Every finding on record at Mado Healthcare - Uptown

Based on observations, interviews and record reviews, the facility failed to complete timely comprehensive smoking assessment for 8 (R6, R8, R9, R21, R39, R79, R89, R110) residents reviewed for smoking. This failure affected ALL 59 smoker residents in the facility. The findings include: R9's admission record showed admit date on 8/5/2025 with diagnoses not limited to Malignant neoplasm of unspecified part of left bronchus or lung, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Anemia, Schizoaffective disorder, Emphysema, Unilateral primary osteoarthritis left knee, Peripheral vascular disease. MDS (Minimum Data Set) dated 11/11/2025 showed R9's cognition was intact. R110's admission record showed admit date on 7/14/2022 with diagnoses not limited to Type 2 diabetes mellitus, Unspecified dementia, Chronic obstructive pulmonary disease, Unspecified asthma, Epilepsy, Chronic kidney disease, Essential (primary) hypertension, Chronic ischemic heart disease, Schizophrenia. MDS dated [DATE] showed R110's cognition was moderate impaired. On 12/9/2025 at 1:50PM Observed R9 up and about, ambulatory with steady gait, alert and oriented x 3, verbally responsive. Stated he has been residing in the facility for 3 months. R9 said he is a smoker and does not carry cigarette and lighter. Stated staff is providing cigarette and lighting cigarette for him. R9 said he has been Smoking in the designated area and there is always staff supervising during smoking time. Stated no accident / incident while smoking. On 12/9/2025 at 2:35PM Observed R110 sitting up on wheelchair, alert and verbally responsive. Stated she is a smoker and does not keep smoking materials - cigarette and lighter. She said staff is lighting her cigarette and smoking in designated area. Stated no accident / incident related to smoking. On 12/10/25 At 2:38PM V1 (Administrator) stated smoking assessment is not done yet in the facility. She said they just got the nursing advantage for the smoking assessment, and it will be implemented in January 2026. V1 stated she is aware that it is a problem or a concern of not having smoking assessment for residents who smoke in the facility. She said the purpose of smoking assessment is to evaluate or determine safety of the resident to smoke. She said there is no assessment for all smoker residents in the facility. V1 said smoking rules and behavior are discussed during admission. Stated residents are expected to smoke in designated areas supervised by staff all the time. V1 said safety of the residents related to smoking are monitored closely. She said there are 5 Behavior Monitor Staff working in the facility and part of their responsibility is to monitor residents during smoking schedule time. V1 said residents do not carry smoking materials (cigarettes, lighters). Stated the Behavior Monitor Staff passes and lighting their cigarette. V1 said all residents are supervised during smoking schedule all the time. On 12/10/25 At 3:05PM V26 (Behavior Monitor Staff) stated he has been working in the facility for 3 years. Observed V26 passing and lighting cigarettes for the residents. Observed residents wearing appropriate weather clothes smoking in the designated area - outside patio supervised by V26 during smoking time. Observed V26 keeping all smoking materials (cigarettes and lighter). Care plan dated 8/6/35 showed in part: SMOKING – R9 is at risk for ineffective health maintenance related to lack of interest in improving health behavior as evidenced by verbal report and residents continued desire to smoke. No smoking assessment found in R9's EHR (Electronic Health Record). Care plan dated 12/9/25 showed in part: R110 is a smoker. No smoking assessment found in R110's EHR. Facility's smoker list showed a total of 59 residents smoking in the facility. FINDINGS INCLUDE: On 12/10/2025 at 3:05 PM, Survey team observed R79 smoking cigarette with staff supervision outside the patio. Review of R79's electronic health records revealed a smoking safety screen was last completed on 1/10/2024. Findings include: R8 diagnosis includes but not limited to Chronic Obstructive Pulmonary Disease, Nicotine