Every finding on record at Landmark of Oak Lawn Rehabilitation and Nursing Ce

Based on observation, interview, and record review, the facility failed to follow its Guidelines for Incontinence Care by not providing timely incontinence care to dependent residents. This applies to 3 of 3 residents (R3, R6, and R11) reviewed for activities of daily living in a sample of 11.The findings include:1.R3 is a [AGE] year-old female admitted with mild cognitive impairment as per MDS dated [DATE]. The MDS also documents that R3 is dependent on toileting hygiene.On 1/27/26 at 10:05 AM, R3 was observed in her bed and stated, They changed me last night, and I think I am wet.On 1/27/26 at 10:22 AM, R3 was observed with dark blackish colored incontinent brief with a strong odor of urine and feces.On 1/27/26 at 10:22 AM, V19 (Certified Nursing Assistant / CNA) stated, I got here at 7:00 AM. I was passing trays and didn't get a chance to change her. I am on my way to change her.On January 28, 2006, at 10:42 AM, R3 stated that she had not changed yet. On 1/28/26 at 10:43 AM, V20 (CNA) stated, I was just pulled from the second floor to the first floor now, and I didn't change R3 yet.On 1/28/25 at 10:50 AM, observed V20 and V21 (CNA) providing incontinent care to R3. R3 was observed with a moderate wet brief with urine.A review of the restorative care plan document that R3 was care planned for neuromuscular bladder dysfunction/incontinence with intervention including check the resident (every 2 hours) and as required for incontinence. Wash, rinse, and dry the perineum. Change clothing PRN after incontinence episodes.2.R6 is a [AGE] year-old female admitted on [DATE], having severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R6 is dependent on toileting hygiene.On 1/27/26 at 1:00 PM, R6 was observed in her bed with her fiance (V18) at her bedside. V18 stated, I was here at 8:40 AM, and nobody checked on R6 between 8:40 AM and 12:40 PM. R6's incontinent brief was heavily soaked with bowel movement and was smelly, and they changed her at 12:40 PM.A review of the care plan document that R6 was care planned for incontinence with interventions including administering appropriate cleansing & peri-care after each incontinent episode.3.R11 is a [AGE] year-old female admitted on [DATE], having cognition intact as per the MDS dated [DATE]. The MDS also documents that R11 is dependent on toileting hygiene.On 1/28/26 at 10:35 AM, R11 stated, I am waiting to be changed. I was changed in the early morning by the night staff. R11 initiated call light, and V20 checked on R11, and R11 was observed with a moderately wet, brownish colored incontinent brief.On 1/28/26 at 10:40 AM, V20 stated, They just moved me from the second floor, and I didn't get a chance to change R11. I didn't get any report as no nursing assistant was assigned to R11. I am going to change R11 now.A review of the care plan document that R11 was care planned for overactive bladder with interventions including assist with toileting needs.On 1/27/26 at 10:35 AM, V2 (Director of Nursing / DON) stated that their staff is supposed to change incontinent residents every two hours and as needed.A review of the facility provided an undated Guidelines for Incontinence Care document: It's the policy of the facility to ensure that residents receive as much assistance as needed for cleaning the perineum and buttocks after an incontinent episode or with routine daily care. Frequency depends on the bladder's daily result and/or routine minimal every two-hour check, as well as care planning.

Based on observation, interview, and record review, the facility failed to follow the physician's order to provide wound treatment and care. This applies to 1 of 3 residents (R3) reviewed for wound treatment and care in a sample of 11.The findings include:R3 is a [AGE] year-old female admitted with mild cognitive impairment as per MDS dated [DATE]. R3 was admitted with an admitting diagnosis including paraplegia, pancreatic cancer, multiple stage-4 sacral pressure ulcers, and diabetes.A review of the wound assessment dated [DATE] by V23 (wound care physician) documented multiple chronic wounds, including a stage 4 left hip, stage 4 sacral, stage 4 left ischium, stage 4 right buttocks, and a stage 3 right heel.On 1/28/25 at 10:50 AM, observed V20 and V21 (CNAs) providing incontinent care to R3. During incontinence care, R3 was observed with a stage 4 sacral and stage 4 left ischium wound with soiled and dirty dressings peeling off and dated 1/26/26.On 1/28/26 at 11:25 AM, observed V22 (Licensed Practical Nurse / LPN) providing wound care to R3's multiple sacral wounds. During wound care, V22 stated that the old dressing is soiled, dirty, and peeling off with date 1/26/26 indicates that nobody provides wound care yesterday.On 1/28/26 at 11:30 AM, observed V22 cleanse the wound with saline, pat dry, medi honey, and calcium alginate applied to stage 4 sacral and stage 4 left ischium wounds.A review of the Physician Order Sheet (POS) and Treatment Administration Record (TAR) document sacral and left ischium wound care document to apply (product) after cleansing site and then covering with Silicone super absorbent dressing daily and as needed.On 1/28/26 at 11:30 AM, V22 stated that she is aware of the (product), and she couldn't find it in the treatment cart to apply to R3's sacral and left ischium dressing change.On 1/29/26 at 9:20 AM, V23 (Wound Care Physician) stated, R3 was admitted with those chronic wounds. I ordered (the product), which will debride the dead tissue from the wound bed. The facility should have used the (the product as ordered) to change the wound dressing.The facility presented an undated Wound Cleansing and Dressing Policy document: It is the policy of the facility to perform wound dressing changes as ordered by the physician using a clean technique on all chronic or contaminated wounds.

Based on interview and record review, the facility failed to follow their elopement policy by not allowing a resident to leave the facility unauthorized without staff knowledge. This affected one of three residents R1 reviewed for leaving the facility unauthorized. This failure resulted in R1 being found about 450 ft from the facility walking down the street within minutes after leaving. Findings Include: R1's hospital referral package dated 6/16/25 documents: Per emergency department patient (R1) with tendency to roam the street. Psychiatric: Cognition and Memory: Cognition is impaired. Memory is impaired. Comment: Highly impaired insight plus judgement. R1 was admitted on [DATE] with the diagnosis of Dementia with other behavioral disturbance. Minimal data set dated [DATE] documents a score of twelve which indicates moderate cognitive impairment. Nursing note dated 6/20/25 documents: Resident (R1) is alert, forgetful and oriented to self and situation. Elopement Risk Review dated 6/20/25 documents: Ambulation: Confined to chair/bed (non-mobile without assistance) no; Predisposing diseases/condition: Does resident have a diagnosis of Dementia/ Alzheimer's or severe mental illness or period of confusion: yes; Cognitive process: does resident pace or wander: yes; History of elopement episodes for the past three (3) months: yes; Does the resident readily accept nursing home placement: no Elopement risk: score twenty-one(21); Category: High Risk for Elopement. R1's care plan initiated 6/20/25 documents: Resident (R1) demonstrates movement behavior that may be interpreted as wandering, pacing or roaming related to the diagnosis of Dementia and problems understanding the immediate environment. Attempting to leave facility without a responsible escort (elopement). Pacing, roaming or wandering in and out of peers' rooms. Engaging in theme behavior, believes he/she is in another time and place with specific responsibilities (must deliver mail due to being a retired mail carrier), the resident is a new admission and not familiar with his/her environment. Nursing note dated 6/21/25 documents: 72 hour charting: Resident (R1) up and about. R1 is alert and orient 1- 2 with confusion, at baseline. R1 indicated to exhibit wandering behavior and is being monitored closely by staff for safety. Community Survival Skills assessment dated [DATE] documents: Due to R1 diagnosis of Dementia, R1 does not appear to be capable of unsupervised outside pass privileges at this time.Nursing note dated 7/4/25 created 7/14/25 documents: (V8 nurse) Writer was informed by staff that the (R1) attempted to exit the facility with accompanying (R2) peer's family members. All families entering the building have been educated not to allow residents to join them in the elevator, given that this is a secure unit with elopement precautions in place. R1 was observed on the first floor; the (V9) receptionist promptly notified nursing, and R1 was redirected back to her room. R1 was reoriented to baseline, with education provided that R1 resides in the facility and may leave only with approved pass authorization from her POA. R1 is known to wander and is considered an elopement risk.Physician Progress note dated 7/4/25 created 7/16/25 documents: V11 (nurse practitioner) Writer informed by V2 DON via message that patient (R1) was noted on the first floor after being on the elevator with another patient family that was leaving the unit. R1 was redirected and assisted back to the second floor. Spoke with nurse on duty and discussed elopement precautions and frequent rounding to be done to ensure R1 does not exit unit unless supervised by POA or staff due to being elopement risk with diagnosis of dementia, understanding voiced. Per nurse on duty the R1 did not leave the building and was easily redirected back to the unit. V11 request that families are made aware that staff should be notified of any residents attempting to leave the unit via elevator when they exit the facility. On 7/16/25 at 9:26am, V3 (complainant) said, she and V4 saw R1 on 95th street (7/4/25 @ 3pm) getting ready to cross the street. On 7/16/25 at 10:00pm, V4 (cna) said, he was off work. V4 said, he left the building around 3:15pm. V4 said, he saw R1 walking down 95th street. V4 said, he called out to R1, asked R1 what she was doing to which R1 replied taking a stroll. V4 said, he brought R1 back to the building, stop at V9's desk to inform her that R1 was found outside the building on 95th street. V4 said, he took R1 to V8 (nurse). V8 was the nurse on R1's unit. V8 did not know R1 left the building. V4's witness statement dated 7/17/25 documents: On July 4th, V4 saw R1 on 95th and walked R1 down the street back into the building. Let the front desk know and then took R1 back upstairs. On 7/16/25 at 10:58am, V8 (nurse) said, R1 attempted to exit the facility with R2's family. R1 went down the elevator. V4 (cna) brought R1 back to the unit. V8's statement documents: On 7/4/25 at 2:40pm, V8 was making the schedule for 3-11 shift when V9 called and asked if R1 was on the unit. V8 completed a head count with peer nurse. R1 was coming off the elevator with cna. On 7/16/25 at 11:02am, V5 (cna) said, she was sitting in the hallway at the end of R1's unit, because R1 got onto elevator, that requires a code, left the building and made it to 95th street. V4 brought R1 back into the building.On 7/16/25 at 11:19am, V9 (receptionist) said, R2's visitors V12-V13 (R2's visitors) signed out on the visitation log and proceeded to exit. V9 said, she saw someone walk pass really fast behind V12/V13. V9 said, she stood up, checked the computer because she was not sure if R2 was leaving with her family. V9 said, she recalled that only two (2) people came to visit R2 and three (3) people were leaving. V9 said, about one minute later, V4 (cna) brought R1 back into the facility. V9 said, R1 was a new admit. V9 said, she had never seen R1 before. V9 said, R1 left the building via the front lobby exit. V9 said, staff was standing in front of her desk but did not intervene. V9 said, V4 took R1 back to her unit on the second floor. V9 said, R1 exited after R2's family around 3:11pm on 7/4/25.V9's witness statement dated 7/16/25 documents: V9 observed a person walking past her behind two family members whom V9 did not recognize while at the front desk. V9 said, she checked the electronic computer system what R2 looked like. Two (V5-V6 certified nursing assistants/cna) knew who R1 was. V4 immediately walked R1 back in the building. As V5/V6 were standing at the front desk and said, that's R1 On 7/16/25 at 11:41am, V2 (don) said, she did not work on the 7/4/25. V2 said, she got some missed calls. V2 said, she got a call from V9 called to report R1 left out the building with R2's family.V2 said, she was informed that V4 brought R1 back in. V2 said, she was not aware R1 was on 95th street. Staff/certified nursing assistant (CAN) on R1's unit had to put in code for R1 to exit via the elevator. R1 was had yellow pass status which meant she need someone (family, staff or power of health care) to take R1 out of the building. On 7/16/25 at 12:51pm, V11 (nurse practitioner) said, she was not aware R1 left the building. V11 said, she was notified via message that, R1 was on the first floor. On 7/16/25 at 1:01pm, V1 (administrator) said, a true elopement is when a resident is found outside facility and staff doesn't know that they are missing, or when someone driving past and see one of the resident that no one knows is out of the building. V1 said, she has not have any true elopements. V1 said, residents that are high risk for elopement are residents who are exit seeking, mobile, with a diagnosis of Dementia, cognitively impairment residents, newly admitted or newly orientated to building. V1 said, R1 was not a true elopement. R1 was witnessed by staff leaving and redirected. V1 said, V9 reported seeing V12/V13 leaving but did not know R1 who left with R2 family. V1 said, the facility does not have a wander guard system. R1's unit has an elevator has a key pad to which the code must be entered to exit R1's floor. Nothing was written down, no new systems was implemented and she did not view cameras for R1 incident. V1 said, the cameras are for quality assurance purpose only. On 7/16/25 at 4:02pm, V12 (R2's visitor) said, he was with V13 when a female resident got on the elevator with him after staff entered the code. The code was enter three different time because the elevator did not come the first time. V12 was unable to identify which staff member entered the code. V12 said, a small, dark skin, thick staff member entered the code once and then another staff member entered the code a second/third time. V12 said, he was unable to determine if the staff member was a nurse or certified nursing assistant but they all had on scrubs. V12 said, he did not received any education from the facility about letting residents on the elevator. V12 said, he thought it was odd that a resident would be allowed on the elevator since staff had to enter a code for the elevator in order exit the second floor. V12 said, the sign out time on the visitation log was correct as far as he could remember. Visitation log dated 7/4/25 documents: V12 signed out at 3:11pm. On 6/17/25 at 9:17am, V4 (cna) said, R1 was found in the corner of 95th in front of the dental office. R1 had turned the corner off [NAME] and was walking east bound on 95th street. Google map documents: The dentist office was 450 feet away from the facility, mostly flat, with a two (2) minute estimate time of arrive (eta) by walking. R1 was returned to the facility less than ten minutes of leaving the facility by V4On 7/18/25 at 7:53am, V14 (R1's power of authority) said, R1 has a history of wandering. R1 would leave the house, go to located business and always find her way home. R1 was probably trying to find her way home when she left the building. V14 said, she wouldn't want R1 roaming the streets because she could have been hit by a car. V14 said, R1 said would have been extremely confused, fearful, agitated and scared wandering the streets in a neighborhood that was not familiar to R1. V14 said, she was scared for R1 during the interview to hear R1 was out of the building and found on the corner away from the facility. V14 said, R1 is mixed raced. V14 said, it is very concerning that R1 was out of the building with no identification or supervision. V14 said, if R1 was seen by united state immigration and customs enforcement R1 could have been detained. V14 said, she received a call from the facility at 9:30pm, informing her that R1 wanted to go home. V14 said, she was surprised by the call. The facility should have been able to address R1's needs. V14 said, she does not recall the nurse or the date she called. V14 said, she spoke to R1, along with other family member, R1 eventually forgot she wanted to leave prior to the end of the phone call. V14 said, she was not aware, R1 was out of the building. Elopement Policy no date document: It is the policy of this facility that all resident are provided adequate supervision to meet each resident's nursing and personal care needs. Resident at risk for elopement will be provide at least one of the following safety precautions, staff supervision of the facility exit either directly or by video camera. Procedure for the response to missing resident: The administrator/designee shall contact the resident's representative.

Based on observation, interview and record review the facility failed to ensure activities of daily living (ADL) for dependent resident's, which included showers and grooming of hair and fingernails, was provided for 4 of 4 resident's (R7, R8, R9 and R10) reviewed for activity of daily living. Findings include: On 6/12/2025 at 2:20pm R7 was observed walking out the dining area with hair not combed and heavy soiled feet. On 6/12/2025 at 2:25pm V12 said showers are twice weekly I'm from the over night shift and I did not shower anyone, I'm assisting R7 now with her hair and putting on some socks I don't know when her last shower was completed her feet are dirty because she takes off her socks and walk around barefoot. On 6/12/2025 at 3:00pm V2(Director of Nursing-DON) observed with this writer R7 hair not combed, and heavy soiled feet, V2 said I don't think she had a shower today her feet are not cleaned, and her hair is not combed, I expect all resident's to be groomed and showered twice weekly and as needed. An admission record dated 6/13/2025 indicates that R7 has a diagnosis of dementia, need for assistance with personal care. A care plan dated 12/10/2024 that has a self-care deficit, and I require assistance with activity of daily living to maintain my highest level of functioning an intervention of aid with activity of daily living as required per my dependence needs, bathing and dressing I usually require extensive assistance and 1 person support. On 6/12/2025 at 2:35pm this writer observed with V11, R8 in the dining area with a full beard. On 6/12/2025 at 2:38pm V11 said I thought R8 daughter shave him she was just here today. On 6/12/2025 at 3:00pm V2 said I expect all resident's to be shaved and groomed daily and as needed he should not have a full beard. An admission record indicates that R8 has a diagnosis of Alzheimer disease, dementia, and need assistance with personal care. A care plan dated 2/10/2025 that indicates R8 has self-care deficit and require assistance with activity of daily living to maintain highest level of functioning, an intervention to aid with all activity of daily living as required per my dependence needs grooming. On 6/12/2025 at 2:38pm this writer observed R9 in bed with a full beard and long soiled fingernails. On 6/12/2025 at 2:40pm this writer observed with V11(Certified Nursing Assistant-CNA) R9 beard and long fingernails. On 6/12/2025 at 2:42pm V11 said R9 has a hospice aid that comes in and shaves and cut his fingernails, I thought she cleaned him up, I'll start cleaning him up now. On 6/12/2025 at 3:00pm V2 said R9 does have a hospice aid but the CNA assigned daily to him should ensure that what ever the hospice aid did not do that she does. An admission record indicates R9 has a diagnosis of orthopedic care after surgical amputation, gastrostomy placement, chronic kidney disease. A care plan for self-care deficit that require assistance with Activity of daily living intervention to aid with all activity of daily living as required per my dependence needs, personal hygiene. On 6/12/2025 at 2:15pm this writer observed R10 in bed with long curved fingernails, R 10 said I don't want my fingernails cut off I want them cut down and I would like a shower. On 6/12/2025 at 3:05pm V2 observed with writer R10 long curved fingernails and R10 complaint of not having a shower. On 6/12/2025 at 3:07pm V2 said that R10 will not allow the staff to cut off her fingernails she never said she wanted them cut down and R10 refuses showers. An admission record dated 6/13/2025 indicates that R10 has a diagnosis of quadriplegia, obesity. A care plan dated 9/27/2024 for self-care deficit and require assistance with activity of daily living for bathing dressing and personal hygiene. Facility Policy: Activities of Daily Living (Routine Care) Policy: Residents are given routine daily care and HS care by a C.N.A. or a nurse to promote hygiene, provide comfort and provide homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed. ADL care is coordinated between the resident and the care givers with emphasis on resident preferences as much as possible. . Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, appropriate skin care (as indicated and as per care plan) as well as encouraging participation in physical social and recreational activities.

Based on observation, interview and record review the facility failed to allow a resident access to a bedroom shower room for 1 of 1 dependent resident (R10) reviewed for showering assistance. Findings include: On 6/12/2025 at 11:15am R10 was observed in bed, R10 said the nursing staff will not assist me with a shower because, I will not go to another floor, I have a working shower in my bedroom the door to the shower room is broken and it has not opened in over a month and that's how long I have not showered, I spoke to the director of nursing and she told me also to use the upstairs shower room. On 6/12/2025 at 11:20am V2 (Director of Nursing-DON) said R10 refuses to shower on the upstairs unit her shower room door will not open, and I don't know how long it's been broken or if the maintenance staff is aware, she's been offered other shower rooms. On 6/13/2025 at 9:45am V10(Laundry Supervisor) said I am not in maintenance, I do not have access as to how long the door has not opened, I did replace the doorknob and it opens now, the entrance to the shower room is open in the joining room my staff cleans it every day. On 6/13/2025 at 9:50am this writer and V10 observed the entrance to R10 shower room door open and the joining room door open, shower room clean and functioning. An admission record dated 6/13/2025 indicates that R10 has a diagnosis of Quadriplegia, paraplegia, obesity, muscle weakness. A care-plan dated 9/27/2024 that indicates R10 require assistance with all activity of daily living with an intervention of bathing and dressing require total assistance and 1 staff for bathing and dressing (Totally Dependent on staff). A skin monitoring comprehensive CNA shower review dated 4/16/2025 and 5/21/2025 no other shower sheets. Facility Policy: Resident Rights As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights as designated below. Exercise of Rights. . You have the right to freedom to exercise your rights of this facility and as a citizen or resident of the United States without fear of discrimination, restraint, interference, coercion or reprisal. (Free Choice). You must be informed of and may participate in planning your care and treatment and any changes in your care and treatment.

Based on observation, interview, and record review the facility failed to assess resident for safe medication self-administration. This deficiency affects one (R5) of three residents in the sample of three reviewed for Medication safety. Findings include: On 6/13/25 at 10:29AM, R5 observed in room, inhaler laying on top of bedside table, no name or open date available. R5 said she is allowed to have it at bedside. On 6/13/25 at 10:35AM, V3 (Licensed Practical Nurse) said that residents are not supposed to have medications at bedside, but some can, V3 said she will check for order. On 6/13/25 at 11:46AM, V9 said that the self-medication administration assessment for R5 was not completed on 2/13/25, the assessment lock date was on 6/13/25, indicating it was not completed until 6/13/25. V9 said that the assessment should have been locked on 2/13/25. On 6/17/25 at 11:07AM, V3 said all medication should be kept inside package so it can have the residents name, medication name and instructions, and date it was opened and stored in package for infection control purposes. On 6/17/25 at 11:31AM, V2 (Director of Nursing) said that the medication kept at bedside should be stored it the packaging sent from pharmacy, it will include resident name, medication instructions and date medication was opened. R5 is admitted on [DATE] with diagnosis listed in part but not limited to multiple sclerosis, chronic obstructive pulmonary disease, epilepsy unspecified, muscle weakness, diabetes mellitus due to underlying condition with hyperglycemia, other asthma. Physician order summary report active order 5/29/25 Albuterol sulfate HFA aerosol solution 108(90) base mcg/act 2 puff inhale orally every 4 hours as needed for shortness of breath. Active order on 2/13/25- May have inhaler at bedside. Self-administration of Medications assessment dated [DATE] not completed. Care plan initiated on 6/13/25 for R5 expresses the desire to self-administer her medications and has capability to administer them safely. R5 will use rescue Albuterol inhaler per orders. 5.3: Self-Administration of Medication by Residents Policy: Self-administration medications will be encouraged if it is desired by the resident, safe for the resident and other residents of the facility, ordered by the attending physician, and approved by the interdisciplinary team. Procedure: 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. c. The medications provided to the resident for bedside storage are kept in the containers dispensed by UnitedRx. 5. A physician order is obtained to self-administer medications if the above storage and skill assessment has been approved for the resident by the interdisciplinary team. The order is recorded on the MAR.

