to re-direct and non-receptive to counseling as he continues to be disruptive on the unit. Resident's physician was contacted and ordered the resident to be petitioned to Hospital for a psyche evaluation. Resident is currently placed on 1:1 behavior monitoring and supervision until paramedic arrives. Staff will continue to monitor, follow up and document progress accordingly. R4's Progress Note (dated 10/21/2022) documents, Alert to resident roommate being physically aggressive toward him. Staff separated them and placed 1:1. Head to toe assessment reveals no injuries. Denies pain or discomfort. No bruising or redness noted. Admin and DON made aware. Doctor called and made aware. POA made aware and thanked writer. Resident instructed to notify the nurse with any concerns/issues. Staff to monitor psychosocial well being. Able to verbalize all needs. Petition for Involuntary/ Judicial Admission (dated 10/21/2022) documents that R3 has displayed physical aggression toward R4 a male peer with harm and is recommended for immediate hospitalization for evaluation. Abuse Prevention Policy (undated) states: It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. This facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other. 40061 R10's Quarterly MDS (Minimum Data Set) assessment dated [DATE] documents in part that R10 is cognitively intact. On 11/30/2022 at 2:17 PM, surveyor entered R10's room for an interview. R10 was oriented to person, place, and time. R10 stated a few weeks ago R11 and R18 came into [R10's] room and shut the door. R10 stated R11 and R18 told [R10] to keep [R10's] mouth shut. R10 stated They were talking about people getting extorted and for me to keep my mouth shut. They thought I snitched on them or something, but I didn't know what they were talking about. Then they just started hitting me. One came on this side of my bed (pointed to side by window) and the other came on this side (side by the bathroom). They just started hitting me. I got knocked out and fell unconscious and fell out the bed. Then they started stomping on me. I was unconscious until they left. Don't know what happened after that. R10 stated When I woke up from the floor, my face was all busted. I was hurting in my face. My nose was fractured. I have to take an inhaler to help me breathe. My jaw and the inside of my mouth were cut. I thought I needed stitches, but they told me to just let it heal. Couple of days later I had to go to the hospital because I couldn't see that well. I had to keep squinting to see. On 12/01/2022 at 9:51 AM, V25 (Nurse) stated [V25] assessed R11 after the incident. V25 stated [R11] told me [R11] went up to the second floor and they [R10 and R11] got into an altercation. [R11] said [R10] called [R11] out of [R11's] name. [R10] said something derogatory to [R11] so they got into an altercation. During a telephone interview with V34 (Human Resources) on 12/01/2022 at 10:44 AM, V34 stated [V34] was the Manager on Duty at the time of the incident. V34 stated staff alerted [V34] to come to R10's room. When V34 entered R10's room, R10 was on the floor. R10 stated two residents came into R10's room saying [R10] stole something and that the two residents put their hands on R10. V34 stated R10 had blood to the face. V34 stated [R11] said when [R11] approached [R10], [R10] kept calling [R11] out of [R11's] name. Even after [R11] walked out the room, [R10] kept calling [R11] out of [R11's] name. That's when [R11] turned around and [R11] used the term 'cold cock' when [R11] told me. V34 stated [R11] said [R10] was calling [R11] out of [R11's] name. I don't remember the verbiage, but it was derogatory. 'Cold cock' means [R11] hit [R10]. V34 stated staff called emergency services, but R10 initially declined hospital evaluation. On 12/01/2022 at 11:56 AM, V37 (Psychiatric Rehabilitation Services Coordinator) stated when staff reviewed the camera footage, they saw R11 and R18 enter R10's room. V37 stated On camera, both [R18] and [R11] went in [R10's] room at the same time. They weren't in there a long time then they left together. Then afterwards I guess [R10] alerted the staff and the nurse called [V34]. V26's (Nurse) progress note for R10, dated 10/23/2022 11:18 AM, documents in part: . informed that resident was sitting on the floor of [R10's] room and had been injured. Upon entering the room resident was sitting on [R10's] floor. [R10] was alert and talking. [R10] stated that 2 residents had come into [R10's] room and began hitting [R10] while [R10] was sitting on [R10's bed. Noted blood on [R10's] upper torso, face, nose, and hand. Noted broken blood vessels to the right eye. Assessed body and cleansed blood from torso and hands. Noted blood was coming from resident's nose. R10's physician order sheets document in part an order to transfer R10 to the hospital for evaluation and treatment related to blurred vision in the right eye the day after the incident. R10's hospital records dated 10/24/2022 document in part R10's complaint in the emergency room included head, neck, and jaw pain related to getting punched in the face at the nursing home. Imaging studies and V39's (emergency room Physician) notes document in part a diagnosis of orbital fracture. R10's discharge instructions included as needed medications to alleviate congestion to help R10 avoid blowing [R10's] nose as it can increase pressure around the fracture and cause muscle entrapment, and permanent vision damage. R1's Quarterly MDS assessment dated [DATE] documents in part that R1 is cognitively intact. On 11/30/2022 at 1:46 PM, surveyor entered R1's room for an interview. R1 was alert and oriented to person, place, time, and situation. R1 stated R2 thought R1 took R2's shoes. R1 stated [R2] saw that I had shoes under the bed. I told [R2] they were my shoes, but [R2] said it was [R2's]. So, when I tried to grab my shoes so [R2] couldn't get to them, [R2] started swinging at me. [R2] hit me on me left shoulder. I was trying to grab my shoes, so I hit [R2] back. R1 stated V27 (Nurse) came in shortly after and separated them. R2's Admission MDS assessment dated [DATE] documents in part that R2 has severe cognitive impairment. Surveyor attempted interview with R2 on 11/30/2022 at 1:32 PM. R2 was oriented only to self. R2 could not recall altercation with R1. V27's progress note for R2, dated 10/12/2022 5:46 PM, documents in part: Resident with increased confusion and agitated, approached roommate bed stating [R2's] shoes was underneath [R1's] bed. Resident was hit by [R1] with handle from wheelchair mirror. Noted with [small] laceration on [left] finger [with small] bleeding. V37's progress note for R1, dated 10/12/2022 5:39 PM, documents in part: Per staff's report, resident was involved in an altercation with [R1's] roommate on the second-floor unit. Resident was difficult to re-direct and non-receptive to counseling as [R1] continues to threaten physical aggression towards peers. Facility's Abuse Prevention Program last revised 11/08/2012 documents in part: It is the policy of this facility to prohibit resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based upon observation, interview and record review the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R6's right foot dressing adhered to wounds, infection and foot pain rated 9/10. Findings include: R6's (7/6/22) BIMS (Brief Interview Mental Status) determined a score of 13 (cognitively intact). R6's (September 2022) Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (7/15/22) Right lateral foot wound cleanse with normal saline solution, apply iodosorb with [MEDICATION(S)] in peri wound daily. On 9/26/22 at 11:56am, R6 stated The dressing on my foot it supposed to be changed every day but it's not. I went a whole week without them doing it. (V5/Wound Care Nurse) walked off about 2 weeks ago, now ain't nobody done nothing for my wound since then. One nurse just wrapped it up but didn't put nothing on it. Another nurse put [MEDICATION(S)] and wrapped it up that's it. They told me to put this other stuff on it cause they don't have nothing on the cart, that's what they said. They call themselves doing my dressing but don't put on nothing, no medicine. Surveyor inquired what other stuff he was referring to R6 presented iodosorb which was in his dresser and affirmed he received this from the hospital (not the facility). Surveyor inquired about pain R6 responded About a week ago I got pain in my foot (rated 8-10). I can't sleep but an hour or two cause I just toss and turn. I wake up from the pain. I take Tylenol every night but it don't help. R6's (September 2022) TAR (Treatment Administration Record) affirms daily treatments to the right lateral foot were NOT documented on 9/2, 9/6, 9/7, 9/11, 9/13, 9/14, 9/17, 9/18, 9/19, 9/20, 9/21, 9/23, 9/24 and 9/25 (14 out of 25 days). On 9/26/22 at 12:48pm, surveyor inquired about concerns with R6's right foot dressing dated 9/24 (2 days prior) V3 (Nurse Consultant) replied It says the 24th, todays the 26th. V3 attempted to remove R6's right foot dressing (calcium alginate covered with gauze - which were not the correct treatments) however it was stuck to both lateral wounds. Surveyor inquired about R6's dressing V3 responded It looks like calcium alginate with gauze however neither were ordered for R6's wounds. V3 poured normal saline atop of R6's dressing and attempted to remove it slowly, a moderate amount of purulent drainage was noted, and calcium alginate was adhered to the wound. V3 stated I see purulent drainage and alginate stuck on. V3 replied I don't think he is( on antibiotics), I'm gonna call the doctor as soon as were done. Immediately after V3 completed the dressing change, R6 reported right foot pain. R6's (9/26/22) physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/29/22 at 9:21am, surveyor inquired about R6's (9/22/22) physician wound assessment V15 (Wound Care Nurse Practitioner) stated There was moderate serous drainage from the wound. V15 stated Purulent drainage is a sign of infection. On 9/29/22 at approximately 3:29pm, surveyor inquired about potential for harm to a resident if a wound becomes infected V16 (Wound Physician) stated It could cause pain. R6's (9/13/22) MAR (Medication Administration Record) affirms that Tylenol 500mg was administered at 3:08am for pain rated 9. R6's pain assessment follow-up is not documented as warranted. The (undated) management of pain policy states pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. Document on the back of the MAR/pain flow sheet the effectiveness of pain medication. Effectiveness should be measured 1-2 hours after administration.