Dependence, Difficulty Walking, Lack of Coordination, History of Falling. R8's MDS (Minimum Data Set) dated 09/10/25 documents in part, intact cognition. R8's care plan indicates he is a current smoker. R8's last smoking-safety assessment screen completed 12/17/24. No updated smoking assessment found in R8's EHR (Electronic Health Record). R21 diagnosis includes but not limited to Chronic Obstructive Pulmonary Disease, Seizures, Unspecified Dementia, Primary Open-Angle Glaucoma, Bilateral. R21's MDS dated [DATE] documents in part, intact cognitive function and requires supervision or touching assistance with self-care and mobility. R21's care plan indicates he is a current smoker. R21's last smoking-safety assessment screen completed 10/13/23. No updated smoking assessment found in R21's EHR (Electronic Health Record). R39's diagnosis includes but not limited to Parkinsonism, Extrapyramidal and Movement Disorder, History of Falling, Mild Intellectual Disabilities. R39's MDS (Minimum Data Set) dated 11/11/25 documents in part, moderately impaired cognitive function and requires supervision or touching assistance with self-care and transfers. R39 has a care plan in place for smoking. R39 last smoking-safety assessment screen completed 11/12/24. No updated smoking assessment found in R39's EHR (Electronic Health Record). On 12/10/25 at 1:43 PM, V18 (Director of Social Services) stated residents who smoke are assessed for safety and compliance with following the smoking rules. V18 stated the social service department used to be the ones doing the smoking assessments, but that responsibility was taken away from the department before he started working at the facility. V18 stated when he started here about four months ago, he was told by the former administrator that the social service department does not have any involvement in the smoking program. V18 stated he does not know if the residents have to sign a smoking contract or not. V18 stated he does not know who is doing the smoking assessments to assess if a resident is safe to smoke. V18 stated the social service department does not deal with the smoking program or management of the program. V18 stated residents should have smoking care plans and those are done by the social service department. V18 stated the behavior monitor tells the social service department if a resident is noncompliant and then that would be include the resident's smoking care plan. V18 said, I really couldn't tell you anything about the smoking program. FINDINGS INCLUDE: R6's admission record showed admit date on 2/24/24 with diagnoses not limited to Chronic obstructive pulmonary disease, paranoid schizophrenia, anxiety and lack of coordination. MDS (Minimum Data Set) dated 10/14/25 showed R6's cognition was intact. R89's admission record showed admit date on 10/9/25 with diagnoses not limited to Chronic bronchitis, anxiety, and unspecified cataract. MDS dated [DATE] showed R89's cognition was intact. On 12/9/2025 at 12:40 PM Observed R6 up in her wheelchair, alert and oriented x 3, verbally responsive. R6 said she is a smoker and does not carry cigarette and lighter, staff is providing cigarette and lighting cigarette for her. R6 said she has been smoking in the designated area (outside patio), and there is always staff supervising. No updated smoking assessment found in R9's EHR (Electronic Health Record). On 12/10/2025 at 1:50 PM Observed R89 sitting up in her wheelchair, alert and verbally responsive. Sated she is a smoker and does not keep smoking materials - cigarette and lighter. She said staff is lighting her cigarette, supervising when smoking in the outside patio, and no accident or incident related to smoking. No smoking assessment found in R89's EHR (Electronic Health Record). On 12/11/25 At 12:55 PM V1 (Administrator) stated smoking assessment is not done yet in the facility. She said they just got the nursing advantage for the smoking assessment, and it will be implemented in January 2026. Care plan dated 3/5/25 showed in part: R6 is a smoker. Care plan dated 10/11/25 showed in part: R89 is a smoker. Facility's smoker list showed a total of 59 residents smoking in the facility.