Based on observation, interview and record review the facility failed to provide a resident with the proper footwear while up in the dining area and the hallway for 2 of 2 resident's R7, and R8 reviewed for dignity. Findings include: On 6/12/2025 at 2:25pm this writer observed R7 exiting the dining area with out socks or shoes on her feet and R8 sitting at the dining room table without shoes on his feet. On 6/12/2025 at 2:30pm V12 (Certified Nursing Assistant-CNA) observed with this writer R7 with out socks or shoes on her feet, V12 said I'm working over form 11-7 shift I'm assisting her with socks and shoes now, she's been in the dining room all morning. On 6/12/2025 at 3:00pm V2 (Director of Nursing-DON) said I expect R7 to have on shoes and socks daily because she walks the hallway. An admission record dated 6/13/2025 indicates that R7 has a diagnosis of dementia, need for assistance with personal care. A care plan dated 12/10/2024 that has a self-care deficit, and I require assistance with activity of daily living to maintain my highest level of functioning an intervention of aid with activity of daily living as required per my dependence needs, a risk for falls and to ensure resident has proper footwear and nonskid socks prior to activity of daily living care dated 12/26/2024. On 6/12/2025 at 2:35pm V11(Certified Nursing Assistant-CNA) observed with writer R8 in the dining room without shoes on his feet. V12 said when I started my shift this morning I couldn't find his shoes, V11 and writer went into R8 room and V11 opened the closet door and located R8 shoes in a plastic bag on the shelf and said I guess his daughter put them up in the closet. On 6/12/2025 at 3:00pm V2 said I expect all residents to have socks and shoes on their feet. V2 and writer observed R8 shoes in the closet on the top shelf in a bag. An admission record indicates that R8 has a diagnosis of Alzheimer disease, dementia, and need assistance with personal care. A care plan dated 2/10/2025 that indicates R8 has self-care deficit and require assistance with activity of daily living to maintain highest level of functioning, an intervention to aid with all activity of daily living as required per my dependence needs, ensure I am wearing appropriate footwear that promote exercise, physical and good traction when ambulating or mobilizing in my wheelchair and during transfers. Facility Policy: Resident Rights As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights as designated below. Dignity. The facility will treat you with dignity and respect in full recognition of your individuality.

Based on observation, interview, and record review the facility failed to update care plan of resident with Self-Medication Administration. This deficiency affects one (R5) resident in the sample of three reviewed for Care plan revision. Findings include: On 6/13/25 at 11:26AM, V9 (Regional Nurse Consultant) said that there should be a care plan initiated when the order for self-medication administration was received, no care plan was initiated on 2/13/25. V9 said the care plan was initiated on 6/13/25. R5 is admitted on [DATE] with diagnosis listed in part but not limited to multiple sclerosis, chronic obstructive pulmonary disease, epilepsy unspecified, muscle weakness, diabetes mellitus due to underlying condition with hyperglycemia, other asthma. Physician order summary report active order 5/29/25 Albuterol sulfate HFA aerosol solution 108(90) base mcg/act 2 puff inhale orally every 4hours as needed for shortness of breath. Active order on 2/13/25- May have inhaler at bedside. Self-administration of Medications assessment dated [DATE] not completed. Care plan initiated on 6/13/25 for R5 expresses the desire to self-administer her medications and has capability to administer them safely. R5 will use rescue Albuterol inhaler per orders. 5.3: Self-Administration of Medication by Residents Policy: Self-administration medications will be encouraged if it is desired by the resident, safe for the resident and other residents of the facility, ordered by the attending physician, and approved by the interdisciplinary team. Procedure: 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. c. The medications provided to the resident for bedside storage are kept in the containers dispensed by UnitedRx. 5. A physician order is obtained to self-administer medications if the above storage and skill assessment has been approved for the resident by the interdisciplinary team. The order is recorded on the MAR. 11. Update the residents care plan quarterly or as indicated by the change in medication scheduling, dose or change in residents's condition with a reassessment of the resident's knowledge and ability to self-administer medication. IDT Care Planning Policy and Procedure (Person- Center Plan of Care) revised 6/2020 Each resident will have a comprehensive assessment completed that will assist in the development of an individualized (Person- Centered) plan of care that will 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 condition. 8. The care plan schedule will be updated weekly and communicated to team members on the weekly schedule.

Based on observation, interview and record review the facility failed to ensure that a dependent resident was not lying flat in bed while an enteral gastrointestinal tract tube feeding was infusing for 1 of 3 residents (R9) reviewed for tube feeding. Findings include: On 6/12/2025 at 11:00am R9 was observed by this writer with head of bed elevated at 20-degree angle and resident laying low in the bed feet touching the foot board. On 6/12/2025 at 11:05am V11 (Certified Nursing Assistant-CNA) observed with writer, R9 laying low in bed, V11 said his hospice CNA left him this way, his head of bed should be at a 40-degree angle to prevent him from choking and he should be pulled up higher in bed, when his hospice CNA is not here for him I should be monitoring R9 and proceeded to pull R9 up in the bed and raise the head of the bed to a 40-degree angle. V2(Director of Nursing-DON) said all residents with feeding tubes head of bed should be at a 30-40-degree angle and pulled up in bed to prevent aspiration. An admission record dated 6/13/2025 indicates that R9 has diagnosis of unspecified protein calorie malnutrition and gastrostomy status and chronic kidney disease and muscle wasting. An order summary report dated 6/13/2025 indicates R9 head of bed should be always elevated at a 45-degree angle except during activity of daily living care every shift. A care-plan dated 1/20/2025 that indicates R9 need assistance with all activity of daily living as required per dependent needs, bed mobility. Facility Policy: Guidelines for Enteral Feeding: Adult Purpose: To provide guidance to qualified licensed clinical staff in hanging and maintaining and managing and administering tube/feeding and enteral nutrition-to residents to include medication administration. Procedure: 6. The nurses will elevate the head of the bed 30-45 degrees while the tube feeding is infusing and will maintain this elevation for 30-45 minutes after the feeding is completed.

Based on observation, interview, and record review the facility failed to ensure oxygen tubing is stored, changed and dated weekly and as needed. This deficiency affects one (R2) of three residents reviewed for Respiratory Care. Findings include: On 6/12/25 at 2:25PM, R2 observed in room with oxygen tubing on top of bedside drawer uncovered. R2 said that the staff places it there when he does not need it. On 6/12/25 at 2:30PM, V2 (Director of Nursing) verified with surveyor oxygen tubing on top of bedside drawer uncovered and unlabeled, said that oxygen tubing should be placed in a plastic bag when not in use and stored in the drawer, the tubing is changed weekly or as needed. R2 is admitted on [DATE] with diagnosis in part but not limited to chronic obstructive pulmonary disease (COPD), essential hypertension, tobacco use, alcohol abuse, anxiety disorder, human immunodeficiency virus, unspecified abnormalities of breathing. Physician order summary report active order 6/6/25 Oxygen at 2-3L/min per nasal cannula every shift for COPD/asthma exacerbation. Oxygen Administration Policy Policy: It is the policy of this facility to provide oxygen to maintain levels of saturation to residents as needed and as ordered by the attending physician. Orders are entered into the clinical under Medication Administration Record. Procedures: 4. Tubing, humidifier bottles and filters will be changed, cleaned and maintained no less that weekly and PRN. Each will be labeled with date, time and initialed by staff completing this service to equipment.

Based on observation, interview and record review, the facility failed to account for the Shift change accountability record for controlled substances. This deficiency affects one of four medication carts (1st floor medication cart). Findings include: On 6/12/25 at 3:15PM, V5(Licensed Practical Nurse) said that controlled substance check is done daily on each shift with incoming nurse to verify narcotic count, V5 observed on controlled substance sing in sheet that dates were missing initials, said that the nurse did not sign. On 6/12/25 at 3:15PM, V6 (Licensed Practical Nurse) said that controlled substance is counted each day on each shift. V6 verified that there were dates with missing initials and said that if the initials are not there it does not mean the count was not done, V6 said she was not here on those dates. On 6/12/25 at 4:05PM, V2 (Director of Nursing) made aware of above findings with V5 and V6 of empty spaces not initialed in the days for 6/3/25, 6/10/25 and 6/11/25 and when asked to provide a copy of sheet the copy was given with all dates filled with initials. V2 said her expectations are that the narcotic sign in sheet is signed by both nurses one for incoming nurse and the other for nurse who is leaving, the narcotic count is done every day three times a day for each shift, said she was unaware of missing initials. On 6/12/25 at 4:15PM, V1(Administrator) said that her expectations for narcotic count is to be done every day /every shift. Is unaware that some days are not signed off on the narcotic daily sign in sheet. V1 made aware of empty spaces in the days for 6/3/25, 6/10/25 and 6/11/25 and was asked to provide a copy of sheet the copy was given with all dates filled. V1 said she understood the concern. 3.3: Controlled Substances Policy: Medications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling, and record keeping. Procedure: 4. While a controlled substance is in use the nursing staff will maintain the following medication records. b. All schedule II-controlled substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: 2. Both nurses will count the number of packages of controlled substances that are being reconciled during the shift/shift count and document on Shift Controlled Substance Count Sheet. 4. Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented.

Based on observation, interview, and record review the facility failed to ensure the medications are stored safely, securely, and properly following manufacturer/supplier recommendations. This deficiency affects one resident (R5) in a sample of three residents reviewed for Self-Administration of Medications by Residents. Findings include: On 6/13/25 at 10:29AM, R5 observed in room, inhaler laying on top of bedside table, no name or open date available. R5 said she is allowed to have it at bedside. On 6/13/25 at 10:35AM, V3 (Licensed Practical Nurse) said that residents are not supposed to have medications at bedside, but some can, V3 said she will check for order. On 6/17/25 at 11:07AM, V3 said all medication should be kept inside package so it can have the residents name, medication name and instructions, and date it was opened and stored in package for infection control purposes. On 6/17/25 at 11:31AM, V2 (Director of Nursing) said that the medication kept at bedside should be stored it the packaging sent from pharmacy, it will include resident name, medication instructions and date medication was opened. R5 is admitted on [DATE] with diagnosis listed in part but not limited to multiple sclerosis, chronic obstructive pulmonary disease, epilepsy unspecified, muscle weakness, diabetes mellitus due to underlying condition with hyperglycemia, other asthma. Physician order summary report active order 5/29/25 Albuterol sulfate HFA aerosol solution 108(90) base mcg/act 2 puff inhale orally every 4hours as needed for shortness of breath. Active order on 2/13/25- May have inhaler at bedside. Self-administration of Medications assessment dated [DATE] not completed. Care plan initiated on 6/13/25 for R5 expresses the desire to self-administer her medications and has capability to administer them safely. R5 will use rescue Albuterol inhaler per orders. 5.3: Self-Administration of Medication by Residents Policy Policy: Self-administration medications will be encouraged if it is desired by the resident, safe for the resident and other residents of the facility, ordered by the attending physician, and approved by the interdisciplinary team. Procedure: 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. c. The medications provided to the resident for bedside storage are kept in the containers dispensed by UnitedRx. 5. A physician order is obtained to self-administer medications if the above storage and skill assessment has been approved for the resident by the interdisciplinary team. The order is recorded on the MAR.

Based on interview and record review the facility failed to follow their activity calendar and implement and engage the residents in social activities of tabletop games on 2/25/25 for 4 of 6 (R6, R7, R8, R9) residents reviewed for social activities. Findings include: On 2/25/25 at 11:25am upon entering the dining room on the second floor. V6 approached with surveyor. V6 introduced herself as the Activity's Director. V6 entered with the surveyor. V6 said she was coming to the second floor to see what activities was taking place. V6 said there were no activities going on. V6 said she does the activities with the residents. On 2/25/2025 at 11:25am V7 (CNA) and V8 (CNA) was observed in dining room, V7 said she was talking to a resident. V8 (CNA) said she was doing one to one monitoring with a resident. Board games were observed stacked up sitting the table. There were no staff observed engaging the residents with activities. R6 was observed in dining room with his head down on the table and not engaged by staff. R7 observed with his head down, not being engaged in social activities. R8 was observed sitting there and not engaged. R9 was observed in chair and not engaged in social activities. Facility activity calendar posted on gray board outside of the dining room, denotes 10:00am - exercise, 10:30am the [NAME] and 11:00am tabletop games. Lunch was served after 12:00pm. On 2/25/25 at 3:00pm V2 (Administrator) said there is room for improvements in the activity department, she is working with the activity department with programs. On 2/26/25 at 2:45pm V4 (Director of Nursing) said the perk is the daily chronicles that the activity aide reads to the resident. Facility policy activity department program policy denotes in-part it is the philosophy of oak lawn respiratory and rehab ctr. to treat each resident as a unique individual with specific physical, psychological, and spiritual needs. It is the policy of oak lawn rehab ctr. To provide a competent variety of therapeutic recreation opportunities designed to meet, in accordance with the comprehensive assessment, the interest and physical, mental, and psycho-social, well being needs of each individual resident. The activity shall provide a structured, series of meaningful programming.

Based on observation, interview and record review, the facility failed to provide appropriate care for residents with incontinence by not ensuring that incontinence care was provided at least every two hours. This affected one of three residents (R10) reviewed for incontinence care. This failure resulted in R10 being left soiled and saturated in urine for over five hours and feeling cold. Finding Include: R10 was diagnosis with hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, functional quadriplegia, reduce mobility and need for assistance with personal care. Minimal data set section C (cognitive pattern) dated 11/1/24 documents a score of twelve which indicates moderate cognitive impairment. Section GG (functional abilities) documents: R10 has impairments on one side to the upper and lower extremity. R10 is dependent (helper does all of the effort) for toileting hygiene. Section H (bowel and bladder) dated 11/6/24 documents: Always incontinence of urine. Care plan dated 5/3/22 documents: R10 is incontinent of bladder/bowel. This problem is related to poor cognition skills, inability to communicate need for toileting. Intervention: Administer appropriate cleansing and peri-care after each incontinent episode. On 1/28/25 at 12:38pm, R10 was observed with V6 (cna). R10 was observed in bed with a strong smell of urine. R10 said, he was cold. R10 was observed laying on a wet chuck/pad with a large dark brown irregular shape ring extended to the edges of the pad. R10's entire adult brief was saturated with dark yellow urine. V6 said, R10 was last changed at 7:30am. V6 said, R10 was a heavy wetter. Residents are supposed to be checked and changed every two hours. On 1/28/25 at 12:41pm, V23 (nurse) said, R10 was soiled and saturated with strong smelling urine, a wet pad and a brown dried urine ring on the pad. V23 said, R10's adult brief was saturated with orange-yellow urine. Incontinence Care policy undated documents: To ensure that resident's receive as much assistance as needed for cleansing the perineum and buttock after an incontinent episode or with routine daily care. Frequency depends on bladder diary result and or routine minimal every two hours checks as well as care planning.

Based on observation, interview and record review, the facility failed to protect a resident with severe cognitive impairment from physical abuse; and failed to follow the facility abuse policy and abuse care planning for one (R1) of five residents reviewed for abuse. This deficiency resulted in R2 hitting R1 in the face. R1 sustained discoloration to left eye, and bleeding to nose and mouth. R1 was sent to the hospital and was diagnosed with facial hematoma as a result of physical trauma. Findings include: R1 is a [AGE] year-old, female, admitted in the facility on 12/03/24 with diagnoses of Dementia in other Diseases Classified Elsewhere, Mild with Agitation; Unspecified Psychosis not due to a Substance or Known Physiological Condition; Schizoaffective Disorder, Unspecified; Anxiety Disorder, Unspecified; and Bipolar Disorder, Current Episode Depressed, Mild or Moderate Severity, Unspecified. MDS (Minimum Data Set) dated 12/10/24 documented: Section C, BIMS (Brief Interview for Mental Status) score of 3, which means severe cognitive impairment. Final incident report dated 12/16/24 recorded that on 12/12/24, R1 was noted with discoloration around left eye. R1 was unable to articulate what happened to her left eye. R1 was sent to the hospital for further evaluation and treatment. Progress notes dated 12/12/24 documented R1 returned to facility with no new orders and negative CT (Computed Tomography) scans results. R1's hospital records dated 12/12/24 indicated that she was diagnosed with facial hematoma because of physical trauma. CT of cervical spine, facial bones and head were performed on R1 with unremarkable results. On 01/06/25 at 11:11 AM, R1 was in the dining room, sitting in a chair closed to V4 (Certified Nurse Assistant, CNA). R1 was observed standing up and pacing from time to time but V4 tried to redirect her until she goes back to sit in the chair. R1 is alert and oriented to self but at times won't look or respond when asked. She (R1) ambulates with her head down. She is verbal but unable to hold a conversation. A light discoloration around R1's left eye was observed. R1 was asked about the discoloration, did not respond. She stood up again and walked towards a wheelchair parked in the corner. She was rubbing the wheelchair seat pad repeatedly, subsequently redirected by V4 again. R1 was asked again on what happened to her left eye, simply stated my roommate hit me. This was heard by V4 and V5 (CNA) who both verbalized that R2 was the roommate and was identified as the alleged perpetrator who hit her (R1) in the left eye. On 01/06/25 at 12:23 PM, V1 (Administrator) was asked regarding incident between R1 and R2. V1 replied, . I did the investigation with R1 and R2. It was that morning that they found R1 with discoloration on the left eye. R1 and R2 were in the room and was then separated. Physician was notified, R1 was sent out. V9 (Restorative Aide, RA) told me that she (R1) has a discoloration to the eye and when they were trying to remove her (R1) from the room, R2 became aggressive and attempted to hit her (R1). V6 (CNA) and V9 were there, they witnessed the incident. R2 did not hit R1. I don't know how she got the discoloration of the eye. When I interviewed R2 and asked if she hit her (R1), she (R2) said that she (R2) wants her (R1) out of her (R2) way and denied hitting her (R1). It is hard for us to say if she was hit by R2 or she (R1) bumped her head to something else. R1 is highly demented, and she wanders around. She (R1) is oblivious to where she is going. On 01/06/24 at 2:19 PM, V9 was interviewed regarding R1 and R2. V9 stated, That day, I was doing my rounds, I walked into R1's and R2's room, I saw dry blood on the floor. R1 was standing, I asked how she (R1) was doing, she turned around and I saw blood from her nose, mouth. The blood was already dry, and she had a black eye on the left eye. I took her (R1) hand, took her out to hallway, I saw V6. She (V6) came to me and asked her (V6) about what happened, she said she doesn't know. We asked other staff for help; they came in and I left. I called V1 and V2 (Director of Nursing). V6 was also interviewed on 01/06/25 at 11:20 AM regarding R1 and R2 incident on 12/12/24. V6 verbalized, That incident, it happened like around 6:30 AM, I came out from another resident's room. One of the RAs said that there was a discoloration to R1's left eye, like a black eye, and there was blood in her (R1) nose and mouth. That those were not on R1's face before. I removed R1 from the scene, called the nurse and the nurse went to assessed her. I saw R2, her (R1) roommate, with blood on her (R2) hand. I asked her (R2) and she said she hit her (R1) because she was in her (R2) space. She (R2) hit her (R1). I notified V1 and V2 and she (R1) was sent out to the hospital. R1 wanders from room to room. She will just stand there talking to herself, but not aggressive. She can be easily redirected. When she (R1) wanders or walk in the hallway, one of us will walk with her and turn her around and bring her back to the dining room. So she won't intrude other's space. R2 is a known offender, she curses all out, verbally aggressive to staff and residents. I have not seen her hit anybody, but she will yell what she will do to you. Her behavior had been reported. Each time she had episodes, we notify nurses. When she (R2) was admitted , she was in another room but had an altercation with R7, her roommate. I heard her (R2) yelling. I went to the room, and she (R2) said that she doesn't want anybody touching her (R2) stuff. So, she (R2) was moved to another room. A week or two later, R1 was moved to her (R2) room. Progress notes dated 10/27/24 recorded that R2 requested to be transferred to another room due to not getting along with peers. Surveyor attempted to ask R7 on 01/06/25 at 11:45 AM regarding incident with R2 but she (R7) did not respond to question. Instead, R7 responded that she had a fall and now she is fine and happy. R7 was confused. Per MDS dated [DATE], R7 has BIMS score of 6 (which means severe cognitive impairment) and has a diagnosis of Unspecified Cerebral Palsy and Cognitive Communication Deficit. On 01/06/25 at 1:58 PM, V8 (Licensed Practical Nurse, LPN) was asked regarding R1 and R2. V8 stated, That day, 12/12/24, I was working that morning. I ran to the floor, and I was asked to assess R1. I went to her (R1) room, she had a discoloration to her left eye. I called physician and supervisors and there was an order for me to send her (R1) out to the hospital. R1 was unable to tell me what happened. I wasn't sure where it came from. I know R2 was her roommate. I asked her (R2) and she said she didn't know. No one reported anything to me or witnessed anything. I was just told that she had the discoloration to her left eye. I am not sure where she got the discoloration to her left eye. V8 was also asked regarding R1 and R2 behaviors. V8 verbalized, R1 is alert, oriented to self; she has Dementia, she is very confused. She is unaware of her safety and unable to make her needs known. We like to keep her in the dining room because she does walk around. When she is in the hallway, staff walks with her. She can easily be redirected. When she is in the room, staff has to do frequent checks on her because she will get up and wanders around. She walks with her head down, she touches things. R1 and R2 were roommates. R2 is alert, oriented, able to verbalize needs; sometimes she could be a little verbally aggressive to me, and to staff. She does have a behavior of verbal aggression. It could be anything or people rummaging through her things. She had a room change last 10/27/24 because she assumed that her roommate, R7, was rummaging through her things. She was yelling to me and wanted a room change that time, that she does not want to be in that room. She curses when she is upset. Per R2's face sheet, she was admitted in the facility on 10/25/24 with diagnoses of Schizoaffective Disorder, Bipolar Type;Schizophrenia Unspecified; and Anxiety Disorder, Unspecified. MDS dated [DATE] recorded R2 has BIMS score of 15 which means no impairment in cognition. Progress notes dated 10/27/24 documented R2 requested room change due to not getting along with peers. Progress notes dated 11/15/24 also documented that R2 was using inappropriate words in the common area. CHIRP (Criminal History Information Response Process) dated 10/25/24 recorded R2 is an identified offender and had history of incarceration for criminal damage to property. On 01/06/25 at 2:35 PM, V10 (Social Services Director) was also asked regarding awareness on R1 and R2's behavior. V10 stated, R1 is confused. She was in my elopement list because she walks with confusion. R2 used to be a resident here. She had delusional behavior. I was not aware of any verbal aggression. She had a room change on 10/27/24 due to resident (R2) choice compatibility. There was no incident reported. She (R2) chose to be removed, or her room be changed. During interview also with V1 on 01/06/25 at 12:23 PM, she was asked regarding R1, R2 and room change. V1 stated, We do room changes when we see residents not getting along with each other and they requested it; and for safety like for fall risk residents by placing them close to nurses' station. Residents who are known for aggression will be removed and put them in a private room by themselves with no room mates. There was no behavior of R2 being aggressive to staff and other residents, but she is resistive to care. If she has a known behavior of aggression to other residents, I will not pair her with a roommate. If a resident is not getting along with anybody, we are not going to pair them up. I am not aware that she (R2) has an aggressive behavior towards staff and residents. Screening Assessment for Indicators of Aggressive and/ or Harmful Behavior dated 12/26/24 documented that R1 appears to be at low risk for indicators of aggressive and/ or harmful behavior currently. Trauma Screening dated 12/04/24 documented R1 appears to be at minimal symptomology for trauma based off this assessment. On 01/07/25 at 2:18 PM, V2 was asked regarding abuse assessment and care planning. V2 replied, I am involved in care planning of residents. We do care planning upon admission. The IDT (interdisciplinary team) will come together and will develop care plan based from problems identified from previous facility. After 72 hours, we meet again and we see where we at, care plans are developed with interventions. If any behavior or fall or any incident occurs, we meet again and develop the care plan. We develop care plan on admission. The care plan is based on the problems upon admission. We don't do care plans for abuse. If there is no abuse, we don't do care plan for abuse. If there is an incident of abuse, it should be care planned. For R1, she has dementia, she is not vulnerable to be abused, so there is no abuse care plan. Further review of R1's medical records showed that there was no abuse care plan, and abuse assessment even after 12/12/24 abuse report. R1's care plan dated 12/04/24 regarding disoriented to place and time, recorded in part but not limited to the following: Intervention - Provide reassurance to help the resident feel safe and secure On 01/07/25 at 12:58 PM, V12 (Physician) was asked regarding R1. V12 verbalized, She wanders around, very confused. Yes, I was notified regarding altercation between her and the other resident. I think its because one of them is getting in another's space. I was notified regarding the discoloration to her left eye, bleeding to nose and mouth, she was sent out for evaluation. I was not sure of what happened. She (R1) is demented and always looking around and roommate didn't like it. Residents should not get injuries and needs to be protected while in the facility. Facility's policy titled Abuse Prevention Program, dated 3/1/21 documented in part but not limited to the following: Policy 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. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a third party. [NAME] Screen-Train-Report-Identify-Investigate-Protect-Prevent Procedure VII. 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. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. Facility's policy titled, Abuse and Crime Reporting dated 01/2019 stated in part but not limited to the following: Policy This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. Facility's policy titled IDT Care Planning Policy and Procedure (Person-Centered Plan of Care), dated 6/2020 documented in part but not limited to the following: Each resident will have a comprehensive assessment completed that will assist the development of an individualized (Person-Centered) plan of care that will include goals and interventions aimed to improve or maintain the residents highest level of function, prevent decline, decrease risk of complications of medical condition, medications and diagnosis, decrease risk of injury or to promote comfort at end of life. The resident has the right to unless adjudged to be incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment changes in care and treatment. The facility must have evidence that the resident and/ or responsible party was afforded the opportunity to participate in care planning. It is the policy of the facility to assist residents to participate (Example: helping residents, families, surrogates or representatives understand the assessment and care planning process; when feasible, holding care plan meetings at the time of day when the resident is functioning best, planning enough time for information exchanges and decision making and encouraging residents to attend). 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. 6. New Admissions/Readmissions will have baseline care plans initiated by nursing with actual and potential problems identified and the comprehensive care plan will continue to be developed with the completion of the MDS Assessment process within the RAI (Resident Assessment Instrument) rules and regulations. New residents will be added to the Calendar within 72 hours of admission and resident/family/responsible party will be notified of the upcoming meeting. 7. Residents care plans will be reviewed and updated as needed with re-admissions, quarterly re-assessments, annually and with changes in conditions (Example: revisions may be made to the problem statement, goals and interventions). New care plans will be initiated with new significant problem area.