Based upon observation, interview and record review the facility failed to ensure that the wound log was updated weekly, failed to ensure that wound care treatments are available, failed to sanitize the table prior to placing wound care supplies on it, failed to clarify (R2's) wound care orders, failed to follow (R6, R7's) wound care orders, and failed to administer treatments (daily) as ordered for three of three residents (R2, R6, R7) reviewed for pressure ulcers. These failures resulted in R2 sustaining a right gluteal/ischial pressure ulcer with bone exposure, wound infection and right buttock wound. R7 sustained a sacral pressure ulcer with bone and muscle exposure. R6 sustained a right (lateral) foot ulcer and infection. R2, R6, and R7's wounds required surgical intervention. Findings include: On 9/26/22, the current wound log was requested V1 (Administrator) presented the weekly wound report dated 7/22/22-7/28/22 (dated roughly 2 months prior). On 9/26/22 at 1:22pm, surveyor inquired about the weekly wound log V3 (Nurse Consultant) stated (V5/Wound Care Nurse) Didn't leave us anything so I have to start from scratch, see what's in PCC (Point Click Care - Electronic Medical Record) and develop a log from that. V3 affirmed that V5 quit about 2 weeks ago. __ R2's (7/5/22) BIMS (Brief Interview Mental Status) determined a score of 15 (cognitively intact). R2's (7/5/22) functional Assessment affirms (2 person) physical assist is required for bed mobility and transfers. R2's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (9/15/22) [MEDICATION(S)] gel apply to right gluteal fold every day for wound care cleanse with 1/2 strength dakin's, pat dry, apply [MEDICATION(S)]/calcium alginate cover with dry dressing (start 9/15/22). On 9/26/22 at 1:28pm, surveyor inquired about R2's daily dressing changes R2 stated Today would have been the 4th day it wasn't done but they did my wound care today, it's a must that they get done every day. I have a wound on my leg at the buttock, it's a big hole. The doctor that comes weekly, said your wounds are not being taken care of. R2's (September 2022) TAR (Treatment Administration Record) affirms the right gluteal fold treatments were NOT documented on 9/2, 9/7, 9/9, 9/11, 9/12, 9/13, 9/15, 9/17, 9/18, 9/19, 9/20, 9/21, 9/23, 9/24, and 9/25 (15 out of 25 days). On 9/27/22 at 9:57am, V3 (Nurse Consultant) removed R2's right gluteal fold dressing, a (new) large right buttock wound was observed and actively bleeding. Surveyor inquired about the bleeding wound on R2's buttock V3 responded The wound edge is bleeding, looks like a shear from the tape. Surveyor requested a description of R2's buttock wound V3 replied It's open, I'm not gonna diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 changed R2's dressing, applied skin prep (which was not ordered) and covered the right gluteal fold with a bordered dressing however the edge of the dressing (with adhesive) was placed atop of R2's open/bleeding buttock wound. On 9/29/22 at 9:05am, surveyor inquired if skin prep was ordered for R2's gluteal fold treatment V15 (Wound Care Nurse Practitioner) responded No. Surveyor inquired about potential harm if dressings are not changed (daily) as ordered V15 stated If it's not being changed as ordered there's really high risk for infection because the biofilm keeps developing and the area around it can become macerated because excess drainage is not being absorbed. On 9/29/22 at approximately 3:25pm, surveyor inquired about the status of R2's right gluteal fold wound V16 (Wound Care Physician) responded it has been a chronic [CONDITION(S)] wound and it's difficult to heal. Surveyor inquired about R2's treatment orders V16 stated He (V3/Nurse Consultant) called me and told me that dressings were not available, so I changed the order and affirmed the call was received on or about 9/26/22 (survey start date). R2's (9/8/22) physician wound assessment include right gluteal/ischial pressure ulcer with exposed bone. Infection: none. Procedure performed: excisional debridements - muscle. R2's (9/26/22) POS affirms orders were received for [MEDICATION(S)] (Antibiotic) 500-125 mg three times daily for wound. __ R7's (7/7/22) BIMS determined a score of 15 (cognitively intact). R7's (7/7/22) functional assessment affirms extensive (2 person assist) is required for bed mobility and transfers. On 9/26/22 at 1:25pm, R7 stated I got a wound on the heel of my butt, last time I had wound care was last Thursday (4 days prior) when the doctor was here. It's supposed to be done every day. R7's POS includes (5/25/22) collagen-antimicrobial sheet apply to sacrum every day for wound care. Cleanse with 1/2 strength dakins, pat dry, apply collagen and calcium alginate cover with foam dressing. R7's (September 2022) TAR affirms daily treatments were NOT documented on 9/2, 9/5, 9/7, 9/9, 9/11, 9/12, 9/13, 9/14, 9/17, 9/18, 9/19, 9/21, 9/24, and 9/25 (14 out of 25 days). On 9/27/22 at 9:47am, R7's sacral dressing was heavily soiled with a dark brown substance and only partially adhered to the skin. Surveyor inquired about concerns with R7's dressing V3 (Nurse Consultant) stated It's soiled and undated. Surveyor inquired (again) when R7's dressing was last changed R7 responded Last Thursday when the doctor was here (5 days prior). R7's wound care orders were handwritten on a dressing package (present in the room). Wound care supplies were brought into R7's room however collagen and calcium alginate were not inclusive (as ordered). V3 removed R7's sacral dressing, cleansed the wound with 1/2 strength dakins, patted the wound dry, applied skin prep (which was not ordered), a foam dressing and border dressing. Surveyor inquired about R7's calcium alginate V3 responded I don't know anything about that, I followed the order. Surveyor advised that calcium alginate was ordered for R7's wound (also written on the dressing) V3 replied I'll redo it, I'll put the calcium alginate on it. R7's (9/8/22) physician wound assessment includes sacral pressure ulcer with bone, muscle exposed. Procedures: excisional debridements removal of necrotic tissue, slough and biofilm. On 9/29/22 at 9:31am, surveyor inquired about potential harm if calcium alginate and/or collagen were not applied to R7's sacral wound (as ordered) V15 (Wound Care Nurse Practitioner) stated The purpose of the calcium alginate is to absorb exudate, so if it's not being used were not really managing the exudate. The skin could macerate and start becoming denuded. On 9/29/22 at approximately 3:33pm, surveyor inquired about the status of R7's sacral wound V16 (Wound Care Physician) stated His wound is stage 4 at least muscle. He (R7) had a surgical debridement. __ R6's (7/6/22) BIMS determined a score of 13 (cognitively intact). R6's (7/6/22) functional assessment affirms (1 person) physical assist is required for bed mobility and transfers. On 9/26/22 at 11:56am, R6 stated The dressing on my foot it supposed to be changed every day but it's not. I went a whole week without them doing it. (V5/Wound Care Nurse) walked off about 2 weeks ago, now ain't nobody done nothing for my wound since then. One nurse just wrapped it up but didn't put nothing on it. Another nurse put [MEDICATION(S)] and wrapped it up that's it. They told me to put this other stuff on it cause they don't have nothing on the cart, that's what they said. They call themselves doing my dressing but don't put on nothing, no medicine. Surveyor inquired what other stuff he was referring to R6 presented iodosorb which was in his dresser and affirmed he received this from the hospital (not the facility). R6's (September 2022) TAR affirms daily treatments to the right lateral foot were NOT documented on 9/2, 9/6, 9/7, 9/11, 9/13, 9/14, 9/17, 9/18, 9/19, 9/20, 9/21, 9/23, 9/24 and 9/25 (14 out of 25 days). R6's (September 2022) POS includes (3/11/22) Right dorsal foot wound cleanse with 1/2 strength dakins, pat dry, apply [MEDICATION(S)], cover with dry dressing daily. (7/15/22) Right lateral foot wound cleanse with normal saline solution, apply iodosorb with [MEDICATION(S)] in peri wound daily. On 9/26/22 at 12:17pm, surveyor requested to see R6's treatments V3 (Nurse Consultant) searched the treatment cart removed Dakins 1/2 strength solution and stated It's house stock, there's no name on it. V3 then removed a half empty bottle of [MEDICATION(S)] (with another residents name) stated It's not his and affirmed R6's [MEDICATION(S)] was not available on the cart. V3 searched for R6's iodosorb to no avail and stated I don't see one with his name on it. On 9/26/22 at 12:48pm, V3 returned to R6's room with an (unlabeled/opened) bottle of [MEDICATION(S)], (unlabeled) bottle of 1/2 strength dakins solution, and R6's iodosorb (which was found in the wound care office). Surveyor inquired where the wound care laptop was located (to access the electronic treatment administration record) V3 responded The prior ownership did not have them. The transition is not final yet, so there's nothing that we can do until its final with technology. V3 then walked behind the Nurse station and wrote down wound care instructions (on the back of a dressing package). V3 subsequently placed R6's wound care supplies on a visibly soiled over bed table. Surveyor inquired about concerns with R6's right foot dressing dated 9/24 (2 days prior) V3 replied It says the 24th, todays the 26th. V3 attempted to remove R6's right foot dressing (calcium alginate covered with gauze - which were not the correct treatments) however it was stuck to both lateral wounds. Surveyor inquired about R6's dressing V3 responded It looks like calcium alginate with gauze however neither were ordered for R6's wound. V3 poured normal saline atop of R6's dressing and attempted to remove it slowly, a moderate amount of purulent drainage was noted, and the calcium alginate was adhered to the wound. Surveyor inquired about the appearance of R6's wound V3 stated I see purulent drainage and alginate stuck on. Surveyor inquired if R6 was prescribed antibiotics for wound infection V3 replied I don't think he is, I'm gonna call the doctor as soon as were done. R6's (9/8/22) physician wound assessment includes right lateral foot excisional debridement. Removal of nectotic tissue, slough and biofilm. To promote healing and prevent infection. R6's (9/26/22) physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/29/22 at 9:21am, surveyor inquired about R6's (9/22/22) physician wound assessment V15 (Wound Care Nurse Practitioner) stated There was moderate serous drainage from the wound. Surveyor inquired what purulent drainage is indicative of V15 responded Purulent drainage is a sign of infection. Surveyor inquired about concerns with applying calcium alginate on R6's wound (instead of iodosorb as ordered) V15 replied The purpose of the iodosorb is to reduce the slough and to soften the tissue. The calcium alginate absorbs. On 9/29/22 at approximately 3:29pm, surveyor relayed concerns regarding incorrect treatment applied to R6's right foot wound V16 (Wound Care Physician) replied There was no order for calcium alginate, normally you put [MEDICATION(S)]. I never ordered alginate on him. __ On 9/29/22 at 3:22pm, surveyor inquired about potential harm to residents if wound care orders are not followed V16 (Wound Physician) stated If they are putting a totally different dressing or not doing the dressings wound can get infected. If they are putting something different there may be slowing of the healing. Surveyor inquired if R2, R6 and/or R7 required surgical intervention of aforementioned wounds V16 responded All of them (R2, R6, R7) have had debridement from me from time to time. The (undated) preventive skin care policy stated good skin care is provided by staff on each shift and as necessary. Medicated treatments ordered by the physician are to be applied by the licensed nurse as appropriate.

Based on interviews and record review the facility failed to ensure (R3) one of five sampled residents received medication for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, on 5/02/2022 R3 was found unconscious experiencing seizures. According to R3's death certificate the [CONDITION(S)] activity contributed to R3's death. This was identified as an immediate jeopardy situation which began on 04/02/2022. On 06/09/2022 the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on 06/10/2022. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: According to the face sheet R3 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's Minimum Data Set (MDS) assessment dated [DATE] for Significant Change in Condition indicated R3 had a [CONDITION(S)] or [CONDITION(S)] since June 4, 2020. Review of R3's care plan on 6/02/22 at 2:45 pm - Care Plan updated on 3/9/2022-Resident is at risk for [CONDITION(S)] activity related to [CONDITION(S)]. Resident will not have any injuries related to [CONDITION(S)] activity thru next review. Monitor resident for [CONDITION(S)] activity, Medication levels as ordered per MD, Administer medication as directed and follow Pharmaceutical recommendations R3's progress notes by V5 (Nurse) dated 5/2/22 at 9:30 am, R3 was noted with [CONDITION(S)] activity. V/s obtained. B/P- 80/50. R-20 p-111 spo2 (oxygen level) -85% on room air. Oxygen applied. Spo2-92% on room air. Resident positioned on her side. Resident [CONDITION(S)] activity prolonged. MD made aware. (V14) (Nurse Practitioner- NP) gave order to send R3 to nearest hospital for evaluation. 