Based on observation, interview and record review, the facility failed to clean and disinfect reusable equipment (glucometer) in between resident's use and ensure staff performed hand hygiene in between resident's care during medication administration. The facility also failed to maintain their hot water temperatures within required parameters and failed to develop and implement a comprehensive water management plan to prevent and control the growth of Legionella and failed to establish control measures for areas at risk for Legionella growth within the facility's water system. These deficient practices have the potential to promote the growth and spread of Legionella in the facility water system and could affect all 112 residents residing in the facility. Findings Include: On 12/09/25 at 12:55 PM, surveyor requested from V1 (Administrator) their water management program for Legionella. V1 stated that the facility has no completed water management program and is working on completing one. V1 said that they started putting it together a year ago, but it's not complete yet. V1 stated the waters were tested for Legionella by a third-party company on 11/21/24 and tested negative. The facility's water management plan binder for Legionella provided by V1 does not show the facility's control measures such as physical controls, temperature management, disinfectant level control, or visual inspections. It also does not show a risk analysis for the facility's hot and cold water distribution. On 12/09/25 at 2:28 PM, V8 (Maintenance Director) stated he's been working full time in the facility for 13 years. V8 said he is not familiar with the water management program to prevent Legionella in the facility. V8 said that an outside company comes in every six months to check the water for Legionella. V8 said that he only checks the temperatures everyday on all floors. V8 said he does not do any testing of the facility's water including chlorine levels and does not check the temperatures in the boiler room where the water heater and water holding tanks are located. On 12/09/25 at 2:36 PM, surveyor and V8 inspected the facility's boiler room. The two water holding tanks and the water heater temperatures read 105 degrees Fahrenheit. On 12/10/25 at 9:43 AM, a second inspection in the boiler room was conducted with V8 and V22 (Director of Building Maintenance). V22 stated he is not in the facility everyday and only comes when needed. Surveyor, V8, and V22 noted the two water holding tanks, water heater, and circulating pipes temperatures read 115 degrees Fahrenheit. V22 said that the water is coming from the city to the facility's water heater, to the holding tanks and then distributed throughout the facility through the circulating pipes. V22 said temperatures in the boiler room should be checked every day and that the normal range should be between 98 degrees Fahrenheit to 120 degrees Fahrenheit. V22 said that if the temperatures are below or above the normal range, they call for service. Surveyor requested from V8 and V22 copies of the temperature logs for the water heater, water holding tanks, and circulating pipes, but none were provided. The Centers for Disease Control and Prevention's (CDC) Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit) documents in part: Water management program (WMP): Multistep process to reduce Legionella growth and spread; includes establishing a team, describing building water systems, identifying areas or devices where Legionella might grow or spread to people, determining control measures, monitoring control measures, establishing remediation activities and interventions when control measures are not met, ensuring the program is running as designed and is effective, and documenting all program activities. Store hot water at temperatures above 140 degrees F (60 degrees C) and ensure hot water in circulation does not fall below 120 degrees F (49 degrees C). Recirculate hot water continuously, if possible. Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. The CDC guidelines titled Monitoring Building Water that can be found on this website: https://www.cdc.gov/control-legionella/php/guidance/monitor-water-guidance.html reads in part: Hot water guidance Store hot water at temperatures above 140 degrees F (60 degrees C). Ensure hot water in circulation doesn't fall below 120 degrees F (49 degrees C) and recirculate hot water continuously, if possible. Maintain water heaters at appropriate temperatures while following local and state anti-scald regulations. Sometimes maximum temperatures allowed by a state may be too low to limit Legionella growth. Engineering controls that mix hot and cold water together at or near the point of use can both: Reduce the risk of scalding. Allow water in pipes to remain hot enough to limit Legionella growth. On 12/09/2025 at 1:00PM Medication administration observation conducted with V11 (Licensed Practical Nurse / LPN), worn gloves and checked R116's Blood sugar = 196. V11 prepared Insulin 2 units and injected to R116's right