Based on observation, interview, and record review, the facility failed to 1.follow their policy on hand washing by not performing hand hygiene when entering the kitchen, 2. failed to follow their policy on use of gloves by not performing hand hygiene prior to putting on gloves and when removed, 3. failed to follow their policy on use of hair restraints by staff entering the kitchen without putting on a hair net, 4. failed to follow their policy on use of wipe cloths by leaving cloths on the food preparation table and not ensuring they are in a sanitation bucket, 5. failed to follow their policy on use of sanitizing buckets by failing to maintain the sanitizing solution at 200 ppm (parts per million) of quaternary solution , 6. failed to follow their policy on use of thermometers by failing to sanitize a thermometer prior to obtaining food temperatures, and 7. failed to follow their policy on use of standardized recipes by not using a recipe during food preparation for lunch. These failures have the potential to affect all 63 residents who receive oral meals from the facility's kitchen. Findings include: On 12/17/27 at 9:55 AM, V13 [NAME] in Training was observed in the food preparation area cooking the lunch meal. Review of the menu for lunch states: beef taco, Spanish rice, seasoned corn, fruit mix, and flour tortilla. V13 [NAME] removed her gloves after touching multiple surfaces, threw them in the garbage and put on a new pair of gloves without performing hand hygiene in the handwashing sink. On 12/17/24 at 10:04 AM, V13 [NAME] removed the thermometer from the holder, rinsed it off under the faucet with water in the food preparation sink, then wiped it off with a wet wiping towel that was lying on the food preparation table. V13 inserted the thermometer into the cooked ground beef then rinsed it off again in the prep sink and laid the thermometer on the food prep table uncovered. V13 did not clean the thermometer with an alcohol wipe and did not put the wet wiping towel into the sanitation bucket. On 12/17/24 at 10:06 AM, V13 [NAME] removed her gloves from cooking, threw them in the garbage, and opened the kitchen door for the delivery person. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink. V13 continued to prepare the lunch meal wearing the gloves touching multiple surfaces. On 12/17/24 at 10:08 AM, V13 [NAME] poured the ground beef in a colander and transferred it to another pan. She removed her gloves, threw them in the garbage, and put on a clean pair of gloves without performing hand hygiene in the handwashing sink. On 12/17/24 at 10:12 AM, V13 [NAME] filled a pitcher with water and poured it into the ground beef with a package of taco seasoning. V13 did use a recipe for the measurement of the water put into the ground beef. On 12/17/24 at 10:15 AM, V13 [NAME] removed her gloves from cooking, threw them in the garbage, and opened the kitchen door for the delivery person. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 10:20 AM, V12 Dietary Manager was asked to test the sanitation bucket in the food preparation area. V12 dipped a chemical test strip into the sanitation bucket which indicated 100 ppm (parts per million) of quaternary solution. V12 was asked what the chemical solution concentration should indicate for proper sanitation. V12 said, It should be 200. Quaternary sanitizer solution concentration range is 150-200 ppm. On 12/17/24 at 10:22 AM, V13 [NAME] removed her gloves from cooking, threw them in the garbage, and opened the kitchen door for the delivery person. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 10:28 AM and at 10:31 AM, V13 [NAME] removed her gloves from cooking/ touching multiple surfaces and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 10:34 AM, V6 Activity CNA (Certified Nurse Assistant) entered the kitchen and put the lunch substitution list on the food prep table. V6 did not perform hand hygiene and put on a hair net upon entering the kitchen. V6 was inquired of entering the kitchen. V6 said, I don't come in here often, I should put on a hair net and wash my hands. On 12/17/24 at 10:37 AM, V12 DM Dietary Manager said, It's been down since I started. Will follow up with administrator regarding maintenance. On 12/17/24 at 10:39 AM, V13 is cleaning the thermometer in the food preparation sink. V13 poured a liquid cleaning substance on a wet wiping towel, wiped the thermometer with the towel, rinsed the thermometer and put the cover on it. V13 placed the wet wiping towel on the food preparation table. V13 did not clean the thermometer with alcohol wipes. V13 did not put the wet wiping towel in the sanitation solution. On 12/17/24 at 10:41 AM, V15 Dietary Aide is removing dishes from the dishwasher and touching multiple surfaces while wearing gloves. V15 removed his gloves, threw them in the garbage, and put on a clean pair of gloves without performing hand hygiene in the handwashing sink. On 12/17/24 at 10:50 AM, V13 [NAME] is preparing two beef burgers for lunch substitutions. V13 put an unmeasured amount of lemon pepper salt on each burger. V13 did not follow a recipe or determine if the residents had any dietary restrictions on salt intake prior to using the unmeasured seasoning. On 12/17/24 at 10:56AM, 10:59 AM, and 11:01 AM, V13 [NAME] removed her gloves from cooking/ touching multiple surfaces and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 11:07 AM, while wearing the same gloves during cooking, V13 [NAME] took the food processor over to the dishwasher machine and washed it. V13 returned to the food preparation area removed her gloves and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 11:09 AM, V12 Dietary Manager is putting away the food delivery in the refrigerator. V12 picked up the wet wiping towel off the food preparation table and wiped the handles and door of the refrigerator. V12 put the wet wiping towel back on the food preparation table. V12 did not put the wet wiping towel in the sanitation solution. On 12/17/24 at 11:14 AM, V13 [NAME] is preparing the tortilla shells in the food processor for the pureed diet residents. V13 [NAME] put pieces of tortilla shells into the food processor and poured two 236 ml (milliliter) cartons of milk on top of them during the process. V13 is not using a recipe with measurements for the puree entree. V13 [NAME] removed her gloves and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 11:31 AM and 11:33 AM, V13 [NAME] washed her hands in the handwashing sink and returned to the food preparation area while drying her hands with a paper towel. V13 placed the paper towel down on the food preparation table, put on clean gloves and continued to prepare the food. V13 did not dispose of the used paper towel in the garbage. By V13 placing the used paper towel on the food preparation table caused it to become contaminated. V13 did not clean and sanitize the food preparation table. On 12/17/24 at 11:36 AM, V13 [NAME] removed her gloves from cooking/ touching multiple surfaces and threw them in the garbage. V13 put on a clean pair of gloves without performing hand hygiene in the handwashing sink and continued to prepare lunch. On 12/17/24 at 11:37 AM, V15 Dietary Aide prepared sandwiches, removed his gloves, put them in the garbage and put on a clean pair of gloves. V15 did not perform hand hygiene in the handwashing sink before putting on a clean pair of gloves. On 12/17/24 at 11:39 AM, V13 [NAME] removed the cover from the thermometer and placed it into a pan of rice to read the temperature. V13 placed the thermometer on the food prep table. V13 did not use an alcohol wipe to clean the thermometer before and after its use. On 12/17/24 at 11:41 AM, V13 [NAME] wiped the thermometer with a wet wiping towel under the faucet in the food preparation sink. V13 removed a pan from the oven. V13 placed the thermometer inside the food and took the temperature. V13 laid the thermometer on the food preparation table. V13 did not use an alcohol wipe to clean the thermometer before and after its use. On 12/17/24 at 11:52 AM, V13 [NAME] picked up the thermometer from the food preparation table and placed it into a pan of broccoli. V13 put the thermometer back onto the food preparation table. V13 did not use an alcohol wipe to clean the thermometer before and after its use. V13 poured an unmeasured amount of lemon pepper salt, garlic powder, and black pepper onto the broccoli. V13 did not follow a recipe or determine if the residents had any dietary restrictions on salt intake prior to using the unmeasured seasonings. On 12/17/24 at 12:00 PM, V13 put water into a container on the stove and poured an unmeasured amount of iodized salt into the water. V13 said, I'm making mashed potatoes. V13 did not follow a recipe or determine if the residents had any dietary restrictions on salt intake prior to using the unmeasured seasonings. On 12/17/24 at 12:12 PM, V16 Dietary Aide is scooping sour cream into condiment cups for lunch on the dishwashing area table. V16 was inquired of his location while preparing food. V16 said, I didn't know where else to go. They wash dishes here; I shouldn't do it here. On 12/17/24 at 12:24 PM, V13 [NAME] was inquired of food preparation concerns. During food preparation when gloves are removed what should be done? V13 said, Wash hands and put on another pair. How should a thermometer be cleaned and used? V13 said, Clean it with sterilized water and soap, then sterilize with sanitized water every time I use it. Where should wet wiping towels be kept and why? V13 said, Should be in the green (soap) bucket. After using put back for cross contamination of area. They shouldn't be on the prep table. What should be used when preparing food to ensure accurate measurements and ingredients? V13 said, A recipe. I didn't have the recipe, but I'd use the measuring cups and spoons. It's important for the resident's health. What is the food preparation sink used for? V13 said, It's only for rinsing stuff off. The three compartment sink doesn't work. When you wash and dry your hands, what should be done with the paper towel? V13 said, Throw it away because of cross contamination. On 12/17/24 at 12:37 PM, V12 Dietary Manager was inquired where wet wiping towels are to be kept and why? V12 said, Put it back into the sanitation or soap bucket for sanitation reasons. On 12/17/24 at 2:23 PM, V1 Administrator was inquired of the three compartment sink not working and maintenance. V1 said, It's been at least a month. We did order some parts. We had the plumber come in, there was a leakage. On 12/18/24 12:02 PM, V12 Dietary Manager was inquired of the kitchen concerns. During food preparation when gloves are removed what should be done? V12 said, Wash your hands for sanitation and stop germs for infection control. How should a thermometer be cleaned and used? V12 said, It should be cleaned with an alcohol pad. It should be inserted into food for thirty seconds. Each time it's put into food it should be cleaned with an alcohol pad. What should be used when preparing food to ensure accurate measurements and ingredients? V12 said, Use measuring cups and spoons, a recipe book tells what and how much to use. What is the food preparation sink used for? V12 said, Just to run water in it to cook with. It's only for food purposes. Not for cleaning. When you wash and dry your hands, what should be done with the paper towel? V12 said, Dispose of it in the garbage. And you shouldn't touch the garbage can. V12 was inquired of having the menu recipes available during food preparation. V12 said, I came in on Sunday and changed out the new recipes for the winter menu. I put the recipe book on top of the cook table in the morning. V13 didn't ask me for any recipes. V12 was inquired of which residents received the broccoli and mashed potatoes prepared by V13 [NAME] and the number of residents who receive mechanical soft and pureed meals. V12 said, Now we have 14 residents with mechanical soft diets and 6 residents with pureed diets. They both received the broccoli. There are 5 residents that don't get rice, they got mashed potatoes. The 4/2017 Food Safety & Sanitation Handwashing policy states in part: Policy: The facility will practice safe food handling and avoid cross contamination through proper and adequate handwashing techniques. Procedure: The Food & Nutrition Department Manager or designee will ensure that employees practice proper hygiene and handwashing at all times. The 4/2017 Food Safety & Sanitation Glove Use policy states in part: Policy: The facility will practice safe food handling and avoid cross contamination through proper use of gloves. Procedure: Employees are required to wash hands before using gloves. The 4/2017 Food Safety & Sanitation Employee Health & Personal Hygiene policy states in part: Policy: Food service employees shall maintain good personal hygiene and free from communicable illnesses and infections while working in the facility. Procedure: Hair restraints will be worn at all times. The 4/2017 Food Safety & Sanitation Sanitizing Buckets policy states in part: Policy: The facility will use sanitizing buckets with wipe cloths to sanitize preparation and food service areas. Procedure: The Food and Nutrition Department Manager or designee will ensure that sanitizing buckets are used in food preparation and service areas and are changed often. Sanitizer concentration range for quaternary 150 - 200 ppm (parts per million). The 4/2017 Food Safety & Sanitation Thermometer Calibration & Use policy states in part: Policy: Thermometers will be calibrated before use. Procedure: Food thermometers will be sanitized between taking food temperatures. Alcohol swab may be used to clean the thermometers between each use. It is recommended to have more than one thermometer available. The 4/2022 Food Safety & Sanitation Standardized Recipes policy states in part: Policy: Standardized recipes will be available in the kitchen and used for food preparation. Procedure: All foods will be prepared using standardized recipes on the menu cycle spreadsheets. Standardized recipes include number of servings, serving sizes, ingredients and preparation instructions.

Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were nine (3) medication errors out of 30 medication opportunities, resulting in a 10% medication error rate. This applies to 2 residents (R20, R42) of 4 residents observed during medication administration. Findings included: 1. On 12/17/2024 at 9:50 AM Medication observation with V17 (Agency Registered nurse) completed for R20. R20 has a diagnosis of anemia, benign prostatic hyperplasia, elevate prostate antigen and failure to thrive. V17 omitted giving Cyanocobalamin Tablet 1000 MCG and finasteride 5mg 1 tab was missing from the medication cart, medication not given. Per Physician order sheet dated: December 2024 reads: a-Cyanocobalamin Tablet 1000 MCG Give 1 tablet by mouth one time a day scheduled for 9:00AM b- Finasteride Tablet 5MG Give 1 tablet by mouth one time a day scheduled for 9:00AM 2. On 12/17/2024 at 9:36 AM Medication observation with V17 (Agency Registered nurse) completed for R42. R42 has a diagnosis of anemia, nausea, vomiting, acquired absence of parts of the digestive tract, volvulus, and gastric-esophageal reflux disease with esophagitis. Pantoprazole Sodium 1 Tablet Delayed Release 40 MG scheduled for 8:00AM given at 9:36AM. Per Physician order sheet dated: December 2024 reads: Pantoprazole Sodium Tablet Delayed Release 40 MG Give 1 tablet by mouth one time a day scheduled 8:00AM. On 12/17/2024 at 9:36 AM during medication administration V17 left medications unattended on the table for R42 to go to her medication cart outside of the dinning room to pick-up a straw for R42 to take his medication with water. R359 was sitting next to R42 during the incident and other residents were in the dining room as well. Surveyor remained by the R42's table. On 12/17/24 at 09:40AM V17 said that she was not supposed to leave medication on the table unattended and go to the medication cart to pick up a straw outside the dining room. V17 said that the facility medication administration policy states that medication must be under the nurse's supervision at all the times and V17 needs to observe R42 to swallowing medications. On 12/17/2024 at 11:32 AM V2(Director of Nursing) said that medications times are 9:00AM, 1:00PM, 5:00PM, 7:00PM, and 9:00PM. Nurses have one hour before and on hour after to administer medications. The first floor has 31 residents and 34 residents for the second floor. Nurse on the first floor can get extra assistance of the unit manager and second floor V2 stated that she can assists the nurse as needed and nurses are aware to call for assistance. V17 is agency nurse and V2 said that earlier today she offered help to V17 who said that she was fine. V2 said not being aware that V17 had medications not administered-on time. On 12/18/24 at 11:14 AM V2 said, nurses are expected to pass medications one hour before and one hour after the scheduled time. If a medication is schedule for 8:00AM and giving at 9:30AM, it is late, and nurse will have to notify the physician, or the in-house nursing practitioner of the medication was given late. If medication is not available in the facility or emergency convenience box, nurse will have to select number 9 under the electronic medication administration record, and it will trigger a response and will require a nurse to chart under the progress notes and call physician or in-house nursing practitioner for directions. V2 said, nurses are expected to keep medications under their supervision at times and observe residents swallowing medications. Facility does not have any resident on self-administration program currently. On 12/18/2024 at 12:00 PM V1(Administrator) presented: Facility Policy titled: 5.2: Medication Administration, undated, reads: 16. Give the resident the medication. 17. Remain with the resident to ensure that the medication is swallowed. 19. Circle initials on MAR if medication is not administered as ordered and record reason in the PRN/Omission Medication section of the MAR or as appropriate in electronic medication administration record. Facility Policy titled: Policy and Procedure, Medication Administration, undated, reads: Unless otherwise specified by physician, medications will be administered within 60 minutes before or after the facility's dosing scheduled, expect before and after meals orders and non-routine orders medications.

Based on interview and record review, the facility failed to prevent an accident for a resident assessed to require two staff assistance with incontinence care. This failure affected one (R1) of three residents reviewed for falls and resulted in R1 experiencing a fall while being assisted with incontinence care by only one staff member. R1 required emergent hospital transfer for evaluation and sustained a left forehead hematoma, skin tear to right forearm, and left fifth metacarpal fracture. Findings include: R1 is an [AGE] year old female admitted to the facility on [DATE] with the diagnosis history of left Peri-prosthetic hip fracture, non-displaced fracture of 5th metacarpal of left hand, left subdural hematoma, COPD, left foot drop, osteoporosis, cataract, depression, hypertension, and Gastro-esophageal reflux disease. Per record review, on 09/28/2024 R1 rolled out of bed while receiving incontinence care requiring R1 to go to the emergency room for further evaluation. Hospital records documented that R1 had a hematoma to the left forehead, skin tear to right forearm and Xray results showed Left fifth metacarpal fracture. On 10/02/2024 R1 had a change of mental status and returned to the hospital. Hospital records reviewed with computerized tomography of the head showed a left 7mm subdural hematoma with 4mm midline shift as well as falcine and tentorial subdural hematoma. R1 was admitted to the NCCU (Neuroscience Critical Care Unit) for closer monitoring. On the (MDS) Minimal data Set assessment of 08/01/2024 section C the BIMS (Brief Interviewed Mental Status) score was 15/15. On MDS of 08/01/2024 GG section R1 is dependent with toileting and roll side to side. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 11/25/24 at 10:44 AM R1 said that V7 (Certified Nursing assistant) was changing her brief and turned her towards the window and she rolled off the bed and hit her face on the oxygen concentrator. R1 said, It happened too fast, I fell face down, the staff helped me back to bed and the ambulance was here. The staff placed the mechanical lift pads under me and lifted me to bed. I still cannot understand what happened, and we did not do anything else differently. I went to the hospital and got all the testing done I got a fracture to my hip, left little finger and a big bump to my left side of my head. I was in the ER until 2:00AM before I came back to the facility. I returned to the hospital because I noticed that I did not make sense and I knew that something was not right. I ended up having a bleed in my brain, the hospital kept me for couple days and I came back. R1 said that she is not able to help with transfers and turn from side to side by herself and requires assistance. R1 said that she requires two assistants when she is getting changed, repositioned and getting out bed but that V7 changed her briefs by herself on the day of the fall. On 11/25/2024 at 12:06PM V7 (Certified Nursing Assistant/CNA) said that R1 rolled out bed during incontinence care. R1 crossed her right leg and rolled out the bed. V7 said that she was providing incontinence care by herself when R1 rolled out bed. R1 requires two person assistance for incontinence care but V7 was the only one providing incontinence care during the fall in question. On 11/25/2024 at 02:08PM V9 (Agency Registered Nurse) said that she was passing medications when she heard a loud boom coming out from R1's room and immediately went there to check and saw the R1 on the floor. V9 stated that R1 was stable and assessed her and assisted her back to bed by using a mechanical lift with two certified nursing assistants and called 911 and sent R1 to the hospital. V9 (Agency Registered Nurse) said that R1 is dependent and requires two person assistance with her care and because of her size and not able to help much. V9 affirmed that on the day of the fall, V7 (Certified Nursing assistant) was providing incontinence care to R1 by herself. On 11/26/2024 at 12:27PM V2 (Director of Nursing) said that nursing is expected to follow (MDS) Minimal Data Set assessment GG section while providing incontinence care. Certified nursing assistants can check under tasks under the electronic medical records and check how many assistants each resident requires and how to care for residents. When a resident is dependent with care, staffs are expected to follow the requirements of two assistants. V7 (Certified Nursing assistant) should have asked for assistance and placed the call light for someone to come and help her with R1's incontinence care. On 11/26/2024 at 02:00PM V1 (Administrator) said that V7(Certified Nursing Assistant) was suspended during the investigation and if R1 required two assistants for incontinence care, V7 should have followed the requirement and gotten assistance. On 11/26/2024 at 02:15PM V10 (Nurse Practitioner) said that R1 fell on [DATE] and gave orders to send R1 to the hospital for further evaluation. R1 returned during the night and on 10/02/2024 R1 was having confusion which is not common for her because R1 is very alert and oriented. V10 gave orders to send R1 to the hospital for further evaluation and computerized tomography scan of the head; report showed that R1 had a subdural hematoma. V10 said, I don't know why the hospital did not keep R1 after the fall to monitor her head trauma. Even though the computerized tomography scan of the head was negative the day of the fall, it is not uncommon to have a subdural hematoma 36 hours to 48 hours later. On 11/25/2024 at 2:23PM V1(Administrator) presented facility Policy Titled, Incontinence Care, (undated) which includes: Policy: It is the policy of the facility to ensure that resident's receive as much assistance as needed for cleansing the perineum and buttocks after an incontinence episode or with routine care daily. Procedure: 7. Assist resident to the side lying position by turning towards caregiver, unless more than one caregiver is present. If more than one caregiver present, one caregiver provides support of the resident side lying position while the other caregiver completes the procedure.