911 arrived. Resident transferred to nearest hospital. Family called. No answer. Left voice mail (v/m). Will continue to call family throughout shift. The surveyor conducted the following staff interviews regarding R3's hospital transfer on 5/02/2022 and the service provided for the prevention for any [CONDITION(S)] activity for R3. On 6/02/22 at 3:47 pm, during a telephone interview with V2 (Former Assistant Administrator), V2 said she was doing rounds and upon getting off the elevator she saw the expressions of staff faces. V2 said she can feel and tell something was going on, V2 said she asked V5 (nurse) and V5 said R3 was having a [CONDITION(S)]. I went to the room, I saw V1 (Administrator), V4 (Dietary Manager) and a new oriented nurse (V7). Three different oxygen tanks were sent to R3's room, the first 2 tanks were empty; V4 ran out of the room to get a third tank which she retrieved from the second floor. R3 was still in a [CONDITION(S)] with her body jerking. Surveyor asked V2 why they did not call a code blue, rapid response or 911. V2 stated V1 (Administrator) told me No, we are not calling 911. I left the room to go find the nurse to tell her to call 911. When I came back, V1 pulled the door up tightly and would not let me come back in. I saw how long it was taking to get help for R3, so I ignored V1's command and called 911 anyway. V2 said she wished she had called 911 right away. V2 stated R3 had not received her [CONDITION(S)] medication ([MEDICATION(S)]) since R3 was discharged to the hospital in March. V2 stated R3's [CONDITION(S)] medication ([MEDICATION(S)]) was not reordered after her return back to the facility on [DATE]. Surveyor asked V2 if R3's [CONDITION(S)] medication was to be carried over from the (POS) Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated Yes During a face- face interview on 6/02/22 at 11:02 am with V3 (Director of Nursing), surveyor asked V3 if she knew R3 did not get [MEDICATION(S)] ([CONDITION(S)] medication) for the entire month of April, May 1st and May 2, 2022. V3 stated she was not aware of that. Surveyor asked V3 if she was aware the facility did not re-order the [MEDICATION(S)] medication when R3 returned to the facility on [DATE], after a hospital stay. V3 said no, she was not made aware of R3 not getting her [CONDITION(S)] medication. On 6/03/2022 at 2:46 pm the surveyor conducted a phone interview with V5 (nurse). The surveyor asked V5 what happened on 5/02/2022 with R3. V5 said I came in the room, and they gave me the oxygen, I applied the oxygen to R3 who was having a [CONDITION(S)] and turned R3 onto her side. R3's saturation levels went up to 93% but she was still not responsive, and her body was twitching/jerking. R3 never stopped breathing so I did not call a code blue. I called the doctor and let him know R3 was still seizing. He told me to send her out to the hospital. I was told by someone, I don't remember, that 911 had already been called. Surveyor asked V5 if she was familiar with R3's history of seizures and that R3 did not have any [CONDITION(S)] medication for the month of April. V5 said no, I am new to the facility but not a new nurse, I have been a nurse for [AGE] years. Surveyor asked V5 how many times she had been R3's nurse, V5 said twice and she was not aware that R3 was supposed to get [CONDITION(S)] medication. During a telephone interview on 6/3/2022 at 2:12 pm with V6 (nurse), surveyor asked V6 if she was aware of the incident with R3 on 05/02/2022. V6 said yes, I was on the third floor and I feel very sad about the incident. Surveyor asked what she meant by that statement. V6 said there was no code blue or rapid response called. I am not saying that the outcome may have been different, but as a more experienced nurse if a code was called other nurses could have responded and given more interventions like administering some [MEDICATION(S)]. I certainly would have done more than apply oxygen and place R3 on her side. On 06/07/2022 at 12:45 pm, V7 (Certified Nursing Assistant - CNA) stated she was the CNA who provided care to R3 on 5/02/2022. V7 stated I went to feed R3, when I walked in the room I sat the tray down, R3 was having a [CONDITION(S)]. I went around the corner to get the nurse (V5) who was new here and I am new. Surveyor asked V7 if the call light was working, V7 said she didn't think to pull the call light. V7 said V5 came in, I told her R3 was having a [CONDITION(S)], V5 did the vitals, and they were low, the blood pressure number on the bottom (diastolic) was 50. The oxygen levels was in the 60's. The Administrator (V1) was in the room observing. Surveyor asked V7 approximately how long was R3's [CONDITION(S)] before the paramedics arrived. V7 stated R3 was seizing at least 40 minutes, I was trying to clean her up because I knew when the ambulance came she was going out to the hospital. On 06/07/2022 at 2:38 pm, V9 (Primary Physician) was interviewed via phone. The surveyor asked V9 if he was familiar with R3's incident on 05/02/2022. V9 said yes. The surveyor asked, V9 what would he expect the nurse to do when one of the residents has a [CONDITION(S)]? V9 stated It is pretty standard if there is a resident that has a [CONDITION(S)], especially one like R3 who has a history of seizures, I am called immediately, and the resident is sent out to the hospital immediately. Surveyor asked V9 if he received a call from the facility about R3 having a [CONDITION(S)] for over 40 minutes and never recovering consciously. V9 stated I did not get a call and that was way too long to have the resident in a [CONDITION(S)] without being in the hospital. The resident has the potential to aspirate. V9 said I do have a nurse practitioner who may have received the call. Surveyor asked V9 if he was aware that R3 had not received her [MEDICATION(S)] medication the entire month of April, May 1st and May 2, 2022. V9 responded, perhaps you mean the nurses forgot to transcribe the order but was giving the patient the medication? The surveyor responded by letting V9 know there was no order transcribed or [MEDICATION(S)] medication noted on the MAR (medication administration record) with signatures indicating the medication was given or refused by nurses. V9 said that is a problem and I hope the facility uses this incident for in-services. According to R3's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no [MEDICATION(S)] documented on the MAR or any signatures of nurses administering [MEDICATION(S)] medication to R3 the entire Month of April, May 1st and May 2. 2022. Review of R3's progress notes, behavioral notes and care plan noted no concerns with R3 refusing her [CONDITION(S)] medication. According to R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 had a medication dosage change on 02/20/2022 noted as a Routine order by V9 (Primary Physician), [MEDICATION(S)] ([MEDICATION(S)]) Give 10 ml (milliliters) by mouth two times a day for seizures. On 06/08/2022 at 4:13 pm, via telephone interview with V13 (nurse), surveyor asked V13 if she was the admitting nurse for R3 on 04/02/2022 when R3 returned back to the facility from a hospital stay. V13 said yes she was the admitting nurse for R13. Surveyor asked V13 what is the procedure for verifying medication orders when a patient is admitted . I call the doctor and let him know the patient has returned, (V14) Nurse Practitioner (NP) is the one we usually talk to. V14 will say continue with discharged Medication Plan of Care. Surveyor asked V13 if a read back of the orders are done while speaking with V14, the response was no, not unless they ask. Surveyor asked V13 how the facility ensure that previous significant medications like [MEDICATION(S)] are re-ordered on return back to the facility, if there is no read back to the physician. V13 stated We don't go back and look at discharged orders, it is too hard to go back and look for previous orders. When the physician says continue with discharged medication plan of care, we reconcile whatever medications are on the hospital discharge list. Telephonic Interview with V14 (Nurse Practitioner) on 06/08/2022 at 3:33 pm, Surveyor asked V14 if V13 (nurse) spoke with him over the phone about R3's return to the facility on [DATE] and medication orders. V14 said yes, I spoke with V13 and gave orders to continue with the hospital medication discharge plan of care. Surveyor asked V14 if a read back is done with the nurses on current and previous discharged medication such as [MEDICATION(S)] for [CONDITION(S)]. V14 stated when a nurse call me I tell them to continue with discharged medication plan of care, I don't have time to read back all those medications, l expect the nurse and the hospital system to work and check the medications. The hospital should have had [MEDICATION(S)] on their discharged medication plan of care. I don't verify any medication discharge or previous medications as you are asking. Telephonic interview with V9 (Primary Care Physician) on 06/08/2022 at 3:03 pm, Surveyor asked V9 how does he ensure that all medications orders are reconciled. V9 stated I always verify the new orders and previous orders with the nurses. He stated he has the nurses to read off the medications and he will tell them what he wants them to transcribe for the patient. Review of the paramedic run sheet dated 5/2/2022: Dispatch time was 09:45:01 (9:45 am), Fire department arrived to the facility- 09:49:09 (9:49 am), Arrived to the patient (R3) - 09:52:00 (9:52 am), Left the nursing at 10:10:42 (10:42 am), Patient (R3) at Destination (Hospital) - 10:16:12 (10:16 am), Patient (R3) transfer of Care 05/02/22 - 10:24:52 (10:24 am). R3 's hospital emergency room (ER) record dated 5/02/2022 at 10:24 am, indicated: Patient (R3) suffered [CONDITION(S)] and code blue immediately after arrival to the intensive care unit after presenting to the Emergency department with [CONDITION(S)] (seizures), [CONDITION(S)] and [CONDITION(S)] due to pneumonia. Patient became pulseless and subsequent code blue was called: Hospital Intensive Care Unit Notes- 5/2/2022 at 11:03 am, Patient is a [AGE] year old female with history of [CONDITION(S)] on [MEDICATION(S)], hypertension, (CHF) Congestive heart Failure and ([CONDITION(S)]) [CONDITION(S)] who presents to the ED (Emergency Department) via EMS (Emergency Medical Services from the nursing home for evaluation of (AMS) Altered Mental Status. Per staff at the nursing home they noticed the patient with [CONDITION(S)]-like activity this morning. Per EMS (Fire Department) they found the patient (R3) with tonic-clonic jerking motions, proceeded to give her 5 mg. (milligrams) of Versed. Afterwards EMS states that patient had not returned back to her baseline. Patient appeared to be tachypneic and saturating at 60% room air. Patient placed on non-rebreather mask and saturations improved to the mid 80's. Patient (R3) was intubated, Laryngoscope size: Mac 3, Tube size 7.5 mm, tube type- cuffed. Patient's still now notably altered and in acute respiratory distress. Patient hypoxic to 87% on 15 L non-rebreather. Patient (R3) not responsive to sternal rub or pain. Patient pupils fixed and constricted on arrival and she was subsequently given 4 mg. of [MEDICATION(S)] to which she had no response. Shortly thereafter patient began having tonic- clonic jerking motions in the upper extremities and some concern for [CONDITION(S)]. Patient (R3) given 2 mg. of [MEDICATION(S)] in [CONDITION(S)] activity persisted. Patient respiratory status continued to decline. R3 is unresponsive, no spontaneous movement, pupils fixed and equal. R3's progress notes by V12 physician on ICU (Intensive Care Unit) dated 5/2/22 indicated: Unfortunately, despite our best and most aggressive efforts, the patient (R3) did not achieve ROSC (Return of Spontaneous Circulation) and ultimately passed. Time of Death was called 15:37 (3:37pm) on 05/02/2022. I discussed with patient's father over the phone and informed him of the clinical course. All questions were answered. R3's death certificate for recorded the following: date of death was May 02, 2022 and noted causes of death as the following: a. [CONDITION(S)] b. None Adherence with [CONDITION(S)] medications c. Aspiration Pneumonia Facility Policy and Procedure - Change in Resident's Condition or Status: Dated 6/26/2011 Purpose: To ensure that the resident's attending physician and representative is notified of changes in the resident's condition and or status Policy: 1. The nurse will notify the resident's attending physician when: There is a significant change in the resident's physical, mental and psychosocial status There is a need to alter the resident's treatment plan significantly The resident repeatedly refuses treatment or medications 3. A significant change in condition is a decline or improvement in the resident's status that Requires interdisciplinary review and or revision to the care plan 4. Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident's condition or status. During medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding and unresponsiveness 911 will be notified for transport to the hospital. Medication Policy: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] It is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure: 1. The facility must have orders from the physician upon admission for: Dietary Drugs (if necessary) Routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. 2. As assessments are completed, orders will be received from the physician to address significant findings of the assessments. 3. Orders that accompany the resident on admission will be clarified by the physician through actions of the nurse who will contact the physician for clarification upon the resident's admission. Care Plan Policy and Procedures - Not Dated Each resident will have a comprehensive assessment that will assist in the development of an individualized plan of care that may include goals and interventions aimed to improve or maintain the residents highest level of function, prevent decline, decrease risk of complications of medical conditions ,medications and diagnosis, decrease risk of injury or to promote comfort at end of life. 1. Each resident will have a comprehensive assessment completed by the Interdisciplinary team upon admission, quarterly and with significant changes and an individualized care plan will be developed and updated as needed with quarterly assessments, re-admissions, and changes in conditions. 8. Residents care plans will be reviewed and updated as needed with re-admissions, quarterly re-assessments, annually and with changes in conditions. The surveyor confirmed through observation on 06/14/2022, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: The facility completed all measures on the abatement plan. Therefore the abatement plan could be approved on 06/10/2022: The following actions have been initiated by Nurse Consultant, Floating DON, DON, and designees: Education: All licensed and registered nurses, physicians, and physician extenders will be in serviced on the following topics which were initiated on 6/6/22 and will be ongoing to ensure that all new hires, shifts and all staff are inserviced: 1. At the time of admission all resident orders must be reconciled from the hospital discharge medications with the facility attending physician to the current plan of care. 2. Orders must be transcribed to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. At the time of admission, orders must be reconciled accurately from the hospital to include plan of care for patient and reviewed by the doctor. Those who were unable to be in-serviced due to FMLA, vacations, agency staff, etc. will not be permitted to work until the training has been completed. The following actions have been completed: 1) All admission medication orders since 4/2/22 have been audited to ensure reconciliation was completed accurately. 2) An audit tool was initiated to verify that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Those who were unable to be in-serviced due to FMLA, vacations, agency staff, etc. will not be permitted to work until the training has been completed. Education will be provided by Nurse Consultant, Floating DON, DON, and designees, this education was initiated on 6/6/22 and will be ongoing to ensure that all new hires, shifts and all staff are inserviced on the following Policy and Procedures: 1) Medication reconciliation upon admission 2) Accurate transcription of medications to EMR 3) Auditing of admission medication orders Those who were unable to be in-serviced due to FMLA, vacations, agency staff, etc. will not be permitted to work until the training has been completed. Moving forward this will be our standard of practice, therefore we have no end date. No changes to policies or procedures have been completed. However, the facility's expectation is that we monitor this practice 1x per week for 3 months with a QA tool that will be monitored by facility Administrator or designee. All findings will be reported to Quality Assurance for review. Last QAPI meeting to address F684 was held on 6/9/22.