arm. Observed V11 did not perform proper hand hygiene after removing gloves. On 12/09/2025 at 1:05PM Medication administration observation conducted with V11 (LPN) and checked R9's blood sugar checked = 232. V11 administered insulin 4 units to R9's abdominal area. V11 did not clean or disinfected the same glucometer used from another resident (R116). V11 did not perform proper hand hygiene in between resident's care, before wearing and after removing gloves. On 12/09/2025 at 1:13PM Medication observation conducted with V11 (LPN) checked R110's blood sugar using the same glucometer not disinfected/cleaned used from previous 2 residents (R116 and R9). R110's blood sugar = 268. Observed V11prepared insulin lispro 40 units and injected to R110's abdominal area. V11 did not perform proper hand hygiene in between resident's care. On 12/09/2025 at 1:20PM Medication administration observation conducted with V11 (LPN) and checked R16's blood sugar checked using the same glucometer used from previous residents (R116, R9, R110) without cleaning or disinfecting the device. R16's blood sugar = 254. V11 prepared 10 units and administered to R16's abdominal area. V11 did not perform proper hand hygiene. On 12/9/2025 At 2:09pm V11 (LPN) said she only used 1 glucometer to check blood sugar for 6 residents on the 3rd floor. Stated she is the only nurse working in the unit. On 12/11/2025 9:52 AM V3 (IP / Infection Preventionist Nurse and Wound care nurse) said Glucometer is supposed to be cleaned and disinfected after each use to prevent spread of infection / contamination. Stated before using and after removing gloves, staff is supposed to do proper hand hygiene / hand washing. V3 said staff should also perform proper hand hygiene in between resident's care or passing medications to prevent bacteria / organism spread to resident and staff. She said proper hand hygiene is very important to prevent spread of infection. On 12/11/2025 at 11:23AM V2 (DON / Director of Nursing) said multi use device such as glucometer should be cleaned after each use using disinfecting wipes to prevent cross contamination. V2 said staff are expected and it is very important to perform proper hand hygiene before and after care or medication administration to prevent the spread of infection. Facility's hand hygiene policy dated 1/1/25 showed in part: hand hygiene is the most effective way of preventing the transmission of healthcare-associated infection to residents, staff, and visitors. Hand hygiene shall be performed: Before and after contact with a resident or resident's environment. Facility's multi-equipment cleaning policy (undated) showed in part: To ensure all shared resident-care equipment is cleaned and disinfected after each use to prevent infection.

Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) store food at least six inches from the floor, c.) store food at least 18 inches from the ceiling, d.) sanitize kitchen equipment based on manufacturers' procedure directions. These failures have the potential to affect all 112 residents receiving food prepared in the facility's kitchen. Findings include: On 12/09/25 at 9:29 AM, V5 (Dietary Manager) stated all prepared or opened food containers are labeled with a prepared or opened date and a use by date or expiration date. V5 stated it is important for the items to be labeled and dated with an open and use by date, so the staff knows how long the product is good for. V5 stated if the product is only labeled with an opened date the staff may not know when the item should be thrown out and they may continue to use the product even though it has expired. V5 stated if an item is not dated appropriately then they throw it out and do not serve to the residents because there is a potential for residents to get sick from food borne illness. On 12/09/25 at 9:40 AM, the following items were observed inside the walk-in cooler:1.) Opened 1-gallon barbeque sauce labeled with a delivery date of 11/19, opened date 12/08/25. No use by or best by date was labeled on the product. 2.) Opened 32-ounce jar of chopped garlic labeled with a delivery date of 10/1. No opened or use by date was written on the product. Best by date not printed on the product by the manufacturer.3.) Opened 1-gallon container of yellow mustard labeled with a delivery date of 11/5, opened 12/03/25. Not labeled with a use by date.4.) Opened 1-gallon container of buttermilk ranch dressing labeled with a delivery date 11/12, opened date 11/12. Not labeled with a use by date.5.) Opened large container of mild salsa labeled with a delivery date 10/2, opened 11/23/25. Not labeled with a use by date.6.) Opened 1-gallon container of Italian dressing labeled with a delivery date 9/24, opened 11/17/25. Not labeled with a use by date.7.) Opened 5-pound tub of peanut butter labeled with a delivery date 12/3. Not labeled with an open or use by date.8.) Opened 11-pound tub of grape jelly labeled with a delivery date of 11/26. Not labeled with an open or use by date.9.) Metal container with apple sauce inside covered with