Based on interviews and records reviewed the facility failed to follow their policy to ensure that medications were stored safely and securely. This affected one of three residents (R4) reviewed for medication storage. This failure resulted in one resident (R4) accessing the medication cart. The findings include: On 11/2/24 at 1:28PM V8, Registered Nurse (RN), said I worked on 10/20/24, on the night shift. V8 said I received in report from V11, Licensed Practical Nurse (LPN), I think that was her, that R4 got into the medication cart. V8 said I was told the CNA reported seeing R4 in the cart. V8 said R4 told me she was counting her medication in the cart, I was counting my oxy. V8 said V11 and R4 did not tell me how R4 got in the cart. V8 said I did not report to anyone because V11 told me she reported to the Director of Nursing (DON). V8 said R4's room was outside the nurses station. On 11/2/24 at 1:52PM V2, CNA, said R4 was loud and rude and she would go off. V2 said I never saw R4 in pain. V2 said if R4's medication comes a minute after it is due then she starts saying she is in pain. V2 said I came out of a resident room and R4 was putting the keys back in the binder on the nurses cart. V2 said I saw R4 with the nurse's keys in her hands. V2 said R4 said she was trying to see if she had 2 cards. V2 said the nurse was taking care of another resident in her room. V2 said R4 walked away to the elevator. V2 said I pushed the lock on the cart and took the nurse the keys. V2 said I handed the nurse the keys and told her R4 had the keys. V2 said I didn't know R4 would do that, but she would look at her medication and say there goes my medication. V2 said the cart was unlocked when I walked into R4. On 11/3/24 at 10:35AM V5, Director of Nursing (DON), said on 10/21/24 a manager reported to me the nurse reported that R4 had the key to the medications cart. V5 said I went to speak to V12, because she reported it and I called V8 and V11. V8 told me V11 said the keys were in the drawer. V5 said the CNAs never reported they saw R4 with the keys to the med cart. V5 said V11 told me she left the keys in the drawer during her wound care to another resident. V5 said I told V11 you should have the keys on you. V5 said the expectation is that they notify me. V5 said I don't know if R4 was in the cart. V5 said the expectation is that the medication cart keys are to stay on the nurses at all times. V5 said the medication that could have side effects, antihypertensives, blood thinner, and diabetics medications are stored in the cart. Attempts to reach V11 on 11/2/24 at 2:03PM and 11/3/24 at 10:12AM were unsuccessful. R4 diagnosis include but are not limited to Low Back Pain, Schizoaffective Disorder, Bipolar Disorder, Insomnia, Sciatica, Personal History of Traumatic Brain Injury, Cannabis Abuse, Nicotine Dependence, and Bariatric Surgery. R4 admitted to the facility on [DATE]. Progress notes reviewed fated 10/18/24 - 10/22/24. No progress notes related to R4 being seen with the medication cart keys. On 10/20/24 R4's progress notes documents a referral to another facility. On 10/22/24 R4 was transported/discharged to another facility. Order Summary Report for R4 documents Psychological Services. Oxycodone -Acetaminophen tablet 5/325mg 1 tablet every 8 hours as needed for pain. R4's Medication Administration Record for October 2024 documents Oxycodone -Acetaminophen tablet 5/325mg administered on 10/19/24 at 1:00PM; 10/20/24 at 12:50PM; 10/20/24 8:18PM; and 10/21/24 at 12:00PM. R4's Preadmission Screening and Resident Review (PASRR) dated 5/11/24 documents you have attempted to end your life in the past by taking your mom's pain pills. You need help from others to make safe decisions. Schedule reviewed for Sunday 10/20/24 identifies V11, LPN, on 3:00PM - 11:00PM shift and V8 RN on 11:00PM - 7:00AM shift. R4's care plan includes interventions for socially inappropriate and maladaptive/disruptive behavior manifested by a disturbed sense of entitlement. R4 refuses to see psychotherapy professional. R4 has a history of substance abuse/chemical dependency related to diagnosis cannabis abuse. Smoking care plan identifies non compliance with safe smoking regulation by smoking at non designated times, begging, borrowing, stealing, selling and or trading for smoking materials. Expectation of Nurses documents DO NOT LEAVE KEYS TO MED CART IN A DRAWER EVER. Witness Statement dated 10/21/24 from V8 regarding R4 for incident date 10/21/24 documents I relieved V11 on her shift she stated to me watch out for [R4] she tried to take her keys. I endorsed behavior to oncoming nurse for 7:00 - 3:00PM shift. Interviewed by V5. Witness Statement dated 10/21/24 from V11 regarding R4 for incident date 10/21/24 documents I saw R4 behind the nurses' station. Interviewed V5 asked V11 where her medication cart keys were. V11 states in the nurses' station drawer. V11 said R4 did not have the key or access to the key. Nurse stated you know this women is crazy and probably looking for Norcs. Witness Statement dated 10/21/24 from V12 regarding R4 for incident date 10/21/24 documents I was informed by outgoing nurse (V8) that R4 was trying to get nurses' keys to get into the Norc box and watch out for the behavior. Facility policy Medication Storage in the Facility dated May 2024 states Medication and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personal. Medication rooms, carts, and medication supplies are locked or attended by person with authorized access: Licensed Nurses, Consultant Pharmacist, Pharmacist Technician, Individual Lawfully Authorized to Administer Drugs, and Consultant Nurses. All drugs classified as schedule 2 of the Controlled Substance Act will be stored under double locks. Residents who have been trained in self-administration will have access only to their individual drug supply.

Based on observations, interviews, and record reviews, the facility failed to provide a safe environment and ensure comfortable room temperatures in resident rooms with temperatures above 80 degrees Fahrenheit and humidity above 60%. The facility failed to identify all residents at high-risk for heat stroke/heat exhaustion. The facility failed to follow their extreme weather conditions policy and implement an effective plan to monitor ambient temperatures in resident rooms. The facility failed to develop and implement an effective plan to monitor residents' physical condition and increasing residents' comfort. This failure has the potential to affect all 47 residents (R2-R48) residing in this facility. The Immediate Jeopardy began on 06/18/2024 when the building temperatures were observed to be above 80 degrees Fahrenheit and humidity above 60%. V1 (Administrator) was notified on 06.21.2024 at 10:10am. The surveyor confirmed by observation, interview and record review the immediate jeopardy was removed on 06.21.2024, non-compliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service and training. Findings include: A review of the facility census on 06.18.2024 there are currently 47 residents residing in the facility. On 6/18/24 at 11:30 AM, this surveyor observed V13 (director of maintenance) check temperature and humidity in each resident room. The resident room temperatures and humidity were checked with central air conditioner and portable fans running on high: Room Temperature w/AC Humidity % 206 83.5 65.3 207 83.4 63.9 218 84.5 64.2 217 84.7 61.5 208 84.7 64.4 209 83.8 63.6 215 83.8 63.4 214 83.7 65.2 211 83.7 64.3 216 84.4 60.9 202 82.9 63 224 81.9 62.1 200 82.2 62.1 223 81.2 67.9 222 82.9 63.9 221 83 63.5 106 83.2 63.4 119 84.1 64.4 121 83.2 64.2 104 83.1 58.6 117 84.4 65.4 120 83.7 59 113 83.4 65 108 83.4 65.9 105 83.7 59.8 122 81.4 63.8 Per www.timeanddate.com/weather, dated 6/18/24 at 10:53 AM, the outside temperature in Oak Lawn, IL was 84 degrees with 61% humidity. The highest temperate was 93 degrees with humidity of 41% at 2:53 PM. On 6/18/24 at 11:35 AM, R2's family member was observed holding a portable fan on high blowing directly onto R2's upper torso and face. R2's family member was observed soaking a mouth swab in ice water and swabbing R2's mouth and lips. On 6/18/24 at 11:36 AM, R8 states as long as she remains one foot away from fan on high she is okay. On 6/18/24 at 11:38 AM, R9 and R10 state that there is no air movement even with AC and fans running. On 6/18/24 at 11:40 AM, R11 states he checked his room temp yesterday and it was 84 degrees. R11 stated that the air conditioner is set on high but no air is blowing out. On 6/18/24 at 11:42 AM, R13 stated that he is hot. R13 stated that staff told him the air conditioning unit in his room was broken. R13 stated that he has been without air conditioning in his room for one month. V13 was observed checking R13's air conditioning unit and informed R13 that there was nothing wrong with his unit, it was turned off and V13 turned it on. Review of this facility's maintenance request log, dated 5/25/24, notes convector unit in R13's room not working. It also notes the control knob on convector unit in R13's room are missing; need to use pliers to turn knob. There is no documentation found noting these concerns were addressed by maintenance. On 6/18/24 at 11:45 AM, R14 stated that the air conditioning unit in her room is on high but room does not feel cold at all. On 6/18/24 at 11:46 AM, R6 stated that, It is not as hot in his room today, like it has been. On 6/18/24 at 11:49 AM, R7 stated that it is too hot in her room. On 6/18/24 at 11:53 AM, R12's family member stated it is too warm in room even with air conditioning on. On 6/18/24 at 2:30 PM, R16 was observed to have a pitcher with clear liquid half full. No ice observed in pitcher. Condensation noted on pitcher and nightstand table. R16's pitcher was on nightstand next to head of bed and was not within reach. On 6/18/24 at 2:30 PM, R17 stated that he has water in his pitcher. R17 stated that staff have not been offering him additional fluids today. R17's water pitcher was observed to be full of clear liquid, no ice. On 6/18/24 at 2:30 PM, R7, R8, R9, R10, R14, and R22 were observed with water pitchers with water, no ice. All stated that their water is warm. All denied being offered cold drinks throughout the day. All denied being offered and assisted into dining area where it is cooler. On 6/18/24 at 11:30 AM, V13 (director of maintenance) stated that he works at a sister facility and started coming to this facility yesterday (6/17/24). V13 stated that he came to facility today at 9:00 AM to fix air conditioner units in main lobby and conference room adjacent to it. V13 stated that he did not check facility temperatures yesterday or today prior to 11:30 AM. On 6/18/24 at 1:39 PM, V2 DON stated that the nurses are checking vital signs once a shift. Stated that the nurses work 12-hour shifts. V2 stated that the staff are monitoring residents' physical condition by checking vital signs twice a day. V2 stated that physician orders were received for residents receiving enteral feedings via gastrostomy tube to increase water flushes to maintain hydration. Review of R15 and R20's POS (physician order sheet) notes orders were obtained to increase water flushes on 6/19/24 with this increase to start on 6/20/24 at 2:00 PM. Review of R21's POS, notes an order was obtained to increase water flushes on 6/19/24 with this increase to start on 6/19 at 3:00 PM. On 6/18/24 at 1:55 PM, V2 presented a computer generated list of all residents' temperature results from 6/15 through 6/18 at 1:50 PM. On 6/15/24, 16 residents had temperature checked only once; 18 residents had temperature checked twice; and 13 residents did not have temperature checked at all. On 6/16, 18 residents had temperature checked only once; 16 residents had temperature checked twice; and 13 residents did not have temperature checked at all. On 6/17, 15 residents had temperature checked only once; 10 residents had temperature checked twice; and 22 residents did not have temperature checked at all. On 6/18, 1 resident had temperature checked and 46 residents did not have temperature checked at all. On 6/18/24 at 1:45PM, V12 (administrator) stated that this is her second day at this facility. V12 stated that the previous maintenance person director walked out on 6/5/24. V12 stated that there has been no maintenance staff present in facility until 6/17/24. V12 stated that she does not know who has been checking facility ambient temperatures, if at all. V12 stated that this facility should be following its extreme weather condition policy at this time. Review of this facility's temperature log book notes last time facility temperatures were checked was on 6/3/24 at unknown time. On 6/18/24 at 2:04 PM, V19 (manager with outside heating and cooling company) stated that their employee came out to switch over system mid-May. V19 stated that the facility called to clean coils on air conditioning unit yesterday afternoon. V19 stated that the service technician has not come to facility yet to perform work order. V19 stated that no call was received regarding resident room temperatures being high. V19 stated that V19 considers temperatures 81-84.7 degrees Fahrenheit to be an emergency, facility did not notify him that this service call needs to be changed to an emergency. On 6/18/24 at 3:05 PM, V12 (administrator) stated that the outside heating and cooling company came out this morning and cleaned the coils in the air conditioning unit. V12 denied notifying company of the high temperatures in facility. On 6/18/24 at 3:20 PM, V14 CNA (certified nurse aide) stated that he worked on Sunday, denied residents complaining of indoor temperature then. V14 stated that he makes sure residents' rooms are cool, gives residents ice water, and checks on residents every two hours to see if they are okay. V14 stated that he refills residents' water pitchers when they are empty. V14 denied residents complaining of elevated room temperatures today. On 6/18/24 at 3:24 PM, V15 CNA worked last night from 11:00 PM-7:00 AM. V15 stated that she is working 3:00 PM-11:00 PM today. V15 stated that during the night the resident room temperatures felt cooler than currently. V15 stated that at the start of her shift, she provides fresh ice water to her assigned residents. On 6/18/24 at 3:31 PM, V16 LPN (licensed practical nurse) stated that she worked 7:00 AM-3:30 PM on first floor nursing unit. V16 stated that at the beginning of shift the resident room temperatures felt a little cooler, then the temperature quickly increased. V16 stated that she makes sure residents are checked frequently. V16 stated that she has been rounding constantly bringing residents with ice water, and taking ambulatory residents outside where it is cooler. On 6/18/24 at 3:46 PM, V17 LPN stated that she is working 7:00 AM-7:00 PM on second floor nursing unit today. V17 stated that the residents' room temperatures were the same as today. V17 stated that she keeps residents hydrated, trying to keep windows and blinds closed, and ambulatory residents taken outside where it is cooler. On 6/18/24 at 6:30 PM, R2's family member stated that a family member is present in this facility daily during the day and evening. R2's family member stated that R2 is not eating, and they use mouth swabs soaked in ice water to swab R2's mouth and lips. R2's family member stated that if they were not present in this facility, staff would not swab R2's mouth. On 6/18/24 at 1:34 PM, V12 (administrator) presented a list of high-risk residents for heat stroke/heat exhaustion. This list contained residents with respiratory diseases. This list did not identify bed bound residents, residents with total dependence on staff for fluid intake, or residents with gastrostomy tubes receiving enteral feedings. On 6/19/24 at 8:30 AM, R18 and R8 stated that room is still hot. Both stated that they must request fluids and ice. Both denied staff offering cold drinks to them. On 6/19/24 at 8:35 AM, R10 stated that yesterday he felt dizzy, weak, and had a headache when the room temperature got high. R10 stated that he does not have any symptoms at this time. R10 stated that his room is still warm and there is no air circulating. R10's water pitcher was observed to be full of clear liquid. R10's cup was on nightstand behind him and not within reach. On 6/19/24 at 8:35 AM, R19 was observed to have a cup half filled with thickened water on R10's bedside table, not within reach. On 6/19/24 at 8:39 AM, this surveyor observed a cooler filled with ice and pitcher of water at the second floor nurses' station. On the second floor nursing unit continuous observation from 8:39 AM until 11:20 AM: On 6/19/24 at 9:00 AM, this surveyor did not observe any staff passing ice water to residents or checking on all the residents' physical condition. R44 stated that her room remains hot. On 6/19/24 at 9:15 AM, this surveyor did not observe any staff passing ice water to residents or checking on all the residents' physical condition. On 6/19/24 at 9:30 AM, this surveyor did not observe any staff passing ice water to residents or checking on all the residents' physical condition. On 6/19/24 at 9:45 AM, this surveyor did not observe any staff passing ice water to residents or checking on all the residents' physical condition. On 6/19/24 at 10:00 AM, this surveyor did not observe any staff passing ice water to residents or checking on all the residents' physical condition. On 6/19/24 at 10:15 AM, this surveyor did not observe any staff passing ice water to residents or checking on all the residents' physical condition. On 6/19/24 at 10:30 AM, this surveyor did not observe any staff passing ice water to residents or checking on all the residents' physical condition. On 6/19/24 at 10:35 AM, R23 was observed exiting room and walking to the nurses' station for a cup of water. On 6/19/24 at 10:45 AM, this surveyor did not observe any staff passing ice water to residents or checking on all the residents' physical condition. On 6/19/24 at 10:50 AM, staff were observed passing out popsicles to residents. R20 nor R22 received a popsicle. On 6/19/24 at 8:40 AM, R18's was observed to have window air conditioning unit sitting on R18's nightstand, not installed. R18 stated that her room is hot. On 6/19/24 at 8:41 AM, signage posted on the wall next to R20, R21, and R22's room notes please pass ice water to residents each shift per diet order. On 6/19/24 at 8:42 AM R20 was observed to have a water pitcher full of clear liquid no ice with a straw piercing the lid. Liquid did not appear to be nectar thickened. Pitcher was not within R20's reach. R20 was observed to have enteral feedings tubing attached to gastrostomy tube, not infusing. R20's POS (physician order sheet) notes R20's diet order is pureed diet with nectar thickened liquids. On 6/19/24 at 8:42 AM, R21 was observed to have a water pitcher full of clear liquid no ice with a straw piercing the lid. Pitcher was not within R21's reach. R21 was observed to have enteral feedings tubing attached to gastrostomy tube, not infusing. R21's POS notes R20's diet is nothing by mouth. On 6/19/24 at 8:42 AM, R22 was observed to have a water pitcher full of clear liquid no ice with a straw piercing the lid. Pitcher was not within R22's reach. R22's POS notes R22's diet order is general diet with thin liquids. On 6/19/24 at 8:50 AM, R23 did not have a pitcher or cup in R23's room. R23's POS notes R23's diet order is general diet with thin liquids. On 6/19/24 at 11:20 AM, this surveyor observed V13 (director of maintenance) check temperature and humidity in each resident room. The resident room temperatures and humidity were checked with central air conditioner and portable fans running on high: Second floor nursing unit: Room Temperature w/AC Humidity % 206 80.6 52 207 80.2 52.1 218 80.6 52.2 217 81 55.4 208 80.9 57.1 209 81 57.7 215 80.8 59.7 214 80.5 59.3 211 80.5 54.6 216 80.9 57 202 79.5 51.7 224 78.4 53 200 78.3 50.8 223 79.1 55.6 222 80.2 50.9 221-A 80.4 53 First floor nursing unit at 11:30 AM: 106 80.4 59.1 119 81 62.2 121 78.7 60.3 104 78.2 60.1 117 81.9 60.3 120 79.6 57.7 113 81.1 59.2 108 81.9 57 105 79.3 62.1 122 77.7 61.5 100 78.1 60.5 102 77.7 61.4 123 77.9 60.3 101 77.9 61.4 103 77.7 59.4 Per www.timeanddate.com/weather, dated 6/19/24 at 7:53 AM, the outside temperature in Oak Lawn, IL was 82 degrees with 65% humidity. The highest temperate was 94 degrees with humidity of 38% at 1:53 PM. On 6/19/24 at 11:30 AM, V13 (director of maintenance) stated that he is putting in window air conditioning units in the resident rooms on the second floor today. V13 stated that he does not have enough window air conditioners to place one in each resident room on the second floor. On 6/19/24 at 1:45 PM, there are 16 rooms with residents on the second floor. Four of these rooms, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER], do not have window air conditioning units installed as of yet. On 6/20/24 at 12:30 PM, V19 (outside heating and cooling company) stated that the rooftop has two compressors and one is totally nonfunctional. V19 stated that he gave V12 (administrator) an estimate to replace the rooftop unit and is waiting for decision. V19 stated that this unit cannot be repaired. V19 stated that yesterday the technician came out to check the outside chiller pumps and these are pumping cold water to the convectors in the resident rooms. V19 stated that these units in the residents' rooms needed extensive cleaning due to not blowing air. V19 stated that he does not know when the facility last performed preventive maintenance on the units in the residents' rooms. V19 stated that once these units were cleaned, cold air was blowing into the residents' rooms. V19 stated that there are three units on the second floor (rooms 222 has two units and room [ROOM NUMBER]) that need new motors which V19 did order today. V19 stated that the technician cleaned a total of 15 rooms yesterday and has 4 rooms that still need to be done; V19 is unsure which rooms still need to be done. V19 stated that the technician will be at this facility tomorrow to finish cleaning the units on the second floor. On 6/20/24 at 3:00pm, V25 (technician with outside heating and cooling company) stated that he spoke with V12 (administrator) and V13 (director of maintenance) yesterday regarding what needs to be done in this facility and estimate of cost. V25 stated that he has been coming to this facility for the past [AGE] years and management has not wanted to do the necessary repairs and now the unit needs to be replaced. V25 stated that the convectors in the residents' rooms are supposed to be cleaned with a brush monthly as preventive maintenance. V25 stated that the company had two technicians at facility yesterday and the convectors were so clogged that they had to use their hands to pull the junk out of it. V25 stated that by what they saw yesterday, the convectors have not been properly maintained for a long time. V25 stated that the filters hadn't been changed for long time. During this survey, this facility was unable to provide intake and output documentation for all residents residing in this facility. The facility's loss of utilities action plan, undated, notes the air-conditioning system shall be capable of maintaining an ambient temperature of between 75-80 degrees F. If temperatures are not maintained between 75-80 degrees F, maintenance director may obtain alternate source of cooling until repairs are complete. If temperatures reach 81 degrees F or higher, the following precautions will be put in place: provide ample fluids to all residents; assess residents for signs and symptoms of heat exhaustion/heat stroke such as headache, weakness, dizziness, nausea, and vomiting. The facility's extreme weather conditions policy, undated, notes during extreme weather periods, ambient air temperature will be monitored and documented for various locations throughout the building such as dining areas, lounges, and a sampling of resident rooms. All high-risk residents will be identified and carefully monitored by nursing personnel for appropriate clothing, over-exertion, body temperature changes, hydration, and other signs and symptoms of hyperthermia. The immediate jeopardy that began on 06/18/2024 was removed on 06/21/2024 when the facility took the following actions to remove the immediacy: The facility has completed or initiated the following corrective actions: Resident Comfort: 1. On 6/18/24, facility Administrator initiated additional monitoring of air temperatures, taking and tracking air temperatures every 2 hours. This is still currently in place and will be continued until all room temperatures are consistently at 75 degrees or below; at which time daily monitoring of temperatures will resume in accordance with facility standard procedures. 2. On 6/18/24, the facility Administrator assigned department managers to assist direct care staff with monitoring residents every 2 hours and questioning residents about comfort. Residents in rooms with the highest recorded temperatures were also asked/encourage to move to another/cooler room. 3. On 6/18/24, the facility Administrator provided residents with fans as available. 4. On 6/18/24, the facility Activity personnel passed out popsicles to residents, in accordance with prescribed diets. 5. On 6/18/24, the facility Administrator instructed licensed nurses and C.N.A.s to increase monitoring of all residents and increase the provision of ice/water. Administrator also encouraged staff to encourage mobile residents ' use of hydration stations provided on both floors. 6. On 6/18/24, the facility DON implemented additional temperature (vital) monitoring (2 times/shift) for all residents. 7. On 6/19/24, facility Nursing Managers identified residents with higher risk for negative effects related to hot temperatures. Residents with mobility, respiratory, g-tube dependent, and other concerns outlined in the facility ' s Extreme Weather policy were identified and additional interventions were put in place, such as additional g-tube flushes, checking/changing of positioning/clothing/linen for residents in bed, etc. 8. On 6/19/24, the facility Administrator and DON initiated a rounding tool to document the 2-hour rounding being completed by nursing management, and ensure the following: i. Frequent monitoring of residents with mobility concern (bed-bound) ii. Frequent monitoring of residents with compromised ability to verbalize discomfort. iii. Frequent monitoring of resident body temperature. iv. Presence of ice/water/appropriate hydration in the resident room. 9. On 6/21/24, the facility ' s nursing management, initiated nurses monitoring for s/s of heat exhaustion and heat stroke every 4 hours; with documentation in the residents ' MARs. 10. On 6/21/24, the facility Administrator conducted education to all staff on facility extreme hot weather policy and checking for s/s of hyperthermia. Mechanical Assessment & Repairs: All resident rooms are equipped with convectors that provide A/C to the rooms. 1. On 6/17/24, the facility RDO arranged for the Maintenance Director at an affiliated facility to assess the HVAC function, in observation of the PTAC units in the lobby and conference room not working, and anticipation of continuous high temperatures expected during the week. Temperatures on the care units were not noted as a concern at this time. 2. On 6/17/24, the assisting Maintenance Director contacted the facility ' s contracted HVAC service provider to provide further assessment of the HVAC system and planned to secure parts for repair of the PTAC units in the facility ' s lobby and conference rooms. 3. On 6/18/24, the assisting Maintenance Director repaired the PTAC unit in the facility ' s conference room and verified availability and function of 17 window A/C units. The assisting Maintenance Director developed a plan and the secured the additional staff needed to install the units on 6/19/24. 4. On 6/18/24, the facility ' s contracted HVAC service provider assessed the HVAC system and performed service to the facility ' s chillers and compressors; providing the facility with 50% function of the system that provides A/C to the public areas, (hallways and dining rooms). The facility Administrator and management was told that a repair to the rooftop unit will be needed and could be scheduled when outside temperatures subside, however the current function % would be sufficient to provide the amount of A/C necessary to maintain appropriate temperatures throughout the building in the interim. 5. On 6/19/24, the assisting Maintenance Director returned to the facility to install window units on the second floor, where the rooms with the highest temperatures were located. A/C units were installed in the following rooms: o 200 (4 bed-room - 2 units installed) o 203, 206, 207, 208, 209, 211, 210, 214, 215, 217, 218, 222, 223, 224 o Facility lobby 6. On 6/19/24, the facility ' s contracted HVAC service provider returned to the facility to do additional assessment and service to the ground level chiller, central A/C units to maximize A/C performance to facility public areas. The provider also initiated assessment and service to the convectors in the resident rooms. The Administrator will ensure that the HVAC service provider provides routine maintenance annually of the HVAC systems, in accordance with the facility PM program. 7. On 6/20/24, the facility ' s contracted HVAC service provider completed the assessment and service to all the convectors in the residents ' rooms. The Administrator will ensure that the convectors area assessed/cleaned/serviced monthly by the Maintenance Director or designee (HVAC service provider). The company ' s corporate maintenance director or designee (HVAC service provider) will perform quarterly audit of the primary HVAC system to ensure proper maintenance/function in between annual inspections provided by the HVAC service provider. The corporate maintenance director or designee (HVAC service provider) will also complete random audits of the individual room convectors on a quarterly basis to ensure compliance with monthly maintenance. No residents have been harmed or noted with reported, observed or assessed discomfort and/or adverse outcomes. Staff education will be on-going. Additional monitoring and resident care interventions will be continued until facility temperatures are maintained at or below 75 degrees. This abatement plan and all related audits/tools will be reviewed by the facility ' s QAPI Committee. The Regional Nurse Consultant/designee will review compliance audits weekly and report findings to the facility ' s QAPI Committee for review at the next meeting, scheduled for 7/19/24