Based on interview and record review, the facility failed to provide blood glucose monitoring and insulin administration services, according to professional standards of quality care and guidelines from the American Diabetes Association, for a resident's elevated blood sugar. This failure affected one resident (R2) of three residents, reviewed for professional standards of care and it resulted in R2 having a critically high blood glucose of 539 on arrival at the hospital. Findings include: On 4/9/21 at 9:07 AM, V13 (R2's Health Insurance Representative) documented R2's complaint over the past year at the facility, R2 has been complaining of chest/stomach pains and feeling nauseous but the facility refused to address the problem. R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/7/21: V6 (R2's Primary Physician) saw R2 by Telemedicine and documented R2's elevated Glucose and elevated Hemoglobin A1c (HgbA1c) of 9/4/20; On 1/21/21: V6 saw R2 by Telemedicine and documented R2's elevated Glucose of 332 mg/dl(milligrams per deciliter) and elevated HgbA1c at 12.9 as shown in the laboratory report of 1/8/21; On 1/25/21, 2/9/21, and 2/22/21, V6 again saw R2 by Telemedicine and documented the same elevated glucose of 332 and elevated hemoglobin A1C of 1/8/21 for all the dates mentioned. On 3/8/21 at 11:17 PM, V6 wrote: Patient seen to have Diabetes Mellitus with HgbA1c on 1/8/21 significantly elevated at 12.9% and a significantly elevated glucose level of 332. Continue to monitor and manage all chronic conditions with current treatment. [MEDICATION(S)] to be added to medications for glycemic control. On 3/22/21 at 11:05 PM, V6 included Diabetes Mellitus in the list of medical history and wrote: Diabetes Mellitus: Start [MEDICATION(S)] 10 units BID (twice a day); check blood sugars BID (twice a day). On 3/31/21 at 1:17 PM, V6 wrote: Patient seen in person. Pt admits to episodes of suicidal ideation but does not state an active plan. Pt admits to polyuria (excessive urination), polydipsia (excessive thirst), and has lost 30 pounds in the last three months. On 4/6/21 at 3:27 PM, R2 was sent to the hospital for suicidal ideation, and had a critically high blood glucose of 539 on arrival at the emergency room . R2's Hospital emergency room records, dated 4/6/21, shows the following: Page 12 shows the blood glucose on arrival at the hospital at 5:07 PM to be critically high at 539 mg/dl(milligrams per deciliter); Page 17, under Consultation, written by V12(emergency room Physician), under Impression, states Type 2 Diabetes, poorly controlled. Discharge Summary, dated 4/17/21, shows R2 has new orders for [MEDICATION(S)] Insulin 100 units/ml 35 units at bedtime; [MEDICATION(S)] Insulin 100 units/ml 10 units before meals; [MEDICATION(S)] 500 mg by mouth at 8am and 5pm; [MEDICATION(S)] 100mg by mouth daily. Page 27 shows that R2's Urinalysis had 4+ Glucose and that the Hemoglobin A1c was greater than 14. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no records insulin was given and no records R2's blood sugar was checked again after the blood drawn on 1/8/21 showed a high blood sugar of 332 and a high hemoglobin A1C of 12.9. On 4/19/21 at 3:54 PM, V2 (Director of Nursing) was interviewed about the procedure for nurses to transcribe physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated most physicians give telephone orders and the nurse is supposed to put the order in the system immediately. V2 explained she is new to the facility and she will give in-service to the nurses regarding this. V2 was asked for records of blood sugar checks or [MEDICATION(S)] insulin as ordered for R2. V2 stated, If it was done, it should be on the MAR and the POS, but it's not there. At this time, V2 presented R2's Laboratory Reports, dated 9/4/2020 and 1/8/2020, showing R2's elevated blood sugars as stated above in the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/19 21 at 4:04 PM, V14 (LPN, Licensed Practical Nurse) was interviewed regarding this. V14 stated the Nurse Practitioners put their orders in the system, but the doctors just give telephone orders, and she will read the order back to the doctor before she puts the order in, and once the order is put in, it will show up on the MAR and it cannot be missed. R2's Care Plan for Diabetes, dated 3/8/21, states under Goals: Resident will maintain blood sugar levels within prescribed limits and not exhibit any signs and symptoms of hypo/[CONDITION(S)] through next review. Intervention #1 states: Monitor blood sugars as ordered and coverage as ordered per sliding scale; #2: Monitor for signs and symptoms of hypo/[CONDITION(S)]; #9: report abnormal labs and blood sugars to MD (medical doctor). On 4/20/21 at 1:29 PM, V6 (Facility's Physician for R2) was asked a general question about his professional opinion about the possible effects of not treating Diabetes and not checking the blood sugar for a long time (referring to last time glucose and A1C was checked) according to doctor's orders. V6 stated it can affect the kidneys and the nerves, and cause [CONDITION(S)], general malaise and weakness. V6 was asked about the order for [MEDICATION(S)] 10 units BID and blood sugar check BID V6 wrote for R2 in March and was not carried out. V6 stated he has not seen the residents in person for some time due to the pandemic, and nurses carry out the orders when he speaks to them on the phone. V6 explained if a resident's blood sugar is high, or if the resident is having polyuria and polydipsia, the nurse should notify the doctor, but if the nurse did not put the order to check blood sugar in, and did not notify the doctor, the doctor will not know that the blood sugar is high. The American Diabetes Association Guidelines on Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association in Diabetes Care Volume 39, February 2016 states on page 4 under Framework for considering Diabetes Management Goals that patients residing in long term care facilities should have hemoglobin A1C less than 8.5 percent. This document also states that Fasting and pre-meal blood glucose should be 100-200mg/dl and Glucose monitoring frequency should be based on complexity of regimen and risk of [CONDITION(S)]. Also, Spectrum Diabetes Journal states: The primary physician had exclusive responsibility for controlling glucose levels and determining types and doses of insulin. Nurses were responsible for blood glucose monitoring, diet control, patient education, and administration of insulin injections. Reference: spectrum.diabetesjournals.org/content/23/4/268

Based on interview and record review, the facility failed to transcribe the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (R2) of three residents, reviewed for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R2 having high blood glucose levels and other Diabetes symptoms that were not addressed for a few months until R2 was sent to the hospital for a different reason and was found to have a critically high blood glucose of 539 on arrival at the hospital. Findings include: On 4/9/21 at 9:07 AM, V13(R2's Health Insurance Representative) documented R2's complaint that over the past year at the facility, R2 has been complaining of chest/stomach pains and feeling nauseous, but the facility refused to address the problem. R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/7/21: V6(R2's Primary Physician) saw R2 by Telemedicine and documented R2's elevated Glucose and elevated Hemoglobin A1c (HgbA1c) of 9/4/20; On 1/21/21: V6 saw R2 by Telemedicine and documented R2's elevated Glucose of 332 mg/dl(milligrams per deciliter) and elevated HgbA1c at 12.9 as shown in the laboratory report of 1/8/21; On 1/25/21, 2/9/21, and 2/22/21, V6 again saw R2 by Telemedicine and documented the same elevated glucose of 332 and elevated hemoglobin A1C of 1/8/21 for all the dates mentioned. On 3/8/21 at 11:17 PM, V6 wrote: Patient seen to have Diabetes Mellitus with HgbA1c on 1/8/21 significantly elevated at 12.9% and a significantly elevated glucose level of 332. Continue to monitor and manage all chronic conditions with current treatment. [MEDICATION(S)] to be added to medications for glycemic control. On 3/22/21 at 11:05 PM, V6 included Diabetes Mellitus in the list of medical history and wrote: Diabetes Mellitus: Start [MEDICATION(S)] 10 units BID (twice a day); check blood sugars BID (twice a day). On 3/31/21 at 1:17 PM, V6 wrote: Patient seen in person. Pt admits to episodes of suicidal ideation but does not state an active plan. Pt admits to polyuria (excessive urination), polydipsia (excessive thirst), and has lost 30 pounds in the last three months. On 4/6/21 at 3:27 PM, R2 was sent to the hospital for suicidal ideation, and had a critically high blood glucose of 539 on arrival at the emergency room . R2's Hospital emergency room records, dated 4/6/21, shows the following: Page 12 shows the blood glucose on arrival at the hospital at 5:07 PM to be critically high at 539 mg/dl(milligrams per deciliter); Page 17, under Consultation, written by V12(emergency room Physician), under Impression, states Type 2 Diabetes, poorly controlled. Discharge Summary, dated 4/17/21, shows R2 has new orders for [MEDICATION(S)] Insulin 100 units/ml 35 units at bedtime; [MEDICATION(S)] Insulin 100 units/ml 10 units before meals; [MEDICATION(S)] 500 mg by mouth at 8am and 5pm; [MEDICATION(S)] 100mg by mouth daily. Page 27 shows that R2's Urinalysis had 4+ Glucose and that the Hemoglobin A1c was greater than 14. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no records that this insulin was given and no records that R2's blood sugar was checked again after the blood drawn on 1/8/21 showed a high blood sugar of 332 and a high hemoglobin A1c of 12.9. On 4/19/21 at 3:54 PM, V2 (Director of Nursing) was interviewed about the procedure for nurses to transcribe physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated most physicians give telephone orders and the nurse is supposed to put the order in the system immediately. V2 explained she is new to the facility and she will give in-service to the nurses regarding this. V2 was asked for records of blood sugar checks or [MEDICATION(S)] insulin as ordered for R2. V2 stated, If it was done, it should be on the MAR and the POS, but it's not there. At this time, V2 presented R2's Laboratory Reports, dated 9/4/2020 and 1/8/2020, that show R2's elevated blood sugars as stated above in the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/19 21 at 4:04 PM, V14 (LPN, Licensed Practical Nurse) was interviewed regarding this. V14 stated the Nurse Practitioners put their orders in the system, but the doctors just give telephone orders and she will read the order back to the doctor before she puts the order in, and once the order is put in, it will show up on the MAR and it cannot be missed. R2's Care Plan for Diabetes, dated 3/8/21, states under Goals: Resident will maintain blood sugar levels within prescribed limits and not exhibit any signs and symptoms of hypo/[CONDITION(S)] through next review. Intervention #1 states: Monitor blood sugars as ordered and coverage as ordered per sliding scale; #2: Monitor for signs and symptoms of hypo/[CONDITION(S)]; #9: report abnormal labs and blood sugars to Md (medical doctor). On 4/20/21 at 1:29 PM, V6 (Facility's Physician for R2) was asked a general question about his professional opinion about the possible effects of not treating Diabetes and not checking the blood sugar for a long time according to doctor's orders. V6 stated it can affect the kidneys and the nerves, and cause [CONDITION(S)], general malaise and weakness. V6 was asked about the order for [MEDICATION(S)] 10 units BID and Blood Sugar check BID that V6 wrote for R2 in March and was not carried out. V6 stated he has not seen the residents in person for some time due to the pandemic, and nurses carry out the orders when he speaks to them on the phone. V6 explained that if a resident's blood sugar is high, or if the resident is having polyuria and polydipsia, the nurse should notify the doctor, but if the nurse did not put the order to check blood sugar in, and did not notify the doctor, the doctor will not know that the blood sugar is high. Facility's document titled Job Description for Licensed Practical nurse and for Registered Nurse states in #B3 and B4: Receives telephone orders from physicians and record on the physicians' order form; Transcribes physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . #C8 states: Reviews medication cards for completeness of information, accuracy in the transcription of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to do an accurate pain assessment, failed to provide effective pain medication, failed to document and assess the resident for vitals and pain on a daily basis, and failed to follow their policy on pain management for 1 (R3) of 3 residents reviewed for pain in the sample of 6 residents. This resulted in an oriented, [AGE] year old male who had multiple gun shot wounds, an abdominal drain, a gastrostomy tube, and a wired shut fractured jaw, being in excruciating pain for the first 3.5 weeks of admission and not receiving any pain medication. The findings include: On 11/19/20 at 10:15 AM, R3 was laying on his back in bed with a [DEVICE] (G.T.) and abdominal drain exposed. R3 stated he was neglected for over a week. R3 stated he did not get any pain medication for many weeks and no enteral feed for the first 2 days and sporadic the rest of the time. R3 stated that no staff member was coming to the room to even check on him or take his vitals. R3 stated he was in excruciating pain, could not get comfortable, and felt he was left to die in the bed. R3 stated it is with much difficulty, but he managed to go to the nurses' station in manual wheelchair for the Tylenol. R3 stated if he did not go to the nurses' station he would not have gotten the Tylenol. R3 stated he was receiving one [MEDICATION NAME] with 2 Tylenol in the hospital, which worked great. R3 stated he was admitted to the facility on [DATE]; he was never assessed for his pain, never given any pain medication nor were staff members checking on him for over a week. R3 stated he called his sisters, his mom, and his girlfriend, and told them about his excruciating pain and not getting any pain medication or his enteral (bolus) feed. On 11/19/20 at 8:16 AM, V6 (R3's sister) stated that R3 has been calling