plastic wrap with a label indicating opened 12/08/25. No use by date was written on the label.10.) Metal container with vanilla pudding inside covered with plastic wrap with a label indicating opened 12/08/25. No use by date was written on the label.On 12/09/25 at 9:50 AM, observed in walk-in cooler six closed bags of liquid eggs being stored on the lowest shelf of the rack. Based on visual estimation the lowest shelf did not appear to be at least six inches from the floor. V5 stated the food must be at least six inches off the floor per regulation based on what he learned in his training. Also, observed loaves of bread stocked on the highest shelf of a rack almost touching the ceiling of the walk-in cooler. V5 stated there is a certain number of inches foods should be stored away from the ceiling. V5 stated he thinks it is eight inches, but he needs to check. Surveyor requested to ask maintenance to bring a measuring tape to the kitchen.On 12/09/25 at 10:15 AM, the maintenance director came into the kitchen and gave V5 a measuring tape. V5 went back into the walk-in cooler with surveyor and V5 measured the distance from the floor to the lowest shelf in the walk-in cooler where the liquid eggs were being stored using the measuring tape. V5 said out loud it is 4.5 inches. V5 stated it should be at least six inches from the floor. V5 then measured the distance from the ceiling to the loaves of bread stored on the top shelf using the measuring tape. V5 said, it is four inches. V5 stated he thinks the distance should be more than that, but he will have to check the policy.On 12/09/25 at 10:19 AM, observed in mini refrigerator to the right of the stove a wedge of bologna wrapped in plastic with no label or dates on it.On 12/09/25 at 10:34 AM, during the tour of the dry storage room observed one storage rack with the lowest shelf which appeared to be less than six inches off the floor containing two large boxes of cookies. The middle of the lowest shelf storing the cookies appeared to be warped and bowing in the middle and therefore even closer to the floor. Using a measuring tape V5 measured the distance from the floor to the front of the lower rack. V5 said, it is four inches. V5 noted that the middle of the lowest shelf was even lower than four inches because it bowed. V5 stated the entire lower shelf should be at least six inches from the floor since they are being used to store food on. On 12/10/25 at 10:49 AM, during pureed food preparation observed V23 (Dietary Aide) wash the blender container, lid, and blade in the three-compartment sink, then rinse each item in the 2nd sink containing water and then handed each of the items one at a time to V21 (Dietary Aide) who proceeded to quickly dip each item into the sanitizing sink one at a time and pull them out. Observed V21 dip blender blade in sanitizing solution in the 3rd sink for 3-4 seconds, blender lid 5 seconds, blender container 8 seconds. None of the items were submerged for 60 seconds. V21 then turned over each item onto a drying rack. On 12/10/25 at 10:54 AM, observed various cooking equipment items being washed in the three-compartment sink. V23 washed and rinsed each items one at a time and then handed them to V21 who proceeded to quickly dip each item into the 3rd sink containing sanitizing solution between three to five seconds per item ( eight-ounce spoodle dipped for three seconds, metal container for four seconds, and large green cutting board for six seconds). None of the items were fully submerged in the sanitizing solution for 60 seconds. On 12/10/25 at 11:01 AM, blender container, blade and lid was given V23 who proceeded to wash and rinse each item and then give them one at a time to V21. V21 dipped blender lid into the sanitation sink for three seconds, the blade of the blender for five seconds and the blender container for three seconds. None of the items were fully submerged for 60 seconds. On 12/10/25 at 11:21 AM, V21 stated each item needs to left in the sanitizing sink for two minutes. On 12/10/25 at 11:22 AM, V5 stated the kitchen uses a Quat type sanitizing solution and each items needs to be fully submerged and left in the sanitizing sink for one minute. V5 stated if the equipment/utensil is not left in the sanitizing sink for the full minute, then the item is not sanitized, and this could make someone sick by cross contamination. Observed wall poster from manufacturer of sanitizing solution on the wall above the three-compartment sink indicating items need to be left in solution for one minute.On 12/11/25 at 11:24 AM, via telephone interview V28 (Consultant Registered Dietitian) stated she has been covering the facility between 14-15 years and is onsite twice a week. V28 stated all opened items or prepared items should be dated with an open and a use by date. V28 stated if the item is not labeled or dated with a use by date the staff would not know when to throw out the item and that labeling and dating is important to monitor for spoilage which could lead to food borne illness if an expired item was