Based on interview and record review, the facility failed to prevent or determine an injury of unknown origin for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining bruising to the left hip, left hand, and left shin and superficial scratches to R1's back and treated at the local hospital. Findings Include: R1 is a [AGE] year old, female resident in the facility with diagnoses of but not limited to: Psychosis not due to substance or known physiological condition, anxiety disorder, acute stress reaction, and adult physical abuse. R1 has a BIMS of 15 (Cognition Intact). Facility Reported Incident with date of occurrence of 3/28/24, reads in part: R1 alleged rough treatment/abuse by agency staff nurse. Upon investigation, R1 has a history of non-receptive to touch and difficulty allowing anyone in her personal space related to history of adult physical abuse. However, body assessment did indicate bruises noted of unknown origin. R1 statement was inconsistent: Stating her clothing items ripped off and cut up (clothing was intact) Stating that 2 staff person in the room (camera indicates one person in the room). R1 stated 'a staff person standing outside guarding her door during alleged abuse (Camera indicated no one standing outside of room during time indicated). Unable to substantiate allegation of R1 was willfully physically abused by the staff person. R1's Facility Progress note dated 3/28/24, reads in part: skin assessment bruise to left lower leg bruise reddish in color, size of a yellow egg yolk. Noted bruise to upper left hip, grayish blue with size of a medium [NAME] seed. Also, noted reddish bruise to both forearms. Lower right back noted two scratches, red, wound edges attached no drainage or bleeding noted. Unable to measure L (length) x W (Width) x D (Depth) of scratches due to resident DX of OCD. Police Report dated 3/28/24, reads in part: Spoke with R1 in the presence of daughter. R1 said she was waiting in her room for her daughter to come to bring her clothes so that she could shower. R1 says that the nurse (V5) comes in and says that R1 has to take shower and got verbally aggressive towards R1. R1 says that they took her roommate out of the room. R1 says that she follows the nurse out of the room when the nurse then pushed her back in the room. R1 said she is pushed into shower. R1 says that the nurse said she was going to use scissors to cut her shirt off. R1 says that she takes her own shirt off but keep her pants on. R1 says the nurse grabs both of her hands and pushes her into the wall, while striking her on the head with the shower head. Writer observed no visible injuries to R1's head during interview. R1 says she got scratches on her wrist, which look like rash marks, scratched to her right shoulder. R1 says from getting pushed into the wall she got bruise to her lower left leg. R1 sad the nurse ripped her shirt off, where V1 (administrator) went and got the clothes from the shower and had no rip marks on them. Hospital record dated 3/28/24, reads in part: R1 presents for evaluation after alleged assault at nursing facility. R1 and daughter at bedside report that there was an altercation approximately 1200 today wherein R1 did not want to shower and was injured by staff as they attempted to force her to shower. R1 reports being hit on Left temporal region of skull with shower head, as well as scratches on back and bruised on Left Hip, L shin during this altercation. Endorses L hand pain. Physical exam. Skin: Bruising left hip, left hand, and left shin present. Superficial nonbleeding scratches to back. Mental status: Alert, and oriented to person, time and place. Psychiatric: tearful and anxious. R1 to ED (Emergency Department) after daughter called 911 due to R1 states she was pushed, grabbed and bruised by nursing staff. On 6/13/24 at 11:03AM, V1 (administrator) R1 reported that staff forced her to take a shower. Rambled on and backing up from me. V1 did not substantiate due to contradicting stories. R1 reported they ripped R1's clothes off, V1 asked and R1 said the nurse. R1 showed me her clothes, and R1's clothes were not ripped. They made R1 take a shower and force R1 to take a shower. Hair was wet, evidence she had taken a shower. R1 reported that she was hit in the head with the shower, facility has detachable shower head. R1 kept saying They for what V1 can see was there was one person, the nurse. Ran back the video tape and observed the nurse was the only person went inside the room, and R1 stated there were several people, could not name them but keep on saying them and nurse. Approximately for a brief time, the only and other person that came in the room before the nurse was the therapy person. Hospital would not give any more information when we tried to do follow up, because the daughter does not want the information to be given to us. V1 also stated that V1 was unable to ascertain how and when R1 sustained the documented injury during complete body assessment. Staff knows to report to Director of Nursing (DON) and DON to report to V1 for any noted bruising in any residents. Nothing was reported to V1 by DON, regarding R1's bruising. V1 was only made aware of the injury after the wound nurse assessed R1. Asked R1 how R1 sustained the bruising, and R1 would not say anything. Police was also called, they have to wait for the daughter because R1 will not talk to the police unless her daughter is present. Daughter was also saying You did this, the facility did this to Mom (R1). V1 stated I do not know how R1 sustained those injuries. I did my due diligence with my investigation. Doing staff and residents interviews, review the recordings. No one reported to me any abuse for R1 or any residents in the facility. On 6/13/24 V11 (R1's Daughter) stated that R1 had bruising on her body. R1 reported to V11 that a nurse hit R1 while taking a shower. Abuse Prevention Program policy with a revised date of 1/2019, reads in part: All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or crime against a resident should be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or crime against resident will result in an abuse investigation. For Resident injuries not involving allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an Injury of Unknown origin. An injury should be classified as an injury of unknown origin when both of the following condition are met: The source of the injury was not observed by any person of the source pf the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (the injury is located in area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injury overtime. VII Prevention: The facility desires to prevent abuse, neglect, exploitation, misappropriation of proper and a crime against a resident by establishing a resident-sensitive and resident- secure environment. This will be accomplished by a comprehensive quality assurance performance improvement approach. Policy: This facility will not tolerate resident abuse or mistreatment of crimes against a resident, including staff member other residents, consultant, volunteer and staff of other agency, family member, legal guardian, friend and other individual. Procedure: Any alleged violation involving mistreatment, abuse, neglect, exploitation, and misappropriation of resident property and any injuries of unknown origin or reasonable suspicion of a crime against a resident must be reported to the Administrator or DON. The Administrator I am the abuse coordinator.

Based on interviews and record reviews, the facility failed to protect a resident (R1) from physical abuse by staff and failed to follow their abuse protocols by staff not promptly reporting an incident of resident abuse. This failure applied to one (R1) of four residents reviewed for abuse and resulted in R1 being emergently transferred to the local emergency room for evaluation of pain to his head, neck and ribs and subsequently being admitted for assault and a fracture to his right third digit; this failure also led to a delay in the initiation of an abuse investigation as a result of staff not immediately reporting the abuse. The Immediate Jeopardy began on 3/2/24 when R1 was physically abused by V3 (Registered Nurse). V1 (Administrator) was notified of the Immediate Jeopardy on 3/12/24 at 10:12AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed 3/14/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's referral documentation from previous facility dated 02/22/2024 reviewed, no behavior documentation noted. R1's electronic medical record indicated that resident admitted to the facility on [DATE]. R1's nursing progress note dated 02/27/2024 23:26 (11:36 PM) indicated R1 admitted from another nursing home and is alert and oriented times three. There was no Brief Interview for Mental Status (BIMS) Score available for R1. R1's general progress note dated 03/02/2024 19:58 (07:58 PM) submitted by V3 (Registered Nurse) indicated that R1 came to the nurse's station that morning to heat up some food in the microwave. V3 offered to heat up R1's food when resident became uncontrollable and was screaming and throwing trays. V3's note then indicated that resident went to his room and called the police then was taken to the local hospital. Note also included the following statement, physical confrontation with the other resident with no further details documented. R1's nursing progress note dated 03/03/2024 03:46 submitted by V4 (Registered Nurse) indicated that R1 was admitted to a local hospital with the diagnosis of an alleged assault. On 03/04/2024, reviewed facility investigation reports submitted to the department of public health by the facility from 12/2023 through current with no investigation report found for R1. On 03/04/2024 at 1:58 PM, V2 (Director of Nursing) said she was informed by V3 (Registered Nurse) that on 03/02/2024, R1 had come out of his room to warm up some food when R1 became agitated with V3, R1 then called the police and was transferred to the hospital. V2 (DON) said she believed, being told by either V3 (RN) or V4 (RN), that R1 had been fighting with someone, whom she assumed was either with the emergency medical technicians (EMT's) or the emergency room staff. On 03/04/2024 at 2:33 PM, V4 (Registered Nurse) said on 03/02/2024, she had received shift-to-shift report from V3 (Registered Nurse) who indicated that R1 was being aggressive and that the resident was sent to the hospital. V4 (RN) added that she could not recall whether V3 indicated that there was any type of a physical altercation with R1. V4 (RN) then said she followed up with the hospital and was told by the emergency room staff that R1 was admitted for an alleged assault. She added that no further details were communicated, nor did she ask for any additional information. V4 (RN) then said that she informed V2 (DON) of R1's status. Reviewed R1's hospital paperwork dated 03/02/2024 that indicated R1 was seen in the emergency room and reported being hit to the head, neck and back areas by a male nurse at the facility. R1 also said he was pushed by this same nurse and sustained an injury to his right finger and complained about pain to the back of his head, neck and ribs. Hospital assessment revealed no aggressive behaviors, generalized tenderness to back of head, mid spine, right shoulder area and lateral chest along with an area of torn skin to his right ring finger. R1's diagnostic results showed a fracture to right third digit. No aggressive behavior documentation was found within R1's hospital paperwork. On 03/05/2024 at 10:43 AM, R4 said R1 was his roommate and that they both recently had admitted to the facility. R4 then said on the morning of 03/02/2024, he was in his room and could hear what sounded like an altercation in the hallway. He then said a few minutes later, R1 came into the room and called the police from his cell phone and reported being assaulted by a male nurse. R4 then said later the day and the following day, some staff were talking to him about the incident and said V3 and R1 had gotten into a fight where R1 punched V3 several times and V3 had punched R1 once or twice. On 03/05/2024 at 11:07 AM, V3 (Registered Nurse) said on day of incident, R1 became upset when he (R1) couldn't heat up a container of food by himself. V3 said after he assisted R1's with his food, R1 went back to his room but shortly after, came out of his room and tried to get on the elevator to smoke but the elevator was full. V3 said R1 began throwing breakfast trays and items from these trays when he (V3) physically took R1's hands from the tray cart and placed them on his walker because R1 appeared unsteady on his feet. V3 (RN) then said R1 calmed down and went back to his room. When asked to clarify the physical confrontation with the other resident from his progress note dated 03/02/2024, V3 said some residents had come out of their rooms when R1 was yelling and throwing trays down the hall near them but no contact was made. He added that at no time was there any physical confrontation between R1, himself or any other resident. V3 (RN) then said the police came shortly after and asked for R1 so he (V3) took them to R1's room where he was sitting on his bed eating. V3 (RN) said he did not notice any injury or bleeding to R1, but the police informed him that R1's hand was bleeding so he (V3) left the room to get supplies from his med cart and when he returned, the police and R1 were both gone. V3 added that one officer stayed behind to get R1's resident information and he (V3) asked this officer why they were taking R1 from the facility but V3 was only informed that the resident (R1) had called them. V3 (RN) then said he called V2 (Director of Nursing) and informed her about the incident, R1's behaviors, and that the police took R1 to the local emergency room . On 03/05/2024 at 12:15 PM, V2 (Director of Nursing) said there is video surveillance in the hallways including on the second floor but, she would need to check if they are working because the last that she knew, they were not working. Surveyor requested to review video surveillance if available at this time. On 03/05/2024 at 1:48 PM, attempted to call R1's provided cell phone number. No answer, detailed message was left. On 03/05/2024 at 1:57 PM, V7 (Certified Nursing Assistant) said on 03/02/2024 she worked with V9 (Agency Certified Nursing Assistant) on the second floor. V7 added that she observed R1 trying to heat up some food, but the second floor male African nurse (V3) was being extremely aggressive verbally to R1. V7 (CNA) added that V3 was trying to tell R1 to use another microwave but R1 did not want to do so and R1 was telling the nurse (V3) to leave him alone. She then said a loud verbal altercation between this nurse (V3) and R1 began and was loud. She then witnessed this male nurse (V3) and R1 hitting each other with closed fists to the upper body, and the nurse was trying to shove R1 back into his room. V7 (CNA) added that she has never seen anything like this incident before and couldn't believe how comfortable the nurse (V3) seemed to be fighting with R1 in the open. She then said about 10-15 minutes after incident, the front desk called the unit indicating that the police were in the building who then left the facility with R1. V7 also said through her agency's app, employees can leave a review for a facility and indicated there were multiple reviews about a second floor male African nurse for this facility that is very rude. She added that she left a review stating this male nurse (V3) had fought with a resident in the hallway and that V9 may not want to say anything about the incident so she can continue working at the facility and not be put on the do not return list. On 03/05/2024 at 2:33 PM, surveyor met with V1 (Administrator) and V2 (Director of Nursing) regarding concerns with R1's and the status of video surveillance review. V1 said the video surveillance has not been working since she started almost two months. At 2:32 PM, V2 (DON) aid after being informed by V4 (RN) of R1's admitting diagnosis, she didn't believe the assault had occurred at the facility, and she thought it had occurred with the EMT's or in the emergency department. At 2:35 PM, V1 said to V2, why didn't you tell me!?! V1 then said she should have been contacted immediately after R1's diagnosis was obtained because it is considered abuse. V1 then said she would have sent the nurse (V3) home and initiated an abuse investigation. At 3:37 PM, V1 (Administrator) said she suspended V3 (RN) and has submitted an initial report to the department. V1 provided surveyor with copy of initial report which indicated she was made aware of an alleged abuse allegation by surveyor on 03/05/2024 that involved V3 (Registered Nurse) and R1; V3 was suspended pending investigation. On 03/06/2024 at 12:15 PM, V9 (Agency Certified Nursing Assistant) said she worked at the facility on 03/02/2024. She added that during the passing of morning trays, a resident, who she was unable to identify by name, had gotten upset because he wanted more coffee. V9 then said this resident began slinging food trays when a male nurse verbally asked him to stop then she saw this same nurse take the tray away from the resident. V9 (CNA) said that she did not see any type of physical altercation between the nurse or resident, she just heard a loud commotion while passing trays to other residents in their rooms. She then saw the police coming off the elevator and a few minutes later take this same resident off the unit. On 03/06/2024 at 2:10 PM, attempted to call R1's cell phone number a second time. No answer, detailed message was left. Requested abuse screen for R1 from facility. As of 03/06/2024 at 03:04 PM, no abuse screen was provided, and no abuse screen or care plan were found in R1's medical records. On 03/12/2024 at 10:12 AM, V1 (Administrator) said based on the information received during this complaint investigation, she has terminated V2 (Director of Nursing) and will be terminating V3 (Registered Nurse). On 03/12/2024 at 10:15 AM, V11 (MDS Coordinator and Restorative Director) said she is not aware of any abuse screens or of the process in which quarterly/annual screening of residents for abuse is performed. On 03/12/2024 at 1:13 PM, V12 (Medical Doctor) said he saw R1 on the day of incident (03/02/2024) that led to R1 being sent out to the emergency room . V12 then said when he saw R1, the resident was nice and calm, talked pleasantly, and displayed no behaviors. V12 added that his size and stature that can be intimidating to some people. V12 also said that no behaviors were reported to him by the facility staff regarding R1 while he (V12) was at the facility, and that R1's behaviors began while at the hospital. (No documentation was found regarding the above mentioned encounter between V12 and R1). Reviewed facility abuse prevention program policy last revised 01/2019 that reads in part: Policy: 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. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a third party. III. Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics: staff obligations to prevent and report abuse, neglect, exploitation, mistreatment, any crime against the resident, theft and how to distinguish theft from lost items and willful abuse from insensitive staff actions that should be corrected through counseling and additional training. Staff should report their knowledge of allegations without fear of reprisal. how to assess, prevent, and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff. 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 sate 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, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the Administrator. In the absence of the Administrator, reporting can be made to the Director of Nursing (DON). Any incident, allegation, or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident is reported to a covered individual; covered individuals are notified annually of these reporting requirements. Supervisors shall immediately inform the administrator or in the absence of the Administrator, the DON of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, misappropriation of property, mistreatment or a crime against a resident. Upon learning of the report, the Administrator or in the absence of the Administrator, the DON shall initiate an incident investigation. VII. 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. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. Abuse and Crime Reporting: Policy: This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or other individuals. All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment, neglect, or exploitation including injuries of an unknown origin. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse, mistreatment or neglect or suspected abuse, mistreatment or neglect, without fear of retaliation or retribution from the facility or its staff. For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: 1. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting 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. 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. 4. Physical abuse: hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. The Immediate Jeopardy that began on 3/2/24 was removed on 3/14/24 when the facility took the following actions to remove the immediacy: 1. The facility Administrator immediately initiated staff education, based on concerns reported by the IDPH surveyor on 3/6/24. a. On 3/6/24, facility SSD conducted re-education on abuse prevention, identification, and reporting, for all employees scheduled on that day. b. On 3/12/24, facility Administrator provided all management personnel with reeducation on the facility's abuse policy, including but not limited to education on the prevention, identification and reporting of abuse. c. All facility personnel who have not yet been in-serviced, will receive re-education upon start of next scheduled shift. Training for all available staff will be completed by 3/15/24. d. All facility and contracted staff who were unable to be in-serviced, due to FMLA, vacations, agency staff, etc. will be prohibited from working until the abuse reeducation has been completed. A tracking tool was put in place on 3/14/24 and will be used to verify training. e. The DON/designee will re-educate contracted agency personnel at the start of their next scheduled shift. A tracking tool was put in place on 3/14/24 and will be used to verify training. This will be on-going. 2. The facility Administrator, SSD, DON, and Nursing Supervisor have been assigned the responsibility of ensuring that all facility and contracted employees receive abuse reeducation prior to working next scheduled shifts. 3. Administrator posted additional signage regarding the reporting of abuse. Signage was posted in prominent places of throughout the facility, directing both staff and residents on process for reporting abuse. 4. On 03/12/2024, the facility SSD, and HIM interviewed capable residents (cognitively able to participate) regarding any occurrences of mistreatment / abuse, and feelings of safety in the facility. Residents were also educated on rights to be free from abuse, and ways to report mistreatment of any kind. SSD and DON performed visual observations of residents for indicators of abuse risk on 3/14/24. SSD and Nursing management personnel will review all existing abuse risk care plans and implement care plans for any residents with newly identified abuse risk accordingly, by 3/15/24. 5. On 3/12/24, the facility Administrator, Director of Nursing, Regional Nurse Consultant reviewed the facility resources and policies related to abuse and no changes were made at this time. 6. On 3/12/24, the facility Administrator developed an audit tool to monitor compliance with the facilities abuse policy and this abatement plan. The Administrator will complete random audits 3 times weekly for 30 days, and 1 time weekly thereafter. 7. This abatement plan and all related audits will be reviewed weekly by the RDO/designee and during the facility's next QAPI Committee Meeting scheduled for 3/22/24. The Regional Nurse Consultant will review compliance audits and report findings to the facility's QAPI Committee for review monthly, for the next 3 months. 8. R1 is not in the facility.