everyone in the family complaining about his pain, saying that the nurses are not checking in on him, nurses are not giving him his medications or his bolus feed, and he is in deep pain and feels weak from no nutrition supplement. R3 is alert, oriented [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's current physician order [REDACTED].T. every 6 hours for pain as needed, along with Tylenol 650 mg via G.T. every 6 hours as needed for pain. R3 was receiving aspirin 325 mg daily via G.T. as a [MEDICATION NAME] for his [MEDICAL CONDITION]. All medications were ordered on [DATE], day of admission. On 11/19/20 at 1:55 PM, V3 (Registered Nurse) stated that there is no bingo card of [MEDICATION NAME] for R3. V3 stated that it must not have been ordered because it may have needed prior approval. V3 stated she does not know why there is no documentation to support why the [MEDICATION NAME] was not ordered. V3 stated she just gave R3 some Tylenol, and he did not mention his pain. Asked if she asked him about pain, no response. On 11/20/20 at 10:45 AM, R3 stated that V3 (Registered Nurse) came to his room last evening (11/19/20) to do a pain assessment. R3 stated that this is the first time a comprehensive pain assessment been done. This pain assessment documents that a pain assessment is warranted, R3 has had frequent pain that has affected his sleep, his activities of daily living, and his mental state. R3 has rated the pain at a 7 for severe pain out of a scale of zero to 10, 10 being the worst pain. The pain is from his jaw that was fractured and wired shut. R3 voiced constant aching pain that is alleviated by the medication. R3 is currently on no scheduled pain medication but has orders for pain medications as needed. The pain assessment, dated 10/16/20 by V7 (Licensed Practical Nurse), documents contrary information. It documents no need to do a pain assessment because R3 has no pain. But then it documents the pain makes it hard to sleep and to do his daily activities. V7 then documents R3's pain at zero and no location is documented. The pain medications documented are the Tylenol 650 mg every 6 hours via G.T. as needed for pain. V7 was not available for interview after several attempts. V14 (nurse practitioner) did a telehealth visit on 10/18/20, with staff and documents multiple gun shot wounds, mandible fracture, right temporal bone fracture, bilateral nasal bone fracture, right middle cerebral artery stroke and right carotid dissection. V14 failed to address the pain level and the medications for the pain. On 11/21/20 at 11:15 AM, V14 stated he never saw the resident (via telehealth because of the pandemic), but relied on the staff nurses to give him an accurate account on R3. V14 stated he was never informed of R3's pain, and if he had been alerted he could of ordered non-narcotic medication for the pain. V14 stated when a person comes in with pain medication orders, it usually means they are in pain. V14 stated that V15 (Attending Physician) would be best to talk on R3's pain and medications ordered. On 11/21/20 at 11:49 AM, V15 stated he has never seen the patient and this patient was assigned to him when he was admitted to the facility. V15 stated that no staff member ever called him about R3's pain and medications. V15 stated that the order for [MEDICATION NAME] was from the hospital, but the hospital did not send a signed, written order. V15 stated if the nurses would have reached out to the hospital physician, he may have sent a signed order. In any case, V15 stated that it is unacceptable, not appropriate, and not good care when staff fail to provide the medications and treatment as ordered. V15 stated that the nursing staff should have followed up with R3's pain by referring him to a pain clinic. Review of the hospital documentation documents that R3 was receiving 5 mg of [MEDICATION NAME] with 2 Tylenol (650 mg) for pain as needed every 6 hours. Hospital also documents that R3 sustained 7 gun shot wounds to the face, upper extremities and back, right carotid artery dissection and bullet retained from abdomen. Review of the October 2020 and November 2020 medication administration record (MAR) documents no Tylenol or [MEDICATION NAME] was given from 10/16/20 to to 11/10/20 (3.5 weeks) nor was there a daily accurate pain assessment. R3 did receive Tylenol on 11/11/20 at 0144 and again on 11/14/20 at 0128 for pain levels at 9 and 7 because he went to the nurses station to complain of pain. It documents the Tylenol is effective, but R3 stated the Tylenol helps a little and is better than no medication. The location of the pain is not documented. R3's vitals were not documented from 10/16/20 to 10/23/20 per the MAR. On 11/20/20 at 11:30 AM, V10 (Nurse Consultant) was asked if there is any nurse who can explain R3's MAR and medications. V10 stated she would send someone down. V2 (Director of Nursing) was not available or in facility. On 11/20/20 at 12:50 PM, V13 (Corporate Nurse) stated she will do her best to explain anything she can since no one else is available but stated she is not assigned to this facility. V13 stated that the blanks in the MAR means the medication was not given. V13 was not able to say why an accurate comprehensive pain assessment was not done by staff, nor why the [MEDICATION NAME] was not followed up on or why the Tylenol was not given for 3.5 weeks. On 11/19/20 between 9:40 AM to 11:15 AM, residents R3, R4, R5 and R6 stated that many vulnerable residents are ignored by nursing. Nurses are not distributing medications as ordered or on time. Nursing staff act impatient when asked for something or when help is needed. They say they will be back but never come back. R5 stated that V3 is the restorative nurse but has been working the first floor as a floor nurse. The residents say the nurses and aides are scarce and hard to find on the floors. The facility's policy labeled Management of Pain documents the facility's policy is promote resident comfort and preserve their dignity and provide effective pain management. This will be achieved through prompt and accurate assessing and diagnosing the pain. Encouraging residents to self report pain. Optimizing the resident's ability to perform activities of daily living. Monitoring treatment efficacy and side effects. Preventing and minimizing anticipated pain. Using pain medication judiciously to balance the resident's desired level of pain relief. Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by physician. The pain assessment will be done upon admission and it will measures the impact of pain on the resident's function, assessing the resident's physical condition, history, mental status and ADLs. The assessment will cover intensity, location, onset, type and frequency, description, change, treatment, effect and what makes it worse or better. Pain monitoring should be documented on the back of the MAR/pain flow sheet the effectiveness of pain medication and the effectiveness should be assessed 1 to 2 hours after pain medication administration.

Based on interviews and record review, the facility failed to follow their policies on Transfer/Mobility and Fall Prevention for one of three residents(R3) reviewed for falls with serious injuries. This failure resulted in V3 (Certified Nursing Assistant-CNA) transferring R3 who is coded on the Minimum Data Set (MDS) as a two person physical assist for transfer/mobility without assistance, causing R3 to fall to the floor. R3 sustained a [MEDICAL CONDITION] femoral shaft. R3 was transferred to the hospital and underwent an emergency surgical procedure. R3 has been hospitalized since 10/2/2020. Findings Include: During review of R3 ' s hospital record on 10/7/2020 at 12:50 pm, R3 an [AGE] year old who sustained a [MEDICAL CONDITION] femoral Shaft. R3 had to have emergency surgery on 10/2/2020. Per the hospital record R3 sustained the fall at the nursing home. The paramedics transferred R3 from the nursing home to the hospital emergency room . On 10/6/2020 at 11:00 am, review of nursing note by V4 (Nurse)read R3 complained of pain on 10/01/2020 at 11:07 pm. Another nursing note entered as a Late Entry by V4, reads; R3 was lowered to the floor after complaining of pain to the left leg on 10/01/2020 at 11:59 pm. During interview on 10/6/2020 at 9:42 am, V2 (Director of Nursing-DON) stated R3 fell and was sent to the hospital on [DATE]. V2 was asked for the investigation report, V2 stated she was still investigating and could only tell me on 10/2/2020, V3 (Certified Nursing Assistant-CNA) said R3 knees buckled and she lowered her to the floor. On 10/07/2020 at 11:40 am, review of R3 ' s Minimum Data Set ((MDS) dated [DATE], Section (G) (Transfer = 3/3, Bed Mobility = 3/3, Dressing = 3/3, Toileting = 3/3, Personal Hygiene = 3/3. R3 requires Extensive assistance with a Two Person Physical Assist. R3 is totally dependent on staff for all activities of daily living (ADL's). Review of R3's care plan for falls noted R3 had 6 falls, 01/03/2020, 01/23/2020, 03/17/2020, 04/13/2020, 07/09/2020 and 10/2/2020. During phone interview on 10/8/2020 at 10:23 am, V3 (CNA) stated she was getting R3 out of bed and transferring her to the wheelchair. R3 stated, I had my gait belt on her (R3) and she was sliding, her knees buckled and I lowered her to the floor. V3 asked if she was familiar with R3 and she said, Yes, I am her regular CNA. V3 was asked if she always transferred R3 by herself and she stated yes. V3 was asked if she knew R3 was a 2 person assist with transfer. V3 said well over her bed is a B-1 and that means a one person assist and that is what I go by. During phone interview on 10/08/2020 at 10:46 am, V5 (Treatment Nurse) stated I was out in the hallway and V3 was yelling for help. When I came in I saw R3 who was not sitting completely in the wheelchair. R3 was saying please don't let me fall. I told R3 I won't let you fall. I helped V3 lower the resident to the floor and I told her to go and tell the nurse that R3 was on the floor. V5 was asked how long has she worked for the facility; she stated, since [DATE]. V5 was asked what B-1 meant over the resident bed, she said 1 person assist. During interview with V4 (Nurse) on 10/08/2020 at 10:27 am, V4 (Nurse) said V3 told her R3's leg was hurting. V5(Treatment nurse) heard V3 yelling for help, she went in and helped assist V3 with R3. V4 was asked how long has she worked at the facility; she stated 7 years. V4 was asked what does B-1 over a resident's bed mean; V4 said I don't know. V4 was asked how would you know what the residents ability for transfer or mobility might be if they needed your assistance. V4 stated, I would go by what the CNAs tells me, they know if they are a mechanical lift or a sit to stand. During phone interview on 10/08/2020 at 10:39 am, V6 (Quality Assurance Nurse - QA) stated I was the nurse who initiated the investigation of R3's incident. V3(CNA) told me she went in to do patient care on R3 before lunch. V3 said she was trying to transfer R3 from the bed to the wheel chair. V3 said when R3 stood up her legs buckled. She tried to put her back in the chair but was not able to put R3 in the chair completely, so she yelled for help. V6 was asked how long had she worked for the facility, she stated, 1 month. V6 was asked what does B-1 over the resident bed mean. V6 stated a 1 on top of the B-1 means, 1 person transfer and the b-1 means bed mobility. Facility's Policy - Fall Prevention and Management : · This facility is committed to safety and maximizing each resident ' s physical, mental and psycho-social well- being. · The purpose of our Fall Prevention and Management Program is to: · Provide our residents with an interdisciplinary approach to assess risk of falls · Provide appropriate interventions to prevent falls · Ensure that in the event a fall occurs, the fall will be investigated, appropriate emergency treatment will be provided and additional interventions will be implemented to prevent another fall from occurring as much as possible. The Fall Prevention and Management Program uses clinical accepted guidelines to guide the prevention and management of falls. The program will: · Identify risks for falls · Decrease the incidence of falls · Decrease the incidence of falls with injuries. Transfer/Bed Mobility Policy and Procedure: Policy: All resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident Care Plan. All residents will be assessed by the facility Care Plan team with regard to the need for bed mobility assistance with transfer activities, mobility or repositioning in accordance with MDS procedures and requirements. The Care plan Team will make determinations regarding the bed mobility, transfer needs and other ADL needs based off the daily nursing Point of Care ADL documentation, speaking with unit staff at minimum during the Assessment Reference Date- ARD time frame of the MDS, review of rehabilitation programming, maintenance of functional abilities and review of chronic and acute medical conditions. Procedure: Sec. B - 1. Transfer assistance, bed mobility assistance and other resident handling and movement task are to be carried out in accordance with the MDS, care Plan and written implementing instructions pertaining to the individual resident. 2. If a variance from the MDS and Care Plan is necessary, the supervisor (DON, ADON, MDS Nurse and Restorative Nurse will be contacted. 3. The staff will develop a plan of care by reviewing the actual resident needs with review of the facility ' s ADL Tracking Point of Care and with interview of the unit staff and also the resident as applicable. This review during the MDS ARD time frame at minimum will assist the MDS, restorative Nursing staff of the actual resident transfer, repositioning and toileting needs. The MDS Nurse scoring of section G will follow the coding directions from the Resident Assessment Instrument (RAI) manual. Residents can and will often have fluctuations in their ADL ' s. 4. The MDS, Section G and the Point of Care ADL Tracking Log will be the primary nursing tool to assist in the assessment and determination of each resident ' s need for assistance with transfer activities, mobility or repositioning. The Care Plan team will determine and identify the proper and appropriate means of transfer and mobility assistance for each resident in accordance with this policy and these will be noted in the care plan and communicated to staff.

Based on interview and record review, the facility failed to protect and supervise a dependent, dementia female (R1) resident from sexual assault by an oriented, ambulatory male (R3) resident which resulted in an Immediate Jeopardy on 5/20/20. This failure affected one resident (R1) of 3 residents reviewed for sexual abuse in the sample of 3 residents. R3 is an oriented ambulatory male resident who placed his penis into R1's mouth who is not capable of consent. As result, an immediate jeopardy was identified. This past non-compliance occurred from 5/20/20 to 5/22/20. The Immediate Jeopardy began on 5/20/20 when R3 placed his penis in R1's mouth and was identified on 6/24/20. V2 (Director of Nursing), V10 (Regional Director) and V12 (Regional Director of Operations) were notified of the Immediate Jeopardy on 7/28/20 at 3:58 PM in the absence of the facility's administrator. The immediate jeopardy was removed 5/22/20 when R1 and R3 were transferred out of the facility and the facility took steps to ensure other residents were safe from sexual abuse. The finding include: According to the quarterly MDS (Minimum Data Set), dated 4/9/20, R1 is a [AGE] year old, ambulatory female who has severe cognition loss per the brief interview mental score (BIMS) of 01. R1 has been a resident in the facility since 7/27/18, with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documents discharged with return anticipated. Nothing documented that resident went to hospital. There is no physician order to send to hospital. R1 is no longer in the facility, and never returned after the 5/22/20 per MDS, nurses' notes, and interviews. According to the quarterly MDS, dated [DATE], R3 is an oriented, [AGE] year old ambulatory male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documents discharged with return anticipated. Nothing documented that resident went to hospital. There is no physician order to send to hospital. R3 is no longer in the facility and never returned after 5/22/20 per MDS, nurses' notes, and interviews. On 6/24/20 at 11 AM, V2 (Director of Nursing) stated that R1 and R3 are no longer in the facility. The following staff interviews were conducted regarding the sexual abuse involving R1 and R3. On 6/24/20 at 11:24 AM, V1 (Administrator/Abuse Coordinator) stated she received the allegation from V4 (Dementia Coordinator/Psychiatric Rehabilitation Service Counselor/PRSC) who received the allegation from V3 (Certified Nurse Aide/CNA). V1 says that V3 was walking by, it was the shift change around 3:30 PM on 5/20/20, when V3 says she saw R3 (male resident) with his privates in R1's mouth (female). V1 says she had V3 demonstrate the assault, and V3 demonstrated R3 having leg/foot on bed and jiggling his privates in front of R1. R1 was seated on her bed. V1 stated that both residents have dementia and denied it happened. On 6/24/20 at 4:10 PM, V3 (CNA) stated she was doing her rounds on May 20th at 2:45 PM, normally works 3 to 11 shift; it was a Wednesday when she saw R3 on R1's bed with his penis in her mouth. V3 stated that R1 was seated upright in the bed, due to Gastrostomy Tube infusing, and was dressed in a hospital gown. V3 stated that R3 was kneeling on the bed with his penis in R1's mouth. When she asked what was going on, R3 stopped, got off bed, put his penis in pants, and zipped his pants. V3 told R3 that he would be reported, and R3 stated, I know. V3 went to the nurses' station and telephoned the receptionist and asked for the administrator. Receptionist asked why, and was told of the assault. Receptionist stated that V9 (Social Service Director/Psychiatric Rehabilitation Service Director) would come to the 3rd floor for report. V3 says that she saw V4 (PRSC) and told her of the assault. V3 stated that R3 was removed and placed at the nurses' station and monitored, then moved to 2nd floor. R3 told V4 that R1 is his girlfriend, which is untrue. V3 says that R3 has behavior of masturbating in his room. V3 stated she reported the sexual assault the same day she saw it, and was adamant it was a Wednesday, the 20th of May. V3 stated that on her way out of facility, she went to V1 (administrator) and asked if she was aware of R3's assault, and V1 replied yes. V3 stated the floor is for dementia residents, but there are alert, oriented residents on the floor also. On 6/25/20 at 11:11 AM, V4 (PRSC) stated it happened on 5/20/20 between 2:30 PM to 3 PM, when V3 (Certified Nurse Aide) came to her and stated R3 was standing in front of R1 in her room with his penis out in his hand and in R1's mouth. V4 stated that V3 then stated she was not sure if penis was in her mouth. Asked why her statement was written up 5/24/20, 4 days after the event, V4 stated she was going out of town and left the facility before writing up the statement. V4 stated she only provided a statement, and was not interviewed about the incident. V4 stated it was the administrator who made the decision to send R3 to the 2nd floor and not out of the facility immediately. V4 stated when R3 was admitted to the facility he was very confused so he was put on the 3rd floor, a closed unit. But during his stay, he presented as oriented times three, and knowing right from wrong. V4 stated she did the BIMS for the 5/19/20 MDS, and admits that she did it quite early in the morning, and R3 was a little groggy waking up. V4 stated he had trouble recalling the 3 words; could only recall 2 words. She was his assigned PRSC, and stated not to be aware of R3's behavior of masturbating. On 6/25/20 at 1:01 PM, V5 (R3's sister) stated that R3 has been in and out of psychiatric facilities his whole life. V5 stated R3 was living in assisted living prior to going to this nursing home. While he was in assisted living, he was not taking care of himself, and had poor hygiene and staying in the bed. R3 was sent to the hospital; it was the hospital staff who informed her of R3's masturbation behavior. V5 stated that R3 is not a bad person but a mentally ill person. Stated that R3 was put on the closed unit because he was so confused and weak. After a couple of months, he started to improve mentally and physically. V5 stated that R3 is oriented and knows right from wrong. Stated she was contacted by a female staff member who told V5 that R3 was being sent to the hospital (2 days after the incident) for inappropriate behavior. V5 stated she needed to press the staff member to say what was inappropriate. Staff member told V5, R3 was having sex with a female. V5 stated she did not understand why this was an issue if both adults are consenting. V5 stated that R3 told her that R1 was his friend. On 6/25/20 at 1:45 PM, V6 (CNA) stated that R3 could hold a conversation with staff. R3 is usually pleasant and walks the unit or stays in his room. She stated she heard from other C.N.A.s about R3's masturbation but never witnessed it herself. On 6/25/20 at 5:45 PM, V8 (Psychiatric Nurse Practitioner) stated she conducted a telemedicine call with a nurse and V9 (SSD/PRSD) on 5/20/20 at 3 PM. (minutes after the sexual assault). V8 stated there was no mention of any sexual assault by R3. V8 stated that R3 is grossly oriented : meaning he is oriented by 3 to 4 spheres. V8 stated that R3 knew the difference of right and wrong. R3 knows who he is, where he is, he can recall details from the past and present. V8 stated her biggest problem is the nurses do not document. A resident will voice an issue that the nurses are aware of, but they fail to document it. Nurses will say they informed the social service department. It makes no sense for the Social Service to document it when the nurses know of it first-hand. It makes it difficult for her to do the job. V8 stated she never heard of any masturbation issue or any issues from the nurses about R3. V8 stated that R3 is now residing in a psych nursing home. On 6/26/20 at 12:30 PM, V11 (Registered Nurse) stated she heard from the aides about R3's masturbation behavior, but she never witnessed it herself. The facility's policy labeled ABUSE PREVENTION PROGRAM documents this facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, agency staff, family members, legal guardians, friends or other individuals. The surveyor confirmed by interview and record review the facility took the following actions to correct the non-compliance: 1. R1 and R3 are no longer in the facility as of 5/22/20. 2. On 6/19/20, all residents were screened and assessed to determine any factors that would contribute to residents being at risk or abuse. The residents' care plans have been updated as needed. 3. On 6/19/20, the facility identified potential perpetrators that exhibit inappropriate behaviors on 6/19/20. The residents' care plans have been reviewed and updated as needed. 4. The facility's Quality Assessment and Assurance Committee reviewed the facility's policy and no changes were made. 5. Staff were re-educated on, but limited to, the facility Abuse Policy and Procedures. The re-education emphasized identifying abuse and providing a safe environment. The re-education provided return verbalization and understanding. This education was completed by Regional Nurse Consultant, Doctor of Nurse Practice, Regional Director of Operations and Licensed Social Worker. This was initiated on 6/19/20 and completed 7/15/20. 6. Administrator and Assistant Administrator were terminated on 7/24/20. 7. The Q.A. (Quality Assurance) audit tool was developed. An audit will be conducted by the Regional Director of Operations to ensure the administrator is reporting abuse timely per the Abuse Policy on a quarterly basis. 8. Any future allegations of abuse will be reported to IDPH immediately. 9. Staff will be in-serviced monthly on Abuse Protocol by the administrator or D.O.N on a yearly basis or as needed.

Based on interview and record review, the facility failed to protect and prevent physical abuse on a resident with serious mental illness from a visitor who inflected bodily harm to R1 on two separate occasions. This failure affected one of three residents (R1) reviewed for abuse/neglect from a sample of 3 residents who was emergently transferred to the hospital for treatment of [REDACTED]. Findings include: R1 is a [AGE] year old with [DIAGNOSES REDACTED]. Review of incident reports show two altercations involving R1 and an unknown visitor occurring on 12/22/18 and 12/24/18 with one of the incidents in which R1 required medical attention for his injuries. 12/22/18 Nursing progress note states, Resident had a physical altercation with a visitor. A complete body assessment performed denoting laceration to left upper lip and forehead. Body assessment and first aid provided by wound care nurse. 911 notified. Police report. Resident currently at hospital being evaluated. 12/22/18 Nursing progress note states, Writer received report from hospital. Resident will be returning to facility and refused sutures however, agreed to bond blue to laceration area. Hospital Emergency Department records dated 12/22/18 shows, Patient has observable signs of abuse. Patient here from Nursing Home for complaints of being intoxicated and getting in an altercation with a visitor at the nursing home. Per patient he was punched in the face by a visitor and then got in a fight with the man. Patient admits to drinking around 8 beers today. Patient arrived combative, screaming at staff. Security at cart side with patient. 12/24/18 Nursing progress note states, Reported by staff, resident was in physical altercation with a visitor. Per the progress note, the resident did not sustain any injuries on this occasion. Resident (R1) decline to be sent to the hospital for evaluation On 12/24/18, R1 was sent to the hospital for an emergency psychiatric evaluation. After being evaluated, R1 was later transferred to an alternate facility for safety. Interview with V1 (Administrator) on 1/7/19 at 11:30 AM states, I did an investigation and there was a visitor that had an altercation with R1 but I did not see any of it. It was a really busy day and a lot was going on. Asked who the unknown male visitor who hit R1, V1 stated, I don't know who he was. Asked if they tried to determine the identity of the visitor, V1 stated, No. Asked if the visitor was the same gentleman involved with both altercations with R1, V1 stated, I believe he was. Asked if they had security on the premises, V1 stated, Yes, we have a guy and he's here from 8:00 PM to 8:00 AM but this incident happened in the afternoon. Interview with V2 (DON) on 1/7/19 at 11:45 AM states, I did not actually see the visitor. The previous director of nursing was present in the room and I heard her shouting for everyone to come and help with the commotion. I heard the previous director of nursing tell the unknown visitor to stop hitting R1 and he did. When I got to the room the altercation had already ended. I think you are getting the incidents mixed up because there were two incidents when R1 got into some altercation with an unknown visitor. The first one happened over the weekend (12/22/18) and the second one happened on Christmas eve. Asked who this unknown visitor was, V2 stated, I have no idea who he was. I can describe him to you but I don't know who he is. I just know he signed in as some other guest and I saw him get off the second floor. Asked if the visitor was the same person involved in both altercations, V2 stated, Yes. Asked if there were any efforts to identify the unknown visitor or prohibit the visitor from returning, V2 stated, No but I know that we never saw him again. Interview with V3 (Social Service Director) on 1/7/19 at 2:00 PM states, There was one altercation involving (R1) on the weekend so I wasn't here to witness that one. The other happened during the week a couple days later, I think on Christmas eve. I don't know who the person was that hit R1 but I know he was visiting someone else in the facility. The visitor got on the elevator and went to the second floor. (R1's) room is on the first floor. I have no idea who this visitor was but I was told he was just hitting (R1)'s face. I saw that it was red but I did not see any injury on him, the nurses took care of that. The visitor was a tall African American man but I don't know his name or anything like that. I know (R1) did not have any privileges to go out on pass due to his history of intoxication. Asked if there were any instructions given to her by administration to ban the unknown visitor from returning, V3 stated, Not that I was informed of. Asked why R1 was no longer in the facility, V3 stated, We met with (R1) and his sister because the sister did not feel like (R1) was safe here although we tried to assure her it was. (R1) is at our sister facility. Interview with V4 (Psychiatrist) on 1/8/19 at 10:25 AM states, I am currently seeing him at his other facility now. I also saw him while he was at his last facility. They (facility staff) told me about the incident there but I did not know it happened two times. They said what happened was about a week or so ago. He went out on pass I think and came back intoxicated that is why I will be restricting his privileges here. Asked if he was told as to how (R1) sustained his injuries, V4 stated, they said it was some visitor. Asked if R1 should have been monitored more closely or not given privileges to go out based on R1's history of [MEDICAL CONDITION], V4 stated, Yes you are correct. we should not have allowed him out to begin with and when he came back inside, should have been monitored more closely otherwise this would not have happened to him twice. V4 added that R1 should be placed in a group home instead of where he currently resides for appropriate treatment. Interview with V5 (security guard) on 1/8/19 at 1:06 PM states, My hours there at the facility is from 8:30 PM to 5:30 AM. I'm just part time. The administrator told me you'd call but I already told her I didn't see what happened with (R1). I don't know who that person is that came in that hit (R1), I just heard about it. Asked what instructions he received for visitors when they came in, V5 stated, Well before, they'd just sign in but from now on ever since that happened with R1, I'm supposed to look at their picture I.D. Comprehensive care plan dated 10/22/18 states, The resident (R1) has a [DIAGNOSES REDACTED]. Symptoms are manifested by: Display of known risk factors, poor safety awareness, aggressive behavior, self-harmful behavior, and/or possible victimization. Observe medical/psychiatric/cognitive conditions that may require on-going assessment, consultation and intervention such as personality disorder symptoms; A concomitant substance abuse disorder. Approaches/Interventions: Minimize risk factors through interventions such as assessment, team consultation, supervision, observation. A facility policy pertaining to resident guests and visitors was requested from V1 (administrator). V1 stated that there was no written policy and that visitors were only requested to sign in when visiting. However, after the incident involving R1, V1 indicated that a new policy will be enforced asking visitors to provide photo identification when visiting. Facility policy dated 9/6/17 titled Abuse Prevention Program states, It is the policy of this facility to prohibit and prevent resident abuse, neglect, and misappropriation of resident property and a crime against a resident in the facility. Protection of residents: The facility will take steps to prevent mistreatment while the investigation is underway. Residents are protected from any retaliation or possible harm. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation.