Based on interviews and records reviewed the facility failed to follow their policy to prevent or determine an injury of unknown origin. This affects one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in (R1) being found with a change in skin pigmentation and sent to the hospital for an evaluation and admitted with a hip wound consistent with a second degree burn. The findings include: R1's diagnosis include but are not limited to Hemiplegia Affecting Right Dominant Side, Dementia, Contracture Left Hand, Hypertension, Cognitive Communication Deficit, Adult Failure to Thrive, and Need For Assistance with Personal Care. R1 is severely cognitively impaired. R1 is African American. On 9/27/23 at 9:47AM V11, Certified Nursing Assistant (CNA) said I worked night shift on 9/22/23. V11 said at 11:00PM I saw R1, she was dry and asleep. V11 said at around 12:00PM -12:30PM the nurse did rounds and came and told me R1 was wiggling and wet so I went to change her. V11 said when I pulled the covers I saw it on her hip, before I took off the diaper. V11 said It looked like a burn to me. V11 said it was puffed up, round, white, and around the diaper had blood on the side. V11 said I told the nurse to come look. On 9/27/23 at 5:03PM V3, Nurse, said stuff happens and no one had told me anything. V3 said I came in at 7:00PM on 9/22/23. V3 said I went in to see R1 and saw a circular area, no blood, a white patch, and no signs of distress. V3 said the area was about the size of a hand. V3 said I didn't call anyone on the night shift, because I didn't see her in distress and I didn't know if she already had it. On 9/27/23 at 9:11AM V5, CNA, said when I left at 11:00PM on Friday 9/22/23 R1 did not have a mark. V5 said when I came in on Saturday 9/23/23 morning the CNA asked me if I knew about the mark, I said no. V5 said I saw the spot, it looked like her skin turned white and I could see pigment spots of her skin on it. On 9/26/23 at 11:02AM V1, Wound Nurse, said the Director of Nursing (DON), told me to check R1 on 9/23/23. V1 said I saw a discoloration, white patch the size of a pear, no drainage, not puffy, and not open. V1 said R1 did not have a history of pressure ulcers. V1 said R1 was sent to the hospital for evaluation. V1 said we didn't understand what it was. V1 said looked like they rubbed her with bleaching cream. V1 said I don't know what it was, I don't know what they were using on her. On 9/27/23 at 10:00am V12, Registered Nurse, said the DON called the facility and asked me to call the hospital and ask about R1. V12 said, I initially was told by the nurse she was admitted for burns. The nurse asked me to call back. V12 said I was confused when I checked the chart I saw she was very dependent on staff. V12 said I told the DON and she said call them back. V12 said then I was told by the nurse, the family did not want the hospital to disclose any information to us. On 9/27/23 at 10:13AM V9, DON, said the clerk spoke to me and said R1's daughter needed the wound nurse. V9 said this call happened around 11:00AM. V9 said the area appeared Saturday morning. V9 said the conclusion is that this is was a skin discoloration, not a wound. V9 said the nurse should have told me about it. V9 said no one mentioned a burn to me, I don't know what it was. V9 said an injury of unknown injury is when something happened that was not witnessed and we don't know what happened. V9 said we would document that on an incident report. V9 said from midnight until the wound nurse saw it, we don't know what it was. On 9/27/23 at 11:30AM V7, Administrator, said I was aware the wound nurse said it was not a wound on R1. V7 said the family insisted calling the police and going to the hospital. V7 said I have not looked at camera footage for the care of R1. R1's progress notes dated 9/24/23 6:30AM written by V3 states general report from CNA that R1 has a wound. Not sure if it was an old wound. Endorsed to the next nurse that left hip missing skin. R1's progress notes dated 9/23/23 at 12:39PM written by V1 states writer made aware on 9/23/23 of intact, discolored skin patch on left hip. 15 x 8.5, size of large pear-shaped diamond, surrounding area small non raised reddish dots. Patch has small block of petechia. R1's functional States dated 8/12/23 notes R1 requires extensive assistance with bed mobility and dressing. R1 requires total dependence with transfer and toilet use. R1's care plan indicates R1 is has allegation of abuse. Goal sates R1 will be treated with respect, dignity, and reside in the facility free of mistreatment. R1 is at risk for alteration in skin integrity. R1's hospital records dated 9/23/23 states: left hip wound concerning for second degree burn 8x10cm area of white leathery discoloration consistent with a second degree burn located on the left lateral hip and extends posteriorly. Due to concerns for patient safety and elder abuse, plan to admit. The facility had no incident report or documented investigation to explain the left hip area observed on R1. The facility Abuse Prevention Program revised 1/2019 states For resident injuries not involving an allegation of abuse or neglect, the administrator will gather facts to decide whether the injury should be classified as an injury of unknown injury. Abuse Prevention Program states if the injury is classified injury of unknown origin the time frames for reporting and investigating abuse will be followed. All incidents will be documented, whether or not abuse occurred, alleged or suspected. The charge nurse must complete an incident report. All staff must report any incident of resident abuse. The facility undated Incident/Accident/ Falls policy states The incident report will be completed as information is obtained. The occurrence will be documented. Some occurrences will require a more extensive investigation. Including skin tears and bruises.

Based on interview and record review, the facility failed to prevent R212 from falling on 4/17/23 resulting in R212 sustaining a laceration to the back of the head requiring 3 staples on the right side. The facility also failed to prevent R212 from falling again on 4/26/23 resulting in R212 sustaining a laceration to the left side of his forehead and receiving steri-strips and surgical glue to the forehead. This failure affected one resident (R212) of four residents reviewed for falls in a total sample of 22. Findings include: On 9/20/23 at 11:30 am, both V1(Administrator) and V2(Director of Nursing) both stated that they were not working at the facility during R212's fall incident and as such cannot answer any questions regarding R212's incident. V1 stated that he started working at the facility on 5/15/23 and V2 started 5/23/23. On 9/21/23 at 10:25 am, V7 (MDS RN) stated that R212 was resistant to care and would attempt to get out of bed. On 9/21/23 at 12:10 pm, V27 (RN Agency) stated that she cannot remember taking care of R212. On 9/21/23 at 12: 20 pm, V28 (RN Agency) was not available for a phone call. On 9/22/23 at 9:15 am, V14 (License Practicing Nurse) was not available for a phone call. Facility was unable to produce an admission fall care plan for 3/17/23. Fall risk care plan document 4/17/23 interventions as follows: bed low floor mats, bed in lowest position, encouragement to request assistance from staff prior to reaching for items outside of his immediate grasp. Facility's fall risk review dated 4/17/23 indicates R212 has a fall score of 15, Category: High Risk for Fall. Progress note entered on 4/17/23 at 2:20 am indicates CNA heard a loud noise and entered the room at 1:45 am. Observed resident sitting on a floor mat . observed laceration to back of head, on the right side. Observed small scratches over the right eye .MD made aware, received orders to send to hospital . Facility incident report dated 4/17/23 indicates, Injury Type: Abrasion -location Right eye, Injury Type: laceration-location Top of scalp. Facility's document reported to IDPH on 4/17/23 indicates, Initial Report; Descriptions of Occurrence: On 4/17/23 at 1:45 am, Resident sustained fall incident with head injury . Final Report; Descriptions of Occurrence: On 4/17/23 at 1:45 am, Resident sustained fall incident with head injury . on 4/17/23 at 10:14 am R212 returned to facility in stable condition with staples to right posterior head. Pain management in place. Progress note entered on 4/17/23 at 10:14 am indicates, R212 returned from hospital. R212 has three staples on the left side of scalp. R212 still seems to be fidgety and unable to be redirected. R212 continuous to attempt to get out of bed. R212's Hospital discharge summary dated 4/17/23 indicates; Diagnoses: Laceration of scalp without foreign body .and Traumatic injury of head ., Done Today; Laceration Repair. Facility's fall risk review dated 4/26/23 indicates R212 has a fall score of 15, Category: High Risk for Fall. Progress note dated 4/26/23 at 8:04 pm indicates R212 had an unwitnessed fall with laceration to the left side of his forehead New orders from NP (Nurse Practitioner) to send to hospital . call light and personal items are in arms reach and will continue to monitor. Facility's incident report dated 4/26/23 indicates, Injury Type: Bruise -location Forehead, Injury Type: laceration-location Forehead. Facility's document reported to IDPH indicates, Initial Report; Descriptions of Occurrence: On 4/26/23 at 9:00pm Resident sustained fall incident with head injury . Final Report: 4/27/23 at approximately 4:00pm, facility notified resident received steri-strips and surgical-glue to left forehead. Occurrence Resolution. Resident remains in the hospital. Family has decided on alternate SNF (skill Nursing Facility) placement. Facility policy undated indicates the following: Fall -Initial plan of Care; if a resident is admitted and is found to be at risk for falls or has a history of falls, the physician should be contacted for any appropriate orders and an initial and individual plan of care will need to be developed with appropriate intervention to prevent falls.

Based on interviews and record reviews, the facility failed to keep a resident free from abuse by staff being rough while providing care and speaking to resident in a rude and disrespectful manner. This failure applied to one (R71) of 19 residents reviewed for abuse and resulted in R71 feeling sad and anxious due to how R71 was treated by staff. Findings include: On 08/31/22 at 04:45 PM R71 stated V24 (Certified Nursing Assistant) who was a large woman rough handled her while providing care. R71 stated while V24 and another CNA were providing her with incontinence care, V24 grabbed her right leg that is typically sore aggressively causing her pain. R71 stated she groaned in pain and asked V24 to lower her leg. R71 stated she cried because of the pain she was feeling from V24 forcing her right leg up. R71 stated V24 responded to her complaints of pain by stating what are you some kind of Diva? R71 stated she would never know what kind of mood V24 would be in. R71 stated V24 would say crying made her angry and would tell her she will walk out on you if you cried. R71 stated she would be afraid and would know what to expect from V24 depending on her mood. R71 stated some of the staff were upset with her for complaining about V24. R71 stated she felt sad because the aide was working with V24 during the incident and was helpful to her during the ordeal and told the police everything she observed was suspended. Facility incident investigation report dated 08/16/2022 documents R71 alleged that staff V24 (Certified Nursing Assistant) handled her roughly and spoke to her inappropriately; staff was immediately placed on suspension pending investigation; V24 was interviewed and admitted to mumbling you're being a diva under her breath but did not think R71 heard her nor did she think it was inappropriate; V24 did state she never handled R71 roughly; R71 reported another staff was present during the incident, intervened and took over her care; local police were notified; R71 later complained of pain and nursing attempted to have R71 x-rayed but she refused and stated she was no longer in pain; she had no concerns during later follow up on her condition; V24 was unable to return to the facility. On 09/01/22 at 11:03 AM V2 (Director of Nursing) stated V24 (Certified Nursing Assistant) was permanent staff. V2 stated V24 did have some previous issues and complaints of residents reporting she was kind of rough with care which is why she was let go due to too many complaints. Employee Disciplinary Action Form dated 05/31/2022 documents on 05/25/2022 it was reported by a resident that V24 (Certified Nursing Assistant) was discourteous towards her. V24 has been named in several unsubstantiated allegations relating to inappropriate behavior. The facility's Abuse Policy reviewed 09/01/2022 states: It is the policy of this facility to prohibit and prevent resident abuse and mistreatment. Supervisors will monitor the ability of the staff to meet needs of residents: Staff understanding of insensitive handling or impersonal care will be corrected as they occur. Facility Incident Investigation Report dated 08/16/2022 requested 09/01/2022 was not provided by the facility by the time of the survey exit.

Based on observations, interviews, and record reviews, the facility failed to follow their policies and procedures for fall prevention by not developing a comprehensive and individualized plan of care for a resident admitted at risk for falls and failed to evaluate and modify interventions following an unwitnessed fall. This failure applied to one (R19) of one resident reviewed for fall interventions and resulted in R19 requiring emergent transfer to hospital as a result of a head injury. Findings include: R19 is a [AGE] year-old female with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's Admission Fall risk review dated 06/24/2022 documents a score of 12 with high risk for falls, is non-ambulatory, incontinent, has gait/balance issues including a balance problem while standing/walking, decreased muscular coordination/jerking movements, and has 3 or more health conditions. On 08/29/22 at 12:30 PM Observed R19 with a large area of bruising on right side of her face. R19 stated she slipped and fell about a week ago. R19's Current care plan documents she is at risk for falls related to: a History of Falls, Cognitive Impairments, Requiring assistance with activities for daily living and for transfers and mobility related tasks, Incontinence of Bowel, Incontinence of Bladder, and Decreased Strength and Endurance, Impaired Gait and Balance, General weakness, as well as diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff to respond promptly to all requests for assistance; Complete the Fall Risk Review per the facility protocol; I would like staff to review information on my past falls and attempt to determine the cause of my fall(s). Record possible root causes on my care plan. Alter/remove any potential causes if possible. Educate me, my family, caregiver and Interdisciplinary Team as to the continued risk factors and interventions used to help prevent future falls; Nursing Staff will complete a Fall Risk Assessment per Facility Fall Protocol; Follow the facility Fall Protocol; right side floor mats. R19's Fall Observation Incident Report dated 08/15/2022 documents R19 was observed on the floor after an unwitnessed fall, was evaluated and noted with a large lump to the right side of her forehead, right cheek red and swollen, and a small lump on the back of the right side of head; R19 was unable to describe what happened, was confused and disoriented; emergency medical services was called; R19 was sent to the hospital. R19's Post Fall risk review dated 08/15/2022 does not include notes of any incidents or concerns; and documents a final score of 7 with a score of 10 or above being higher risk. R19's Hospital Record dated 08/15/2022 documents her chief complaint as a fall with head injury with History of Present Illness information including: head injury to right side of forehead, onset sudden with trauma. Presents to emergency department after suffering a head injury; mechanical fall at nursing home hitting the right side of her forehead, arrived with hematoma (bruise) to right forehead and back of head; patient is not anticoagulated; Emergency Medical Responders documented she recalled the incident, was alert and oriented, and reported that she tripped and fell from walking. R19's Hospital Discharge Summary dated 08/15/2022 documents she was discharged with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/31/22 at 10:26 AM V28 (Corporate Vice President/Registered Nurse) stated she observed a bruise on R19's face and was informed by the resident and staff that it was the result of a fall she experienced 10 days ago. On 09/01/22 at 09:57 AM V2 (Director of Nursing) stated R19's fall assessment was done on admission. V2 stated R19 is not on any blood thinners. V2 stated R19 still has a bruise on her face from her fall. V2 stated V29 (Licensed Practical Nurse) was speaking about R19's bruise yesterday and stated at the time of her fall she had some swelling around her eye and cheek area. V2 stated R19 had not had any falls prior to this incident. V2 stated she is not sure why fall mats were only recommended for one side of R19's bed. V2 was unable to provide a root cause analysis or contributing factors for R19's fall. V2 stated after a resident falls a root cause analysis is performed and the care plan is updated to include findings. V2 was unable to explain how R19's fall risk decreased per her 08/15/2022 fall risk review completed after her fall. V2 stated there should have been personalized interventions in R19's care plan to prevent her from falling and there are not currently any personalized fall interventions included in her care plan for fall prevention. V2 was unable to identify any personalized interventions that may prevent R19 from falling. V2 stated an internal report dated 08/16/2022 documents per the interdisciplinary team the resident will be educated regarding mobility safety. The facility's Fall Policy reviewed 09/01/2022 states: The purpose of our Fall Prevention and Management Program is to: Provide appropriate interventions to prevent falls. Through an interdisciplinary approach, this facility will provide fall prevention and implement interventions to prevent falls as much as possible. The facility will achieve these goals through: Interventions that are implemented based upon the identified risk factors. Fall Prevention includes: Implement individualized approaches/interventions based upon resident risk. Interdisciplinary care plan is implemented for residents at risk and may include: Supervision as appropriate.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for preventing and minimizing pain by not ensuring that pain was adequately controlled by not ensuring that pain medication was available to be administered as ordered. This failure applied to two (R33 and R49) of two residents reviewed for pain management and resulted in R33 and R49 experiencing pain greater than a level ten for multiple days. Findings include: Reviewed grievance/concern log entry for R33 dated 06/21/2022 that showed R33 was concerned that he doesn't have anymore [MEDICATION(S)] for pain and the PRN (as needed) Tylenol and Ibuprofen is not helping. Staff called pharmacy to follow-up with refill request, informed medication would be delivered that evening. R33's log dated 08/30/2022 showed same concerns with pain medication again not being available. On 08/30/22 at 08:59 AM, R33 said he had not received his pain medication ([MEDICATION(S)] 50mg) for a couple of days. He then rated his current pain level as 10 on numerical scale from 0-10. At 09:05 AM, observed V4 (Registered Nurse) administer to R33 Ibuprofen 200mg two tablets in place of his scheduled pain medication ([MEDICATION(S)] 50mg) which was unavailable for morning dose administration. V4 said the pain medication was reordered on 08/29/2022 and should've come in. On 08/30/2022 at 3:20 PM, R33 said he isn't always receiving [MEDICATION(S)] two times a day, hasn't received it all on some days, then said the ibuprofen doesn't help his pain. R33 then said he gets upset and feels sad when he does not receive his [MEDICATION(S)] twice everyday. Reviewed R33's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Reviewed R33's medication administration record (MAR) for August 2022 that showed [MEDICATION(S)] sodium gel 1% was not administered at 1700 (5:00 PM) on 08/09 and was not administered at 0900 (9:00 AM) on 08/12, 08/25, and 08/30. MAR showed that R33 was not administered [MEDICATION(S)] 50mg at 0900 on 08/12 and 08/30 and was not administered at 2100 (9:00 PM) on 08/28. MAR also showed R33 was not administered [MEDICATION(S)] 300mg capsule at 0900 and 1300 (1:00 PM) on 08/12. Requested copies of R33's [MEDICATION(S)] controlled substance logs for the last three months. Facility provided logs for June and July 2022 only. Reviewed log with date received of 07/18/2022 that showed R33 only received one dose of his scheduled [MEDICATION(S)] 50mg on 07/26/2022 at 5:00 PM. Reviewed R33's electronic medication administration record for August 2022 that showed R33 is scheduled to receive [MEDICATION(S)] 50mg at 9:00 AM and 9:00 PM daily. Reviewed R33's care plan last revised 07/27/2022 that showed he is at increased risk for alteration in pain/comfort related to recent history of fall with fracture, history of spinal fusion, past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Reviewed R33's pain assessment dated [DATE] at 10:34 that showed R33 has a scheduled pain medication regimen, receives as needed pain medications as well. Assessment also showed that R33 reported having frequent pain in the last five days and rated pain scale at 10 on a numerical scale of 1-10 with moderate intensity. Reviewed facility's undated medication administration policy that showed nurses administer medications according to times documented on the medication administration record (MAR) and medications that are refused or not administered should be documented with reason for missed dose. No documentation found regarding multiple missed doses of R33's pain medications and/or pain gel. 2. On 08/30/22 at 09:50 AM R49 stated she has been waiting on her narcotic pain patch since Friday. R49 stated V5 (Licensed Practical Nurse) paged the doctor about this and has not gotten a response. Observed R49 crying stating I'm just in so much pain. R49 stated she is in so much pain she gets jitters. Observed R49 hunched over to her right side with expressions of pain on her face. R49 stated her pain level has been over 10 consistently. R49 stated her back, arm, hands, and neck are in pain. R49 stated she has had brain and spine surgery. R49 stated she hasn't slept because of her pain, and she is tired. R49 stated the nerves in her body are going crazy because of the pain. R49's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R49's current care plan documents she is at risk for reoccurrence of increased uric acid and flare ups of painful joints related to Gout and at increased risk for alteration in pain/discomfort related to impaired mobility with interventions including: Complete the Pain assessment upon Admission, Re-admission, Quarterly and as needed for new onset of pain; Medications as ordered per physician; Report any changes to physician; Assess and document the frequency and intensity of the pain symptoms. Use the residents verbal reports and staffs clinical judgement for the assessment; Monitor for verbal and nonverbal expressions of pain; Administer analgesic medication as ordered per plan of care; Offer as needed analgesic medication prior to activities of daily living/rehabilitation, wound care etc. and as indicated for pain management. R49's August 2022 Medication Administration Record documents she did not receive her narcotic pain patch scheduled for application topically every 72 hours from 08/07/2022 - 08/10/22, and 08/26/2022 - 08/31/2022. R49's Medication Administration Progress note dated 8/8/2022 05:46 documents narcotic pain patch 25 mcg/hour scheduled every 72 Hour to be applied transdermally for pain was not available. Called pharmacy and was notified it needs signed script. R49's progress notes from 08/26/2022 - 08/31/2022 does not document an attempt to administer her narcotic pain patch nor the status of the medication. R49's Narcotic Pain Patch Pharmacy orders requested from the facility 09/01/2022 was not provided at the time of exiting the survey. On 09/01/22 at10:48 AM V2 (Director of Nursing) stated R49 receives a narcotic patch for pain. V2 stated per R49's medication administration record she did not receive her narcotic pain patch from 08/07/2022 - 08/10/22, and from 08/26/2022 - 08/31/2022. V2 stated R49 received the patch on 08/04/2022 at night and should have received it again on the 08/07/2022. V2 stated R49 should have received her narcotic pain patch during those times. V2 stated the concern with R49 not receiving her scheduled narcotic pain patch would be experiencing pain. V2 stated there was a strong possibility there had been an ongoing issue with obtaining a prescription from the physician. V2 stated there has been a delay in having the physician sign for the prescription and difficulty with contacting the physician. V2 stated the nurse should requested a refill before R49 completely ran out of her narcotic pain patch. The facility's Pain Management Policy reviewed 09/01/2022 states: The facility's mission is to promote resident comfort. The purpose of the policy is to accomplish that mission through an effective pain management program, and providing our residents the means to receive necessary comfort. We will achieve these goals through: o Preventing and minimizing anticipated pain when possible. o Using pain medication judiciously to balance the resident's desired level of pain relief with avoidance of unacceptable adverse consequences. For the purpose of this policy, pain is defined as (whatever the experiencing person says it is, existing whenever the experiencing person says it does).