Based on interview and record review, the facility failed to investigate and identify a visitor who inflicted bodily harm on a resident with serious mental illness on two separate occasions. This failure resulted in physical and psychosocial harm for one of three residents (R1) reviewed for abuse/neglect from a sample of 3 residents and with R1 emergently transferred to the hospital on one of the occasions for treatment of [REDACTED]. Findings include: R1 is a [AGE] year old with [DIAGNOSES REDACTED]. Interview with V1 (Administrator) on 1/7/19 at 11:30 AM states, I did an investigation and there was a visitor that had an altercation with R1 but I did not see any of it. It was a really busy day and a lot was going on. Asked who the unknown male visitor who hit R1, V1 stated, I don't know who he was. Asked if they tried to determine the identity of the visitor, V1 stated, No. Asked if the visitor was the same gentleman involved with both altercations with R1, V1 stated, I believe he was. Asked if they had security on the premises, V1 stated, Yes, we have a guy and he's here from 8:00 PM to 8:00 AM but this incident happened in the afternoon. Interview with V2 (DON) on 1/7/19 at 11:45 AM states, I did not actually see the visitor. The previous director of nursing was present in the room and I heard her shouting for everyone to come and help with the commotion. I heard the previous director of nursing tell the unknown visitor to stop hitting R1 and he did. When I got to the room the altercation had already ended. I think you are getting the incidents mixed up because there were two incidents when R1 got into some altercation with an unknown visitor. The first one happened over the weekend (12/22/18) and the second one happened on Christmas eve. Asked who this unknown visitor was, V2 stated, I have no idea who he was. I can describe him to you but I don't know who he is. I just know he signed in as some other guest and I saw him get off the second floor. Asked if the visitor was the same person involved in both altercations, V2 stated, Yes. Asked if there were any efforts to identify the unknown visitor or prohibit the visitor from returning, V2 stated, No but I know that we never saw him again. Interview with V3 (Social Service Director) on 1/7/19 at 2:00 PM states, There was one altercation involving (R1) on the weekend so I wasn't here to witness that one. The other happened during the week a couple days later, I think on Christmas eve. I don't know who the person was that hit R1 but I know he was visiting someone else in the facility. The visitor got on the elevator and went to the second floor. (R1's) room is on the first floor. I have no idea who this visitor was but I was told he was just hitting (R1)'s face. I saw that it was red but I did not see any injury on him, the nurses took care of that. The visitor was a tall African American man but I don't know his name or anything like that. I know (R1) did not have any privileges to go out on pass due to his history of intoxication. Asked if there were any instructions given to her by administration to ban the unknown visitor from returning, V3 stated, Not that I was informed of. Asked why R1 was no longer in the facility, V3 stated, We met with (R1) and his sister because the sister did not feel like (R1) was safe here although we tried to assure her it was. (R1) is at our sister facility. Interview with V4 (Psychiatrist) on 1/8/19 at 10:25 AM states, I am currently seeing him at his other facility now. I also saw him while he was at his last facility. They (facility staff) told me about the incident there but I did not know it happened two times. They said what happened was about a week or so ago. He went out on pass I think and came back intoxicated that is why I will be restricting his privileges here. Asked if he was told as to how (R1) sustained his injuries, V4 stated, No they said it was some visitor. Asked if R1 should have been monitored more closely or not given privileges to go out based on R1's history of [MEDICAL CONDITION], V4 stated, Yes you are correct. we should not have allowed him out to begin with and when he came back inside, should have been monitored more closely otherwise this would not have happened to him twice. V4 added that R1 should be placed in a group home instead of where he currently resides for appropriate treatment. Interview with V5 (security guard) on 1/8/19 at 1:06 PM states, My hours there at the facility are from 8:30 PM to 5:30 AM. I'm just part time. The administrator told me you'd call but I already told her I didn't see what happened with (R1). I don't know who that person is that came in that hit (R1), I just heard about it. Asked what instructions he received for visitors when they came in, V5 stated, Well before all this, they'd just sign in and go in, but from now on ever since that happened with R1, I'm supposed to look at their picture I.D. Asked if he knew whether R1 was allowed to go out the facility, V5 stated, Yes I think so because he went out a lot since he got here. Review of facility incident reports show two altercations involving R1 and an unknown visitor occurring on 12/22/18 and 12/24/18 with one of the incidents in which R1 required medical attention for his injuries. 12/22/18 at 3:05 AM, Nursing progress note states, Resident had a physical altercation with a visitor. A complete body assessment performed denoting laceration to left upper lip and forehead. Body assessment and first aid provided by wound care nurse. 911 notified. Police report. Resident currently at hospital being evaluated. 12/22/18 at 10:22 PM, Nursing progress note states, Writer received report from hospital. Resident will be returning to facility and refused sutures however, agreed to bond blue to laceration area. Hospital Emergency Department records dated 12/22/18 shows, Patient has observable signs of abuse. Patient here from Nursing Home for complaints of being intoxicated and getting in an altercation with a visitor at the nursing home. Per patient he was punched in the face by a visitor and then got in a fight with the man. Patient admits to drinking around 8 beers today. Patient arrived combative, screaming at staff. Security at cart side with patient. 12/24/18 at 6:50 AM, Nursing progress note states, Reported by staff, resident was in physical altercation with a visitor. Per progress note, resident (R1) did not sustain any injuries and declined to go to the hospital for evaluation. On 12/24/18, R1 was sent to the hospital for an emergency psychiatric evaluation. After being evaluated, R1 was later transferred to an alternate facility for safety. Comprehensive care plan dated 10/22/18 states, The resident (R1) has a [DIAGNOSES REDACTED]. Symptoms are manifested by: Display of known risk factors, poor safety awareness, aggressive behavior, self-harmful behavior, and/or possible victimization. Observe medical/psychiatric/cognitive conditions that may require on-going assessment, consultation and intervention such as personality disorder symptoms; A concomitant substance abuse disorder. Approaches/Interventions: Minimize risk factors through interventions such as assessment, team consultation, supervision, observation. A facility policy pertaining to resident guests and visitors was requested from V1 (administrator). V1 stated that there was no written policy and that visitors were only requested to sign in when visiting. However, after the incident involving R1, V1 indicated that a new policy will be enforced asking visitors to provide photo identification when visiting. Facility policy dated 9/6/17 titled Abuse Prevention Program states, It is the policy of this facility to prohibit and prevent resident abuse, neglect, and misappropriation of resident property and a crime against a resident in the facility. Protection of residents: The facility will take steps to prevent mistreatment while the investigation is underway. Residents are protected from any retaliation or possible harm. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation.

Based on observation, record review and interview, the facility failed to protect 1 resident (R11) from being sexually assaulted, failed to report the assault to the appropriate authorities in a timely manner, failed to seek treatment for [REDACTED]. This failure resulted in an immediate jeopardy. The Immediate Jeopardy began on 6/29/13 when R11 was sexually assaulted by R10. The facility's Administrator (E1) and Director of Nursing (E2) were notified of the Immediate Jeopardy at 2:40pm on 08/07/13. The Immediate Jeopardy was abated on 08/7/13 at 7:40pm, when the facility identified and assessed all residents for potential sexual assault. When the Immediate Jeopardy was removed on 08/07/13 at 7:40pm, a deficiency remained at a potential level 2 because the facility has not yet in-servicing all staff (sexual abuse and handling of a crime scene). Findings Include: The medical record date 06/07/13 indicates R11 [DIAGNOSES REDACTED]. R11's Minimum Data Sets ((MDS) dated [DATE] indicates C0500 Summary Score was 00 (resident unable to complete the interview). C1300 (A), Inattention and Disorganized thinking was scored 1 (Behavior continuously present does not fluctuate). R11 was observed on 07/03/13 at 9:00am, sitting in her room in a wheelchair with chair alarm in place. Resident was alert and oriented X 2. Surveyor asked R11 was she found in bed with a male resident (R10). R11 stated, " No, I was not in his room or bed. No, I was not in his room Saturday and I don't know what you are talking about." R11 was very confused and unable to tell what happened on 06/29/13 with R10. On 07/03/13 at 9:10am, E1 (Administrator) stated, "There were two residents found in bed. It happened on a Saturday. It was the Certified Nurse Aide (CNA) that found them in bed. They were in the male's room(R10). It was reported on Sunday (06/30/12). We didn't call the police or send her out to the hospital. The physician didn't give any orders. She was checked by the nurse. I cannot determine if the female resident (R11) gave her permission. She is confused at times. R10 is on every 15 minutes monitoring." On 07/03/13 at 2:50pm, E17 (CNA) per telephone stated, "It was around 2:30pm. I was going to answer a call light. I heard the alarm going off. It was approximately 3 - 4 minutes when alarm went off. Upon stepping in the room, I saw the wheelchair to the right of the bed in (R10's room) . I noticed (R10) on top of (R11). I asked (R10) to get off (R11) and he didn't get off of her. I tried to get him off but was unable to get (R10) off her. He was moving up and down on (R11). (R11) was undressed from the waist down. (R10's) pants were pulled down where you could see the buttocks. I noted a housekeeper coming down the hall. I told her to get the nurse and the nurse came to the room. (R10) was still on top (R11) when the nurse came down. (R11) bottom clothes were off. Her diaper and pants were on the floor. (R10) pants were pushed down to his middle thigh. You could see the back and top part of the buttocks. E19 (nurse) and I got (R10) off (R11). His pants were down and he pulled the pants up. E19 escorted (R10) out of the room. She asked him to go to the nurses' station. (R11) is confused and does not understand when told do something. (R10) is on every 15 minutes monitoring." E18 (Housekeeping) on 07/03/13 at 2:36pm, stated "I was leaving out of the dining room. I looked down the long hall, E17 said to get the nurse. So, I waved to E19 and told her E17 needed her. I was waving at her and she came running. She asked what was wrong. I said I don't know why they needed you right away." E19 (Nurse) on 07/03/13 at 10:00am, stated, "I was on the phone getting report for a resident coming back to the facility. When I stood up I saw the housekeeper down hall and she was gesturing me to come down the hall. I went down the hall. I asked the housekeeper to call another nurse (E22). When I enter (R10's) room. I saw (R10) and (R11) lying in bed. (R10) was lying behind (R11). I immediately told him to get up. He was fully dressed. There was nothing exposed on (R10). She (R11) was undressed from the waist down. The other nurse and I walked him to the Nurses' station and placed him on 1:1. I had CNA (E17) take (R11) to her room. I went to (R11's) room and did body assessment. Afterwards E22 (Nurse) and I called the manager on duty (E20). He (E20) came up and he called the administrator (E1). He interviewed both residents. The nurse (E22) and I (E19) called the physician. I was given an order from the Nurse Practitioner (Z10) to get lab work for [MEDICAL CONDITION] (STD) for (R10). No, I didn't send (R11) out to the hospital or call the police department. E20 said that the policy and procedure is to call the administrator and physician. I did a body assessment on (R11). She was taken to the shower room and washed up. I notified E20 and went by his leadership. The Nurse Practitioner (Z10) didn't give an order to send (R11) out to the hospital. (R11) is alert and oriented X 1. (R10) is on every 15 minutes monitoring." When asked did R11 understand what happened to her? E19 stated, "No, she does not understand what happened to her. The CNA said she just heard the alarm going off." On 07/03/13 at 10:50am, E20 (MDS Coordinator/Manager on Duty) stated, "I was the manager on duty. I was doing rounds on the 1st floor. I was called to the third floor. When I came up there, a nurse (E22) made me aware that a couple of residents (R10 and R11) were found in the room lying in bed. They were separate when I got up on the floor. He (R10) was at the nurse's station. I was told they were lying in bed