Based on interviews and records reviewed the facility failed to prevent an incident of staff to resident mental abuse by cutting the call light cord for a resident assessed to require extensive assistance. This affected 1 of 3 resident reviewed for mental abuse. This failure resulted in R8 feeling scared, repeating I want my call light, and becoming anxious. Findings include: R8 is [AGE] years old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's cognitive assessment notes on 5/2/22 she as score of 15, intact. On 6/9/21 at 1:38PM R8 observed in her bed with a bright orange call light string next to her. R8 said she always takes the call light from me. R8 was not able to give more description or details. On 6/10/21 at 9:51AM R8 told the surveyor when they took my call light, I felt scared. R8 said she used the call light to call for help. On 6/9/22 at 1:55PM V1, Administrator, said I was called and told the CNAs cut R8's call light string. I was told the CNAs did not want to cooperate with giving a statement or leaving the facility. V1 said we had to threaten to file charges against them to leave the facility. V1 said she spoke to R8 and she said her call light string had been cut. V1 said I confirmed with the nurses and they said everyone knew it was cut. V1 said on the Friday before this happened we had replaced all the call light strings with a solid orange colored string, when I saw the string after the allegation it had been cut and pieced together in a different color string. V1 said she went to interview R8 and she said she hates those two, but did not give a further statement. V1 said she was told about the allegation by V13, Licensed Practical Nurse (LPN). V1 said her investigation findings was that the CNAs (V3 and V4) did act inappropriately and they were terminated. V1 said we substantiated abuse. On 6/9/22 at 2:08PM V12, Dietary Manager, said he was the manager on duty on 5/15/22. V12 said when V13, LPN, told him about the allegation he called V1. V12 said V1 told him to get statements from V3 and V4 and then they must leave the facility immediately. V12 said he spoke with V3 and V4 but they refused to give their statements. V12 said he went to speak with R8, but she did not speak with him. V12 said the nurse reported that V3 and V4 had been speaking in a loud voice to R8. On 6/9/22 at 2:26PM V13, LPN, said V38 (LPN) told her that the CNAs were being inappropriate with a resident. V13 said she went to check if this was any kind of abuse. V13 said she spoke with V3 and V4 and asked for a statement but they refused to cooperate. V13 said I told them they have to leave and they refused. On 6/10/22 at 2:13PM via phone interview, V38, LPN, said she was assigned to R8 on 5/15/22. V38 said V3, Certified Nursing Assistant (CNA), was R8's assigned CNA. V38 said she had been exchanging words with V3 about the care she expected for R8, including maintaining her head elevated while in the bed because R8 is on oxygen. V38 said she had instructed V3 to not be on the phone while on duty. V38 said she heard V3 say this will be a fisting night. V38 said R8 had kept putting her call light on. V38 said she heard V3 say to R8 dang, you got the light on, I am right here. V38 said she spoke with V3 about the comment made. V38 said she then went to provide care to R8's room mate then she heard R8 repeating I want my call light, I want my call light. V38 said R8 was anxious and worked up. V38 said the call light is important to R8. V38 said she looked and saw that R8's call light string was in pieces, it looked cut, and it was a clean cut. V38 said she was discussing the situation with V3 when V4, CNA, approached. V38 said she told V3 this is abuse and one of the CNAs said to R8 Stop pulling this call light. V38 said she left the room and called the manager, the scheduler, and the administrator. V38 said in the meantime V3 and V4 became more outrageous. V38 said V4 told R8 shut up, you doing too much. V38 said the situation was getting heated, the police had been called. V38 said V3 and V4 slammed a door in the police face. A review of the facility investigation incident date on 5/15/22 notes V3 and V4, both CNAs are staff involved. R8 stated both CNAs cut her call light, spoke to her inappropriately, and handled her inappropriately Agency nurse interviewed and agreed with the resident's statement. Administrator attempted to interview both CNAs and both refused to cooperate with the interview. Witness Resident Form date of incident from R8 states R8 alleged staff cut her call light, was very rude to her on purpose. She does not like the CNAs from Sunday. Review of R8's Functional Status assessment dated [DATE] notes she requires extensive assistance from 2 persons for bed mobility, dressing, toilet use, and personal hygiene. Review of Employee Disciplinary Action Form for V3 and V4 dated 5/19/22 notes both V3 and V4 refused to leave the facility resulting in the facility having to request police assistance to remove them. While leaving the facility V4 made a threatening statement towards the nurse supervisor, threatening to slap her. V3 and V4 were terminated, effective date 5/20/22. The facility Abuse Prevention Policy revised on 3/1/21 notes It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and crime against a resident in the facility.

Based on interviews and records reviewed the facility failed to develop a plan with interventions to prevent or reduce the risk of falling for 2 of 3 residents (R2/R1) reviewed for fall prevention protocols. This failure resulted in R2 falling from the bed being transported to the local hospital and treated for traumatic hemorrhage of the cebrum and R1 having at least 4 subsequent falls in a 2 month time frame. Findings include. Review of R2's admission fall risk review documents a score of 13. A score of 10 or above represents High risk for falls. On 6/9/22 at 10:18 AM V48 (Family) states she stressed to the facility when R2 was admitted that he could not fall because R2 was on blood thinners. V48 states his nurse V6 (Nurse) she was at the facility when it opened and they would not let her stay the night. V48 states V6 called her at 5:30 AM on 4/11/2022. V48 states, she was awakened out of her and sleep and she thought she heard V6 say R2 tried to stand on right leg. V48 states when she got to the facility, R2 was distraught and said I want to get out of here and go home. R2 said they let him fall and he was on the floor for 4 hours in his feces. V48 states she immediately told the nurse that was there and called V6 on the phone and asked why he did not tell her that R2 fell . V48 states V6 stated that is why he called her to tell her. V6 (nurse) documented the following note in R2's electronic medical record: 4/11/22 at 5:51 PM. Resident was observed with his right side lower to the floor and his weak left side and his lower extremities still in bed. Staff immediately lowered resident to the floor on a [NAME] pad and transferred resident back to his bed. On 6/10/22 at 11:01 AM V6 remembers R2. Had a tendency move a lot. V6 states when he went to start medication around 5:00 am he found. R2's legs were in the bed, but his right side of body, head, and right shoulder off bed. His head was pointing downward but didn't touch the floor. V6 states he called wife and she said send R2 to the hospital. V6 states, he notified the doctor and the doctor said send R2 to hospital. V6 states he told the incoming nurse that morning that the doctor said send the resident to the hospital. On 6/9/2022 at 2:05Pm. V5 (LPN) states the wife was angry when she came in that morning. V5 states, she called the provider and told them exactly what the wife had told her, and the provider said send R2 to the hospital V5 (Nurse) charted the following in R2 electronic medical record: 4/11/2022 at 5:51 PM wife at bedside and states her husband said his head was on the floor along with his right side. On 6/17/2022 9:57 V2 (DON) states the definition of a fall is a change in plan, both assisted and unassisted. V2 states, Charting is a legal document. V2 states staff should be charting the facts. R2's nursing progress note dated 4/11/2022 at 7:03 PM documents: Doctor at particular hospital phoned facility. admit diagnosis: Contusion with bleed. Review of hospital records from hospital dated 4/11/2022 documents the following: Visit Diagnosis: Fall, initial encounter (primary). Traumatic hemorrhage of cerebrum without loss of consciousness, unspecified laterality, initial encounter. History of present illness: This is a [AGE] year male with PMH, of MI, CHF, [CONDITION(S)] with residual L sided weakness & [CONDITION(S)], [CONDITION(S)], CAD, DM, [CONDITION(S)], afib on [MEDICATION(S)] presents from Nursing home after a fall from his bed. Patient, initially complained of headache. Patient was taken to an [hospital] where Head CT was done showed petechial hemorrhage. Patient transferred to [hospital 2] for further work up of hemorrhage. NUS consulted d/t IPH. Page 16: Documents: R2 was admitted to [hospital 2] on 4/11/22 from [Hospital 1] following unwitnessed fall at Skilled nursing facility, found to have acute traumatic R frontal IPH. Page 36 Documents the following: Recommendations: Right frontal IPH, likely secondary to trauma while on anticoagulation. R1 admitted to the facility on [DATE]. R1's Fall risk review dated 3/4/22 documents R2 as a high risk for fall with score of 14. R1 progress notes documents the following: 3/3/2022 at 8:25 pm by V6 (nurse): Resident called the staff stated She wanted to use the bathroom but walk by herself to the bathroom. Staff informed resident that It is not safe for her to walk by herself that we can help her with the assistance of a wheelchair. Resident slid to the floor from her bed with staff assisting her to the floor. Complete body and pain assessment initiated with no injury noted resident refused to be transferred back to her bed with staff assistance stated, she preferred to sleep on the floor. Family member called with no response. MD made aware. Requested from facility all falls reports, investigation, root-cause-analysis and nothing was given for the 3/3/2022 fall. 3/4/2022 at 9:15 PM V6 (nurse): Resident was observed sitting by the side of her bed. Complete body and pain assessment initiated with no injury noted, skin w/d touch not c/o pain, verbalized at this time. Resident was immediately transferred back to her bed. MD called with no new order and family member notified. Review or falls and Accident/incident resident management review (FARMR) for 3/4/22 and dated 3/7/22 does not document previous incident and there is nothing listed that may have contributed to the accident. No root cause documented. The interventions documented on this form bed in lowest position, floor mat, ask to wait for assistance. This FARMR form state care plan reviewed/updated. Care plan does not document bed in low position or floor mat. 4/2/2022 at 7:10 AM V30 (LPN): Resident observed in bed asleep at 12:30 AM Rounds made @1:50 AM, observed sitting on the floor. When resident questioned how she ended up on the floor, Resident stated. I was on the bed and I reached for my blanket and I fell . Full body check done. No apparent injuries observed. Assisted of floor with hoyer lift back into bed. Encourage resident to ring call light and ask staff for assistance. Floor mat place on side of bed. FARMR assessment dated [DATE] for 4/2/22 incident. There is no root cause. Contributing factors are her diagnoses of Cognitive communication deficit and Bells Palsy. This FARMR documents to decrease future falls encourage to use call light and that Care plan was reviewed/updated. Review of resident's appears that encourage to use call light for assistance was there since 3/10/22. There is no apparent new interventions. 4/23/2022 at 6:50 AM V30 (LPN): Resident seen in bed awake at 4:00 AM during rounds. Rounds made 5:50AM, observed sitting on the floor mat. When writer questioned resident, how she ended up on the floor, the resident stated, I was trying to walk to the washroom. The FARMR form dated 4/24/2022 for 4/23/2022 incident documents: care plan reviewed/updated. Call light education. Floor mat to the right of bedside. Contributing factors are diagnoses of Cognitive communication deficit and not utilizing staff assistance. This FARMR documents to decrease future falls: call light education, Floor mat to right of the bedside. Care plan is not updated with any new interventions. On 6/17/2022 9:57 V2 (DON) states the definition of a fall is a change in plan, both assisted and unassisted. V2 states, Charting is a legal document. V2 states staff should be charting the facts. On 6/10/22 at 1:30 PM V2 (DON) states there should be a post fall review of records and update care plan, put interventions in place. V2 states they do and investigation. Not called a root cause analysis. V2 states there should be documentation on care plan as to falls. Interventions should be on the care plan. Do post fall assessment. Review what is charted and talk to the staff. Facility's Fall risk policy documents the following: Fall prevention B. Implement 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 factor identified. IV implement additional interventions to reduce risk.

Based on interview and record review, the facility failed to provide wound care treatments daily as ordered, failed to notify the wound care physician when treatments were not performed as ordered and failed to document that wound care treatments were performed on a daily basis which affected one resident (R289) of five residents reviewed for pressure sores in a sample of 32. These failures contributed to the deterioration of R289's sacral wound. Findings include: R289's Admission Record documents that he was admitted to the facility on [DATE] with a sacral pressure sore. R289's Medical [DIAGNOSES REDACTED]. The wound measurements for R289's sacral pressure sore were as follows: 7/18/19: 5.6 cm (centimeters) length (L) by 5.2 cm width (W) by 0.8 cm depth (D). Hydrogel was ordered for wound treatment to be done daily. 8/12/19: 8 cm (L) by 9 cm (W) by 1.2 cm (D). Wound treatment was changed to cleanse wound with Dakins to be done daily and apply Dakins soaked gauze to sacrum. The wound increased in size for length, width and depth. 8/22/19: 9 cm (L) by 9 cm (W) by 0.8 cm (D). The length of the wound increased and now there is slough. The previous wound treatment on 8/15/19 did not indicate that R289's sacral wound had slough. 9/5/19: 15.5 cm (L) by 11 cm (W) by 1.2 cm (D). R289's sacral wound deteriorated in length, width and depth. It is documented in this assessment that R289's sacral wound deteriorated. 9/12/19: 8 cm (L) by 15 cm (W) by 0.9 (D). The width of the sacral pressure sore increased with undermining now present. This wound assessment documents a change in wound treatment to cleanse wound with Dakins and [MEDICATION NAME] to be done daily. 9/27/19: 14.5 cm (L) by 9.3 cm (W) by 0.6 cm (D). The length of the wound increased. Wound treatment was changed to Calcium Alginate to be done daily. During this visit, a wound debridement was performed. 10/4/19: 14.5 cm (L) by 9.3 cm (W) by 0.6 cm (D). 10/11/19: 14.5 cm (L) by 9.3 cm (W) by 0.6 cm (D). 10/18/19: 15 cm (L) by 18 cm (W) by 0.5 cm (D). The length and width of the wound increased. Wound treatment was changed to Dakins to be done daily according to the weekly wound rounds document. 10/25/19: 16.5 cm (L) by 9 cm (W) by 0.5 cm (D). The length of the wound increased. Wound treatment was changed to Dakins with Calcium Alginate to be done daily according to the weekly wound rounds document. R289's July 2019 Treatment Administration Record (TAR) does not document that Hydrogel wound care treatments to the sacrum were performed daily as ordered for the following dates: 7/19, 7/20, 7/21, 7/22, 7/23, 7/24 and 7/26. There is no documentation in R289's progress notes that V23 (Wound Care Physician) was notified regarding the wound care treatments that were not performed for these dates. R289's wound care treatment was changed to Dakins solution on 8/8/19. R289's August 2019 TAR documents that Hydrogel treatments to R289's sacrum were performed on 8/9, 8/10, 8/11, 8/12, 8/13, 8/14, 8/18, 8/20, 8/24 and 8/25 despite the change in order to Dakins solution. It is also documented that the facility performed Dakins wound care treatments in addition to Hydrogel treatments on 8/12, 8/13, 8/14, 8/18, 8/20, 8/24 and 8/25. There is no documentation that wound care treatments were performed on R289's sacral pressure sore for the following dates: 8/15, 8/16, 8/17, 8/19, 8/21, 8/22, 8/23, 8/26, 8/27 and 8/29. There is no documentation in R289's progress notes that V23 was notified regarding the wound care treatments that were not performed. R289's September 2019 TAR does not have documentation that wound care treatments were performed on R289's sacral pressure sore for the following dates: 9/3, 9/5, 9/6, 9/10, 9/11, 9/16, 9/19, 9/20 and 9/27. There is no documentation in R289's progress notes that V23 was notified regarding the wound care treatments that were not performed. On 10/18/19, R289's sacral wound care treatment was changed to Dakins solution to be done daily. R289's October 2019 TAR documents that there were no sacral wound care treatments performed on the following dates: 10/3, 10/4, 10/8, 10/10, 10/13, 10/17, 10/21, 10/22, 10/24, 10/26, 10/28 and 10/30. There is no documentation in R289's progress notes that V23 was notified regarding the wound care treatments that were not performed. There is no Care Plan that documents that R289 is resistive to wound care. On 10/7/20 at 12:15pm, V5 (Wound Care Nurse) stated, Medications are applied during wound care treatments. So because wound care treatments are procedures, they need to be documented and signed out. There is space on the TAR to document if a resident refuses treatment or is out of the building. If they don't sign out a wound treatment, I can't necessarily say that it was done. Yes, the wound can worsen in size and character if wound treatments are not performed as ordered. It is possible that a resident can [MEDICAL CONDITION] in the wound if wound treatments are not done as ordered. V5 confirmed that she looked at R289's TAR's for July 2019 through October 2019 and that there were multiple blank spaces where wound care treatments should have been signed out. On 10/7/20 at 5:07pm, V23 (Wound Care Physician) stated, In general, it was an ongoing issue with that facility. I had multiple conversations on multiple levels with the Director of Nursing, Administration and multiple nursing staff regarding trying to get them to do what I was asking them to do in order to prevent the pressure sores from deteriorating. During my rounds, I was noticing more acquired wounds which is a red flag and questionable whether my orders were being followed. The turning, the offloading, the treatments. If not performing the wound treatments as ordered, you definitely could develop an infection in the wound. Yes, can [MEDICAL CONDITION] if wound dressings are not changed or treatment is not followed. But when I see an increase in acquired wounds, it's definitely concerning. R289's hospital record dated 10/30/19 documents that R289 was admitted to a local hospital. Impression and Plan: Diagnosis - Acute septic shock, UTI (urinary tract infection), back and sacral pressure ulcers. A facility policy dated 4/10/15 and titled, Physician order [REDACTED]. A facility policy dated 5/19/17 and titled, Wound Cleansing and Dressings documents: Policy: It is the policy of the facility to cleanse all wounds to clear exudates, bacterial contamination, and debris from the wound bed. Optimal wound healing cannot proceed until inflammation-producing substances are removed from the wound bed. Wound cleaning is completed as indicated in the physician's orders [REDACTED]. 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. III. Dressing changes 2. The physician's orders [REDACTED]. B. Apply new dressing after cleansing the wound per physician order. V. Documentation A. Documentation of the dressing change is completed on the Treatment Administration Record (TAR).

Based on observation, interview and record review the facility failed to monitor and supervise a cognitively impaired resident by leaving the automatic doors at the facility entrance unlocked and unattended, and failed to stop the resident from exiting the front doors unsupervised. This failure affected 2 of 3 residents (R3, R8) reviewed for accidents and incidents in a total sample of 11. This failure resulted in R3, a cognitively impaired resident, leaving out of the facility on foot and walking towards a 6 lane intersection sometime between 9:00pm and 10:45pm. R3 fell down a parking ramp near a garage adjacent to the facility and struck the right side of the face. R3 was found by a non-facility staff person, the paramedics were called and R3 was transported to the hospital for evaluation and treatment. This was identified as an immediate jeopardy on 11/9/2018 and it was removed on 12/07/2018. On 12/5/18 at 2:31pm V1 (Administrator) and V2 (DON) were notified of an immediate jeopardy with concerns related to safety and supervision of cognitively impaired residents. Findings Include: The Face sheet documents R3 is a [AGE] year old admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The current Care Plan dated 11/1/18 documents R3 is at risk for falls and has impaired decision making, poor logic, and poor ability to understand cause and effect. The Minimum Data Set ((MDS) dated [DATE] documents that R3 has a Brief Interview for Mental Status (BIMS) Score of 7 indicating that the resident has severe cognitive impairment. The Physician order [REDACTED]. The Community Survival Skill assessment dated [DATE] documents R3 requires supervision while out in the community and is not a candidate for independent pass privileges. The Elopement Risk Review dated 11/1/18 documents R3 is not an elopement risk at this time. The Incident Report dated 11/9/18 documents that R3 was displaying exit seeking behaviors after being made aware by family that they would be taking the resident out on pass. The police report dated 11/9/18 documents R3 was dressed in cold weather attire to leave with a family member. R3 left the faciity on foot before the family member arrived on scene. R3 walked to a medical office building adjacent to the facility on a 6 lane, high traffic intersection. R3 fell down a parking ramp near a garage adjacent to the facility and struck the right side of the face. R3 fell . R3 was found by a community person and transported to the emergency room before it was known that R3 was a resident of the facility. 911 was called at 11:13 PM, and the police notified the facility at 11:37 PM that the resident was found outside and was taken to a nearby hospital. On 12/04/18 at 10:32am V2, Director of Nursing (DON) stated, The only exiting seeking behavior the resident showed was refusing to remove the coat and hat. R3 had the coat on all day and was waiting to go home. R3 had an urgency of wanting to go home after being out on pass with family and would continue to ask to go home with family. All of the staff working that day saw the resident with the coat on. R3 was able to put the coat on without assistance and only needed help with the zipper. When the CNA (certified nurse aide) went to do night care that day the resident refused and kept saying I'm going home. R3 can walk with 1 person physical assist but is able to ambulate alone; I'm just not sure for how long. The only intervention in place was redirection. R3 never wandered or tried to exit the facility. The resident's room was located on the North wing of the first floor in the middle of the hallway. The resident had to pass the Nurse's Station when exiting through the front door. None of the staff saw the resident leave the building. The front doors are always locked by the receptionist at 8pm when the receptionist leaves for the day. The only camera we have is the one outside above the door but we did not review the camera footage. All staff enters and exits through the front door. The hospital record dated 11/10/18 documents R3 presented to the emergency room after being found wandering outside. R3 reportedly escaped from the nursing home for no more than a 12 hour period. A bystander called emergency medical services after witnessing R3 fall and strike the right side of R3's face. R3 complained of facial pain on arrival. R3 was given a baseline neurological exam and there were no deficits noted. Computed tomography (CT) scan of the head was negative for fractures or brain bleeds but showed some bruising of the right facial bone under the eye. On 11/16/18 at 12:23 PM, V2 stated, The family has to check the resident out with the nurse before leaving the building. The sign out book is left at the receptionist desk, even after hours, and family should see the nurse and then sign a resident in and out before leaving the facility. That didn't happen here. On 11/16/18 at 2:12 PM, V2 stated Some of the residents watch staff leave the building and they know how to use the switch above the door to get in and out of the building. Also staff enters and exits through the front door and should have another staff member lock the door behind them at night. On 11/16/18 at 1:49 PM, V4 (LPN) stated, I was on break at 9:30 PM - 10:00 PM and saw a car waiting in the front. I assumed it was R3's family coming to pick the resident up. I didn't see R3 in the car, and I didn't see R3 leave the building. On 11/16/18 at 1:59 PM, V5 (Manager on duty) stated, When I left that night, I saw the family's truck outside the facility. I assumed they were picking up R3. On 11/16/18 at 2:30 PM, V6 (LPN) stated, I work the night shift (11 PM - 7 AM) so when I came in, the evening nurse told me R3 was supposed to go out on pass with family but R3 was missing. The evening nurse checked the bathroom but R3 was not there. R3's family member was here too. They started looking around upstairs in other rooms. I went downstairs to clock-in and I did not see R3 in the basement. We then went to look in the back of the facility to see if the resident got out that way, but R3 wasn't there. That's when the Police came and asked if we were missing anyone and we told them 'Yes'. The Police said R3 had been taken to the emergency room . The family member told us R3 had never left the facility with family. On 11/16/18 at 3:00 PM, V2 stated, On the night of (MONTH) 9th, there were three call offs so the manager on duty and myself stayed until about 9:00 PM that night to help out. R3 was still here waiting on family when I left. On 11/16/18 at 3:36 PM, V7 (CNA) stated, R3's family member came around 10:00 PM and went into R3's room. The family member came out and said, 'Where's R3?' I told the family member that R3 had left with a different family member that was visiting the resident that day. The family member told me, 'There's no way because the other family member is at home right now. I have been trying to get a ride all day for R3 so I just came now.' I told the nurse, and we all started looking for R3. On 11/20/18 at 2:47 PM, V13 (Nurse Practitioner) stated, R3 can't take care of self so R3 should not be out in the community alone. R3's cognition is impaired. I would say R3 is alert and oriented to 1-2 (self and place) depending on the day. On 11/20/18 at 3:03 PM V2 stated, No staff told me they saw R3 with a family member. We just all assumed the resident left with family because of the family's car being in the parking lot and staff seeing the family member carry out R3's clothing and incontinence briefs. On 11/21/18 at 11:00 AM, V9 (LPN caring for R3) stated, I never saw R3 leave the building with a family member. I just thought that's where R3 went because R3's family member was here all day with R3. I didn't hear any alarms go off that night. The Immediacy includes R8; this resident is ambulatory and is currently residing on the first floor and the MDS documents that R8 has moderate cognitive impairment. On 11/16/18 at 9:00 AM upon entering the facility it was noted that there were 2 sets of automatic double doors that enters into the lobby and leads to the first floor nursing unit. When exiting the lobby and leaving the facility both sets of doors has an ON/OFF switch that measures approximately 67 inches from the floor. There are no alarms or keypads attached to the automatic doors leaving the facility. Once the double doors are switched into ON Mode, they will automatically open. On 11/20/18 at 9:55 AM, V1 stated, We put in an alarm on the front door over the weekend. If someone tries to leave the building after the door is locked, an alarm will sound. The building has never had this before. Now all visitors will sign out with the Nurse. On 11/20/18 at 11:08 AM, V2 stated, The front door is locked at 8:00 PM by the receptionist. After that the first floor staff is responsible for locking the doors after they open them to let someone in or out. There is a sign in and out book at the receptionist desk. After hours, the nurse should be seen to sign residents out before a resident leaves the facility. The nurse is always seen to make sure the resident has all needed medications. On 11/20/18 at 1:40pm an environmental tour was done to check all doors exiting the facility. There are 4 doors located on the first floor that can be used to exit the building. The door on the south end of the building and the back of the building has a key pad and requires a code to be entered before the door can be opened. The door on the North end of the building and a door in the dining room leading to the patio can be opened but an alarm will sound until a code is entered into the key pad. The resident is believed to have left through the 2 sets of automatic double doors in the front of the building because no alarms were heard during the time the resident left the facility. On 11/28/18 at 9:48 AM, V1 demonstrated the front door alarm system to the surveyor. After hours, a code is entered into the key pad, then a switch above the door is turned to night mode which allows the door to remain locked preventing anyone from entering or exiting the building. Once the door is taken off of night mode the door will open, but an alarm sounds above the door when someone attempts to exit the building. V1 stated, Only this alarm sounds. No other notifications are sent anywhere else in the facility. We never looked at the camera footage, everything erases in 72 hours. By the time the surveyors entered the facility, the footage would have been deleted. On 11/28/18 at 2:30PM, V20 (Receptionist) stated, The second door that leads to the outside does have a lock on it, but we don't need to use it anymore because of the new alarm system. On 12/6/18 at 11:57AM, V20 demonstrated how the double, automatic, front doors remain locked with the key even when switch is placed in night mode. V20 stated, The receptionist or someone now stays at the desk 24 hours. The key is key at the reception desk at all times. The cameras are also being monitored now at all time. On 12/6/18 at 12:10PM, V2 stated, Someone has been hired for the night receptionist position already, but still needs to go through orientation. The doors will still lock at 8 pm when visiting hours are over even though we will have someone sitting at the desk 24 hours. On 12/6/18 at 12:21PM, V17 (Regional Operations Manager) stated, The switch is now removed. The door is only locked and alarmed with the key. On 12/6/18 at 2:15PM, V1 stated, We had a company come out and check to see if all the cameras and door alarms were working. They also installed the switch box for the door that locks with a key now. They put a feature in where once the door is locked with the key, the switches are disabled. On 12/6/18 between 1:55PM and 2:06PM, V18 (LPN) and V19 (CNA) were interviewed to verify that education and in-services were completed on the new processes. On 12/7/18 at 1:10PM an abatement was provided by the facility documenting new systems in place. The abatement plan provided by the facility is as follows: OAKLAWN RESPIRATORY NURSING & REHAB CENTER Abatement Plan THESE ARE THE STEPS THAT THE FACILITY TOOK TO IMMEDIATELY REMOVE THIS ALLEGED DEFICIENT PRACTICE. 1. The DON/designee initiated in-servicing on supervision of residents prior to going out on pass, this in-servicing will be on-going. Prior, the pass policy indicated that a sign out was sufficient, however now Oak Lawn Respiratory and Rehab as now implemented a HOT PINK SHEET that shows someone's ability to go out on pass, this was not in place prior. Also we have implemented 24/7 monitoring of all door to ensure residents and family's correct use of pass. The in-servicing on this will be on-going every quarter and as needed. New hires will be in-serviced upon employment by the DON/designee. The DON/designee will conduct an audit of the in-service using an employee in-service log form. 2. Social service re-assessed all residents for their potential for risk for elopement on 11/14/18. 3. If and when a resident has been identified as having exit seeking behavior Oak Lawn Respiratory and Rehabilitation will place interventions as needed, redirect, use wanderguard, identified resident's picture will be placed at front desk as well as each nurse's station, family and MD will be notified and update care plan. 4. Residents who are identified to be an elopement risk will have a wander guard in place (currently no residents are at risk) and can be identified via a picture. The photos of residents who will be at risk for elopement will be located at each nurse station and at the receptionist desk. Care plans will be updated once assessed. 5. Social service will complete an elopement risk assessment upon admission then provide a wander guard as needed, this will be for any residents who have been identified as a risk. Currently we do not have anyone in house. 6. The DON/designee in-serviced on the proper protocol for residents with exit seeking behavior. The DON/designee will in-service quarterly. New employees will be in-serviced upon hire The DON/designee will conduct an audit of the in-service using an employee in-service log form. 7. Main switch has been removed and replaced with a key. This key will be monitored by the 24 hour receptionist. This key will ONLY be in the hands of the person monitoring the main desk. The key's placement is at the front desk, only Maintenance Director and Administrator have copies. 8. The door alarms are checked daily by the maintenance department/designee. The door alarm checks are logged daily using the Daily Alarm Check Log form. The door alarm log will be checked by the administrator/designee once weekly. The Administrator/designee will audit the door alarm log weekly. The Administrator/designee will provide a signature on each log to indicate that it has been reviewed. 9. The DON/designee will initiate in-servicing on 12/5/18 on the Facility Elopement Policy and Procedure. In-servicing will be completed on 12/6/18. In-servicing will be done quarterly by the DON/designee or as needed. New employees will be in-serviced upon hire. The DON/Designee will audit the in-services using an employee in-service log form. 10. New alarm at the front entrance door was installed on 11/19/18 and in the interim the front door was monitored continually. Key alarm was installed on 12/5/18. 11. Elopement policy was changed to reflect more recognition of at risk residents, meaning environmental precautions have been set in place to increase supervision of exits. Elopement drills will occur 1x monthly for 6 months. This will be monitored by the Administrator using a QA tool. 12. A Department Head/designee will monitored the front doors for 24hr daily starting 12/5/18. The Department Heads/designee will monitor each door via the camera's that are located at the front desk. The monitoring will be on-going by the Department Heads/designee to ensure safety. Receptionist is seated at front desk from 8:00 am to 8:00 pm, at 8:00pm the N[NAME] Concierge will be expected to monitor the front desk, main entrance and exit cameras (monitor located at the desk). This position is from 8:00 pm to 8:00 am. 13. QA Meeting was held on 12/7/16, medical director included as well as Department Heads, reviewed Removal Plan and the changes made to Pass policy (new form, front desk responsibilities, N[NAME] Concierge, and front desk coverage 24/7) and reviewed the Elopement Policy and the environmental factors that can play a role in safety of residents, visitors and employees. 14. In-service details: - Exit Seeking behaviors: interventions as needed, redirect, use wanderguard, identified resident's picture will be placed at front desk as well as each nurse's station, family and MD will be notified and update care plan. - Elopement: recognition of at risk residents, meaning environmental precautions have been set in place to increase supervision of exits. - Door Monitoring: 24/7 monitoring of the door no exceptions. - Pass Policy: Implement actual HOT PINK PASSES rather than sign out. On 12/7/18 the facility was notified the abatement plan was accepted at 3:55PM.

Based on observation, interviews and records reviewed facility failed to perform comprehensive fall assessment and initiate immediate interventions to prevent falls on a newly admitted high risk resident (R3). This failure resulted in R3 sustaining a fall incident with severe head injuries requiring hospital and surgical interventions. Facility also failed to implement care planned fall prevention interventions on 6 high risk for falls residents (R13, R7, R10, R12, R5 and R8). This applies to 7 of 13 residents reviewed for falls in the sample of 13. R3 admitted to facility 01/15/15 from the hospital with [DIAGNOSES REDACTED]. R3's 01/16/15 fall incident report includes: On 12/08/14, R3 had a occipital craniotomy, tumor resection for cerebral mass with obstructive [DIAGNOSES REDACTED] complicated by hemorrhage and on 12/15/14, R3 had a VP shunt placement. R3's 01/07/15 hospital discharge records (that accompanied R3 to facility on admission), include: - 01/14/15 and 01/15/15 "Transition of care report's" document "High Fall Risk", awake and alert but forgetful at times. Ambulates in room with assistance. - 01/15/15 "Nursing Summary Patient Data Report," include High Risk for falls, use gait belt, bed/chair exit alarms, fall precaution signage posted and hourly rounding implemented. R3 has history of falls within past 3 months, fell during previous hospitalization [DATE]. - Nursing progress notes of intermittent confusion, restlessness and forgetfulness. - physician progress notes [REDACTED]. 01/13/15, intermittently confused and hallucinating. Personality disorder possibly related to premorbid condition or somehow related to brain metastases (mets), and [DIAGNOSES REDACTED]. R3 has stage 4 squamous cell [DIAGNOSES REDACTED] of the lung with met's to the brain. Cerebellar 4th ventricular skull tumor post craniectomy and VP shunt in 12/2014. On 01/12/15 drainage noted from surgical incision and Cat Scan of brain completed. R3's 01/12/15 Cat Scan of brain showed fluid collection at suboccipital craniectomy site with focus of gas. - 12/30/14 rehabilitation conference summary document: very impulsive, poor safety awareness, requires supervision, cues and a sitter. R3's 01/15/15 "Facility admission/re-admission department notification assessment," states, high risk for falls, needs a low bed, placement as close to nursing station as possible, frequent checks and falling star. R3's 01/15/15 Fall assessment include high risk for falls but fails to include recommendations for individualized fall precaution interventions. R3's 01/15/15 admission nursing assessment includes; requires extensive assistance with ambulation, has unsteady gait. Requires extensive assistance with activities of daily living (ADL's). R3's "Admission Care Plan," includes Fall Risk, use mobility alarm and floor mats. R3's 01/16/15 fall incident report includes: On 01/16/15 at approximately 2:35AM, a loud noise heard from R3's room. R3's room mate in hall stating her room mate was on the floor. R3 found lying face down on the floor in the middle of her room. R3 was initially verbally responding to questions but the became unresponsive. 911 called and R3 sent to the hospital. R3 admitted to hospital with [DIAGNOSES REDACTED]. R3's 01/16/15 hospital records include: R3 admitted to emergency room after being found down and unresponsive at nursing facility. Upon admit to emergency department, R3 found to have a large subdural hematoma with a midline shift, new parenchymal bleeds compared to prior cat scan (01/12/15). R3 was unresponsive with unequal pupils that were unreactive to light and positive babinski. R3 was sent from emergency department directly to surgery for [REDACTED]. Post surgery, R3 never re-gained consciousness and required artificial life support until 01/21/15 expiration. During staff interviews 01/10/15 and 01/11/15, the following information obtained: - During 02/10/15, 9:30AM telephone interview, E4 (nurse), stated, R3 was admitted to facility 01/15/15 on the evening shift. E4 completed R3's admission assessments and assessed R3 to be delusional. E4 also said, during report from the hospital nurse, E4 was told R3 was a fall risk. E4 said if a resident is a fall risk, facility staff monitor the resident every 15 minutes, keep the resident close to nursing station, apply bed alarms, floor mats and keep call light in reach of resident. E4 also said bed alarms are usually kept in the medication rooms but on 01/15/15, there were no alarms available for R3. E4 said "I'm sure I notified the night shift nurse that R3 was a fall risk and I believe I documented such in facilities 24 hour nurse report." E4 also stated that bed alarms are locked up in the restorative office and not accessible on evening and night shifts. Facilities 01/15/15, first floor 24 hour nurses report does not include documentation of R3 being a fall risk. - During 02/10/15, 3:05PM telephone interview, E10 (nurse aide), stated she was R3's 01/15/15 evening shift (3PM- 11PM), nurse aide. E10 also stated R3 was not on fall precautions but when toileted was "woozy." E10 also stated, R3 had no bed alarms, floor mats or falling star postings in place 01/15/15. E10 said residents that are fall risks are provided bed bolsters, chair and bed alarms and provided constant supervision. - During 02/11/15, 11:29AM telephone interview, E13 (nurse), stated, E13 was R3's 01/15/15 11PM through 01/16/15 7AM, night shift nurse. E13 said she received a brief report regarding R3 being a possible fall risk. R3 was alert and responsive and did not have any bed alarms or floor mats in place at the time of her fall incident. E13 validated information documented on R3's 01/16/15 fall incident report. E13 stated, on 01/15/15 there were no bed alarms or floor mats available to apply on R3. E13 also stated "I was terminated from facility for failing to contact management in an attempt to obtain bed alarm and floor mat for R3 prior to the fall incident. E13's personal file include documentation stating, on 01/21/15 E13 was placed on a 3 day suspension pending investigation of a residents fall incident. E13 was then terminated for failing to follow facility documentation protocol. - During 02/10/15, 2:45pm telephone interview, E11 (nurse aide), said, on 01/15/15 night shift, R3 was not using any bed alarms, fall risk postings or floor mats. E11 also said that she was unaware that R3 was a fall risk. During 02/10/15, 10:15AM interview, E5 (restorative nurse), stated when a resident is identified high risk for falls, nursing staff are to utilize the "Fall Prevention Kits", kept in the medication rooms. E5 said the fall prevention kits include sensor pad alarms, batteries, tab alarms, non-skid pads, a use call light sign and a "Falling Star" symbol. E5 also stated there is a fall prevention kit on the first floor and the second floor in the medication rooms. E5 said these kits are checked and refilled daily on day shift by restorative staff. On 02/10/15 at 10:20AM, one fall prevention kit observed in each of the 2 medication rooms. The fall prevention kits observed to include one sensor pad alarm, one tab alarm, batteries, one use your call light posting and star shaped symbols. No floor mats observed in the medication room. Facilities 01/15/15 Admission Report documents 4 residents admitted . During 02/10/15 individual interviews E12, E8, E18 and E7 (nurses), all stated if a resident is identified as a high risk for falls, staff are to apply bed alarms, low bed, floor mats, falling star posting at bedside and increased monitoring with frequent rounding's. Licensed Practical Nurses E6, E8 and E12 were not aware of facility's "Fall Prevention Kit's." Facilities "Falling Star Program" policy and procedure include: - Residents are assessed on admission to facility for fall risk. - Residents assessed to be fall risk, are to have a "falling star" symbol placed by the residents room, on their name plate and on the residents mobility device. - A plan of care will be initiated utilizing fall prevention strategies to reduce or eliminate each residents fall risk. - Safety movement devices will be used as an integral tool to prevent unassisted ambulation. Facilities "Falling star program" protocol does not list the specific fall prevention strategies staff are to initiate. During 02/11/15, 10:20AM telephone interview, Z1 (R3's attending physician), stated he was unaware of facilities fall precaution protocols other than using low beds and sometimes side rails on beds. On 02/10/15, between 10:15AM and 11:55AM, R10, R5, R13, R8, R12 and R7 (facility identified high risk for fall residents), observed as follows: - R10 up in a wheel chair in his room, using oxygen per nasal cannula that was tautly extended from head of bed to dresser beyond the foot of his bed. No staff were present in the room with R10. R10 had a sensor pad alarm on his wheel chair but not connected to alarm sounding box. No alarm box present on R10's mobility device (wheel chair). R10 had a falling star symbol over the head of his bed. R10's 01/16/15 fall assessment includes high risk for falls. R10's current fall care plan documents intervention to use sensor alarms in bed and chair at all times. R10's [DIAGNOSES REDACTED]. R10's 01/10/15 MDS include unable to perform brief interview mental status assessment, requires extensive assistance with bed mobility, transfers, ambulation, dressing, toileting and hygiene. R10 had 2 recent unwitnessed fall incidents in his room: - 11/13/14 at 3:45AM, found on the floor. R10 was attempting to sit on the side of his bed without staff assistance. - 01/16/15 at 9:40AM, found on the floor at bedside with skin tears to the face and anterior left lower leg. R10 was confused. R10's 01/16/15 incident report does not document bed alarms were in place at the time of the fall. R10 was receiving anti-coagulants at the time of his fall. R10 was readmitted to facility from hospital 01/15/15, same day as R3 admitted . - R5 in bed with a falling star symbol over head of bed and without any bed alarms in place. E7 present at time of this observation and E7 stated R5 should have bed alarms in place at all times. R5's 01/15/15 fall assessment includes high risk for falls. R5's 01/15/15 MDS include severe cognitive impairment and requires extensive assistance with bed mobility, transfers, ambulation, toileting, dressing and hygiene. R5's current fall care plan include need to utilize bed alarms. On 12/05/14 at 8:33AM, R5 had an un-witnessed fall from bed. R5's 12/05/14 incident report includes R5 is only oriented to self, confused and with memory impairments. - R13 in bed, turning himself over toward side rails without any bed alarms in place. R13's 02/08/15 fall assessment documents high risk for falls. R13's 01/16/15 minimum data set assessment (MDS), include severe cognitive deficits, is totally dependent and requires extensive assistance with bed mobility, dressing, toileting, transfers, hygiene and ambulation. R13's current fall care plan includes interventions to utilize bed alarms. - R8 in bed awake, alert and non-verbal. R8 had no falling star symbol or use call light sign posted. R8 had no floor mats or bed alarms in place. E9 (nurse aide), present at time of this observation and E9 stated R8 should have bed alarms and floor mats. R8's 02/08/15 fall assessment documents not a high risk for falls but R8's current care plan and facilities high risk for fall list, state R8 is high risk for falls. R8's 01/06/15 MDS, include severe cognitive deficits, is totally dependent and requires extensive assistance with bed mobility, dressing, toileting, transfer, hygiene and ambulation. - R12 in bed pulling himself up and over onto his right side rail. R12 had no bed alarms in place. R12 had a falling star symbol over head of bed. R12's 01/11/15 fall assessment document high risk for falls and inability to stand independently. R12's 02/04/15 MDS document severe cognitive deficits, requires extensive assistance with bed mobility, transfers, toileting, ambulation, dressing and hygiene. R12's current fall care plan include requires sensor pad alarms to the bed. - R7 in bed without any bed alarms or floor mats present. E9 stated R7 should have bed alarms in place. R7 identified by facility on high risk for fall list.

Based on observation, record review and interview the facility failed to provide adequate preventive measurements, identify the presence of pressure ulcers, and obtain treatment for [REDACTED]. As a result of these failures, R7 developed four pressure ulcers, that were not treated by staff. Findings include: On 7/25/2011 between 10am and 11am, R7 was observed in bed. R7 was positioned laying on the back part of the body. The surveyor noted a fowl odor in the area of R7's bed at the time. R7 had a [MEDICAL CONDITION] and was receiving oxygen at the time. E9 (assistant director of nursing/ADON) accompanied the surveyor at the time and was asked if R7 had any pressure sores. E9 asked, E10 (treatment nurse) if R7 had any pressure sores on the back side. E10 reported no treatments for any pressure sores on R7's buttocks. The surveyor asked to look at R7's body without the covers on R7. R7 had multiple blackened areas on the right and left feet, including areas on the big toes. On 7/26/2011 at 11:50 am, R7's buttocks area was observed with the assistance of E15 (nurse) and E16 (restorative aide). Upon entering the room, the surveyor noted the fowl odor. R7's bilateral heel protectors were located around the ankle areas, instead of the foot. R7 was observed with multiple open areas near and on coccyx area. R7's incontinence brief had a yellowish-brown substance, with moderate about of blood. The surveyor asked E15, who was in-charge of R7's care, if she knew about the areas. E15 stated, "No". The surveyor asked, if the E10 (treatment nurse) could come to examine R7. At 12:15pm, E10 entered the room and examined R7. E10 stated, the only physician's orders [REDACTED]. R7 was observed lying on a regular mattress. E10 stated she would order a low air mattress for the resident. R7's order for July 15, 2011 at 2pm, documented, "Cleanse left great toe with NSS (normal saline solution), dry and apply [MEDICATION NAME] daily. Have heel protectors on daily." -R7's physician's orders [REDACTED]. No discharge order for this treatment was documented in R7's medical record. The surveyor obtained a copy of this original order. R7's initial resident assessment instrument after a thirty day hospitalization had a references date of 6/17/2011. This assessment indicated R7 had no presence of any type of ulcers. On 7/26/2011 at 2pm, E10 provided the surveyor with the evaluation of R7's open wounds, physician's orders [REDACTED]. E10 told the surveyor R7's body was examined and the only area found with a pressure ulcer was the left great toe. The nurse's note dated 6/13/2011 had this information as well. The areas identified after surveyor's prompting were: sacral, right inner buttock, right great toe and right medial foot. The nurse's note dated 7/26/2011 at 1:20pm documented the following regarding the condition of the pressure ulcers, "Area noted to sacral area measures 3.0 by 2.5, area has reddish pink granulated tissue, with a scant amount of serosanguinous (mixture of blood and clear) drainage. Old pink scar tissue surrounding with maceration (wrinkle type skin) area on stage III. Has 2nd site open to right inner buttocks area measures 1.0 by .8 area. Has reddish pink granulated tissue. Has a scant amount of serosanguinous drainage, area as stage II with surrounding pink scar tissue and maceration. Right great toe (area) extending to right medial foot area, area an stage one and not opened." On 7/28/2011 at 10:30am, E1(administrator) presented two signed statements from E12 and E20, nurse's aides taking care of the R7 on 7/25 and 7/26/2011. According to both statements neither of the staff identified any type of pressure ulcer during care for R7. The surveyor asked, E2 (director of nurses/DON) and E9 (ADON) as nurses if it is possible for R7 to have no type of pressure ulcer present, and go to a stage II and stage III pressure ulcers. E2 attempted to answer the surveyor's question and E1 stated, "We just don't know". On 7/28/2011 at 12:51pm, E10 told the surveyor the treatment order for R7's sacral wound was discontinued. On 6/10/2011 the admitting nurse(E21) reported R7 having a pressure ulcer and she obtained the order for treatment. On 6/13/2011 E10 examined R7 and found pink scar tissue and discontinued the order. The surveyor requested the discontinued order from the doctor. -At 1:25pm, E10 returned to the surveyor with a copy of the original order and POS for July 2011 with DC (discontinued written) on top of the order. E10 provided the surveyor with a treatment sheet for the month of June 2011 with DC written on it. No treatment was documented as given. The surveyor asked E10 why the original order was not follow for 6/10/2011. No answer was given. The surveyor then asked, E10 why DC was written over the order for July 2011, since the original POS did not contain it. No answer was given. -At 2:50pm, E21 (admitting nurse for R7) told the surveyor R7 had no pressure ulcer. E21 made a mistake and did not know where she got the order for the treatment of [REDACTED]. -R7's care plan dated 6/17/2011 documented, R7 is at increased risk for alteration in skin integrity and will not develop any skin integrity issues thru next review. Interventions included but not limited to the following: -Skin will be checked during routine care on daily basis and weekly bath or shower. Any concern to be conveyed to charge nurse for further evaluation and/or treatment changes or interventions and call medical doctor (MD) as needed. Off load heels as needed and pressure reducing/relieving mattress and wheelchair cushion. These care plan interventions were not implemented as stated as above and the facility had an ineffective method in place to identify the beginning pressure ulcer (stage I) as a result, R7 developed four new areas, two of the areas open with bleeding and unknown drainage.