together. (R11) was taken to the dining room. I told them to take her (R11) to her room and do body observation. She was taken to the bath/shower room and cleaned up. I didn't call the police or send her out to the hospital. I called the administrator." On 07/03/13 at 2:10pm, Z10 (nurse practioner) stated, "I received a call about (R11) from one of the nurses. She informed me that (R11) was found in the room with a male resident (R10). The nurse informed me that they were possibly having sexual intercourse. There was no evidence of sexual assault." Surveyor asked Z10 if she came to facility to assess the R11 for vaginal trauma or injury. E10 stated, "No, I didn't check her. The nurses informed me what happened, I ordered a STD panel." On 07/09/13 at 2:00pm, Z12 (family member) per telephone stated, " The facility said it was consensual sex. She (R11) has dementia. I don't know if she can make decisions for herself. The male had taken advantage of her. My husband has the Power Of Attorney for his mother. She cannot make decisions for herself." The resident was not sent out to the hospital to be assessed nor were the police notified. The care plan was not updated or revised on how (R11) will be monitored, supervised or protected from R10. The medical record date 3/6/13 for R10's [DIAGNOSES REDACTED]. The incident report dated 06/29/13 at 4:00pm, indicates "(R10) is alert and oriented with periods of confusion. Allegedly R10 was observed lying on another resident (R11) in an inappropriate manner. R10 and R11 were immediately separated and provided one to one supervision". On 07/03/13 at 9:15am, R10 was observed sitting in the dining room during breakfast. R10 was alert and oriented with some confusion (dates and time). R10 was observed ambulating throughout 3rd floor unit. On 07/03/13 at 9:30am, surveyor asked R10 if a lady was found in his bed. R10 stated, "Yes, I don't know her name. She was in my bed. I had intercourse with a lady." During the interview R10 asked, "Could I touch your thigh?" R10 left the dining room at 11:40am and went into his room. At approximately 1:00pm, R10 came out of his room and continued to walk the unit, and at one point looked into a room which a female resident resided. From 11:40am to 1pm there were no staff monitoring or supervising of R10. The Screening Assessment for indicators of aggressive and/or harmful behavior for R10 dated 07/01/13 indicates A. Risk Assessment (6). History of abuse/neglect either as a recipient or perpetrator including abusive and/or inappropriate sexual behavior score 1 and 2 (moderate problem and substantial or significant). B. Recommendation and Outcome (3). In need of structure, medication management, supervision. In addition, the resident may benefit from evaluation and on-going intervention from licensed mental health professional. R10's total score was 11. C. Comments were that a total score 11 will be referred for psychiatric evaluation. No evidence of a psychiatric evaluation being conducted on R10 was found. The social services progress notes indicates on 06/04/13 "staff reported to writer that resident was making inappropriate comments towards staff. Writer met with resident regarding report on sexually inappropriate behavior. Writer educated resident (R10) to refrain from making sexually inappropriate comments or threats to staff". 06/08/13 "staff reported to writer that resident (R10) was swearing and threatening staff". 06/25/13 "Staff reported that resident (R10) was swearing at peers". 07/1/13 at 8:45am, "met with resident (R10) name below to provide education on safe sex practices. Resident (R10) is encouraged to communicate with staff if he has any interest in pursuing sexual relationships with other peers". 07/04/13 "staff reported to writer that resident (R10) was making sexually inappropriate comments and threatening staff. Writer meet with resident (R10) regarding report on sexually inappropriate behavior. Writer educated resident (R10) to refrain from making sexually inappropriate comments or threats to staff". The nurses notes dated 06/29/13 does not indicate that R10 was sent out to the hospital for evaluation. On 07/08/13 at 10:00am, Surveyor asked E23 (nurse), where R10 was located. E23 (nurse)stated, "R10 was sent out to the hospital for aggressive and inappropriate sexual behavior." The nurses note dated 07/06/13 indicates R10 had inappropriate sexual behavior and was sent out to the hospital. E23 (Nurse) on 07/08/13 at 10:30am, stated, "I worked on Saturday (7am to 3pm) shift. I was doing my last round at the end of the shift. I walked into (R10's) room and I said Hi. He asked me do you want to be my friend? I told him, I am your nurse. When I was walking pass he was trying to hug me. He grabbed me so tight, I was unable to get away from him. He asked me could he kiss me in my mouth. I said "No". I was trying to redirect his behavior while he was holding me. I was trying to break away from him. He asked me if I was married. I said yes, he loosened up and I broke away and got a male certified nurse aide (CNA). He was alright with the male CNA. He was placed on a 1:1 monitoring. I called the physician and was given an order to send R10 out to the hospital. On 07/08/13 at 3:30pm, E21 (Memory Care Director) stated, "We were monitoring him every 15 minutes and 1:1. He was not sent out for evaluation until after the incident of 07/06/13 with the staff." The care plan (physical and psychosocial needs) dated 01/14/13 indicates R10 has a history of inappropriate sexual behavior, of touching staff that provide activity of daily living care. There was no assessment or revised/updated intervention on care plan for inappropriate sexual behavior for R10. The facility took the following actions to remove the immediacy: 1. R10 was discharged from the facility on 07/07/13. No further intervention can be completed for R10. 2. All residents will be assessed upon admission and change of condition. 3. Facility staff were in-serviced regarding what constitutes inappropriate sexual behavior, sexual abuse reporting, including notification of the police and interventions to be instituted by the Administrator/designee on 08/07/13 and before subsequent start of the next shift 100% compliance is attained. 4. All residents have been reassessed for aggressive sexual behavior on 08/07/13 by Social Service Director/designee. No resident was identified with aggressive sexual behavior. 5. Policy/Procedure for Handling of a Crime Scene within the facility has been reviewed and update as appropriate on 08/07/13. 6. Facility staff have ben in-service on Policy/Procedure for Handling of a Crime Scene on 08/07/13 by the Administrator/designee and before the subsequent start of the next shift until 100% compliance is attained. 7. The Administrator/designee will monitor that all residents have been assessed for aggressive sexual behavior and associated care plans have been put in place. 8. The administrator /designee will monitor that all allegations of the sexual abuse have been reported to the Administrator, investigated, and reported to IDPH, reported to the police and new intervention put in place. All identified trends will be reviewed by the QA (Quality Assurance) committee and a plan will be discussed and implemented until resolution.

(A). Based on record review, and interview, the facility failed to provide the necessary care and services to promote healing, prevent infection, and prevent new pressure sores from developing for 1 of 10 sampled residents(R3). These failures resulted in R3 hospitalization . These failures has the potential to affect all of the residents with pressure sores. Findings Include: R3 is a [AGE] year old readmitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. On 10-12-10 at 4:00pm, R3 showed change in condition as evidence by mental change and shortness of breath, left foot/toes cold to the touch, blood pressure 89/60. The facility contacted EMS(Emergency Medical Services) . At 4:04pm, EMS arrived. At 4:15pm, R3 left the facility enroute to the local hospital for evaluation. At 11:20pm, the local hospital contacted the facility that R3 will be admitted with initial [DIAGNOSES REDACTED]. Evidence indicates that at the time of transfer, R3 had the following pressure sores: 1. Right Heel -Stage III-Healing-No S/S of Infection. 2. Right Ischium-Stage IV-Healing Slowly-No S/S of Infection. 3. Left Heel-Stage II-Healing-No S/S of Infection. 4. Right Medial Ankle-Stage III-Non Healing- No S/S of Infection. 5. Left Lateral Foot-Unstageable-Non Healing-No S/S of Infection. 6. Left Medical Foot-Stage IV-Non Healing-No S/S of Infection. 7. Left Lateral Heel-Stage III-Non Healing-S/S of Infection. 8. Right Lateral Foot Proximal-Unstageable-Non Healing-No S/S of Infection. 9. Right Lateral Foot Center-Unstageable-Non Healing-No S/S of Infection. 10. Right Lateral Foot Distal-Unstageable-Non Healing-S/S of Infection. # 1,2,and 3 were acquired; the remaining pressure sores were all unacquired. Interview with E4(Licensed Practical Nurse/Treatment Nurse) on 11-5-10 at 11:30am stated that the doctor was aware of the wounds that were showing S/S of infection, and that interventions were in place. Medical interventions included the order to obtain a test to determine urine infection, was ordered on 10-11-10. Interview with Z3(Attending Physician) on 11-5-10 at 2:45pm stated that the facility followed all orders , and that based on R3 multiple medical co-morbidities, that it is difficult for all of the wounds to heel. Hospital Record Review on 11-9-10 Review of the emergency room Report dated Room nursing dated 10-12-10 at 4:45pm indicates that " multiple decubitus ulcers, " " very unkept, " " strong necrotic odor from patient wounds. " The Medical Decision portion of the emergency room record indicates " severe dehydration, infected decubitus ulcers, and urinary track infection. " Review of the emergency room Lab data indicates that the BUN(Blood-Urea-Nitrogen) was elevated at 75(7-18). Review of the Physician Consultation sheet dated 10-12-10 indicates that R3 " severely emaciated. " The medical [DIAGNOSES REDACTED]. " Review of the Right Hip wound culture dated 10-15-10 indicates positive ESBL [MEDICAL CONDITION] infections. Nasal screening [MEDICAL CONDITION] infection dated 10-15-10 was positive. Interview with Z4(Physician) on 11-9-10 at 9:35am stated that to some extent, R3 condition could have been medically prevented. Z4 further stated that neglect played a part in the presentation of the patient. Z4 also stated that the severe dehydration, multiple wound infections, and the malnourishment of R3 could have possibly been prevented. Evidence indicates that the condition of the multiple pressure sores contributed to the change of condition and subsequent hospitalization . Interview with E8(Registered Dietician) on 11-9-10 at 11:45am stated that the nutritional interventions were initiated, but weight loss continued, and that wound healing did not occur as desired. Evidence indicated that R3 weighed only 80 pounds at the time of transfer, and that R3 had lost 13 pounds during the past 3 months, which exceeds 7.5% weight loss. . (B). Based on record review and interview the facility failed to implement a pressure ulcer intervention to prevent the development of a facility acqiured pressure ulcer for 1 (R2) of 1 resident with a pressure ulcer in the sample. Findings Include: Record review of R2, [AGE] year old black female with [DIAGNOSES REDACTED]. hip. Nurse states in her notes that Z2 (doctor) was notified on 8/31/10 and that Z2 ordered to apply [MEDICATION NAME] ointment to right hip three times a day for 7 days. Record review of R2's Skin treatment sheet denotes from August 31-2010 to September 7 2010 doctors orders for [MEDICATION NAME] was not transcribed to treatment sheet. as a result of this failure, the treatment was never done. Interview of Z2 at 1:30 PM on 11/4/10 states that she did not know nursing did not follow her order for [MEDICATION NAME] to be applied to the right hip Record review of R2's treatment sheet denotes that treatment for [REDACTED]. Record review of R2's skin alteration record (wound assessment record) on 10/27/10 stages the right hip as a stage 4 ulcer. Record review of R2's skin treatment sheet on 11/4/10 at 11:23 AM that E5 (licensed practical nurse) documents she is cleaning the right hip with normal saline and applying Hydro [MEDICATION NAME] every day. The record review of the physician orders [REDACTED]. Interview of E5 on 11-4-10 at 11:30 AM states that she is not using Hydro [MEDICATION NAME] but instead following the new orders from Z2 to clean both hips with normal saline and apply the Dakins solution. E5 states that she signed the treatment for [REDACTED]. Interview of E3 (assistant director of nursing) at 11:35 AM on 11/4/10 states that he did not know why E5 signed that she applied the hydro [MEDICATION NAME] dressing even though she states that she did not use the hydro [MEDICATION NAME] dressing but instead used the Dakins solution on the guaze. E3 further states that she used the Dakins solution but did not transcribe the new order to the treatment sheet. Interview of E4 (wound nurse) on 11/4/10 at 12:06 PM states that she informed E5 yesterday that Z2 was in the process of changing the Hydro [MEDICATION NAME] to Dakins solution but that it was not clarified until today. E4 states that she was writing the new order now for the Dakins solution. E4 denies that she told E5 to start the order this morning for the Dakins solution because she had not get the order clarified from Z2. Interview of E4 at 10:10 AM on 11/5/10 states that E5 resigned yesterday afternoon.