served to a resident. V28 stated regarding storage guidelines the bottom shelf should be at least six inches from the floor, and the distance between the ceiling and the food should be at least 18 inches. V28 stated this important for proper air circulation and so if there was a fire the sprinkler heads work properly and are not blocked. V28 stated any equipment item being cleaned manually in the three-compartment sink needs to be fully submerged in the sanitizing solution for 60 seconds. V28 stated this is important to effectively kill any bacteria on the equipment and fully sanitize the item. V28 stated if the items being washed are not sanitized for the full minute, then there is a potential risk to the resident, and this could lead to a food borne illness. V28 stated all the residents in the facility receive an oral diet, there are no residents who are NPO (nothing by mouth). On 12/09/25, V5 provided list of diet orders for all residents in the facility. The diet order list indicates there are no residents receiving nothing by mouth (NPO). Facility provided policy titled, Food Date and Labeling (undated) which documents in part, all food once open, must have a use by date written on the label. Facility provided policy titled, Food Storage Policy dated December 2025 which documents in part, store all food items at least six inches off the floor on shelves and maintain a minimum of 18 inches of clearance from the ceiling to allow for air circulation and access to sprinkler heads. Facility provided policy titled, Three Compartment Sink Policy (undated) which documents in part, it is the policy of (facility name) to wash, rinse and sanitize equipment and utensils in a 3-compartment sink before using to prepared or serve food, and sanitize equipment/utensils in the third compartment, fill the sink with water and Quat solution and immerse equipment and utensils in this solution for 1 minute or 60 seconds. Facility provided copy of wall poster hanging on the wall over the three-compartment sink produced by the manufacturer of the sanitizing solution which documented in part, submerge in sanitizer sink for one minute as specified on product label and/or local guidelines.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate was less than 5% for 5 (R28, R29, R46, R103 and R116) of 16 residents reviewed for medication administration. There were 26 opportunities and 5 errors resulting in a 19.23% medication error rate. The findings include: R 1. R46's admission record showed admit date on 6/4/2025 with diagnoses not limited to Other asthma, Essential (primary) hypertension, Type 2 diabetes mellitus, Other schizophrenia, Neuromuscular dysfunction of bladder. MDS (Minimum Data Set) dated 9/9/2025 showed R46's cognition was intact. On 12/9/2025 at 10:01AM Medication administration observation conducted with V4 (Licensed Practical Nurse / LPN) and gave Symbicort inhaler to R46. Observed R46 inhaled 1 puff and in 2 seconds interval inhaled another puff. R46 did not wait for at least 1-2 minutes before the 2nd puff inhalation. 4 R46's POS (Physician Order Sheet) and MAR (Medication Administration Record) showed in part: Symbicort Inhalation Aerosol 160- 4.5 MCG/ACT (Budesonide[1]Formoterol Fumarate Dihydrate) 2 inhalation inhale orally two times a day. Ordered time at 8AM AND 5PM. R46's Medication Audit report dated 12/11/25 showed Symbicort was administered on 12/9/25 at 8:36AM but medication was given at 10:01AM as observed by surveyor during medication administration. 2 2. R28's admission record showed initial admit date on 4/22/2022 with diagnoses not limited to Type 2 diabetes mellitus, Anemia, Bipolar disorder, Essential (primary) hypertension, Anxiety disorder, Spinal stenosis cervical region. MDS (Minimum Data Set) dated 10/7/2025 showed R28's cognition was intact. On 12/09/2025 12:10PM Medication observation conducted with V12 (Registered Nurse / RN) and checked R28's blood sugar = 139. R28 observed sitting on the side of the bed, alert and verbally responsive, stated he ate lunch already. Observed V12 (RN) prepared and injected Insulin Aspart 6units to R28's left arm. R28's POS and MAR showed in part: Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject 6 unit subcutaneously before meals. Ordered time at 6:30AM, 11:30AM and 4:30PM. Insulin was given after meals as observed during medication administration. R28's medication administration audit report dated 12/11/25 showed Insulin Aspart was administered on 12/9/25 at 12:18PM3. R103's admission record showed initial admit date on 6/24/2025 with diagnoses not limited to Encounter for surgical aftercare following surgery on the digestive system, Emphysema, Gastro-esophageal reflux disease, Chronic obstructive pulmonary disease with (acute) exacerbation, Anxiety disorder, Essential (primary) hypertension, Schizoaffective disorder. MDS dated [DATE] showed R103's cognition was intact.On 12/09/2025 at 12:45PM Medication observation conducted with V4 (LPN) and prepared Pseudoephedrine 30mg 2 tablets and administered to R103. Observed R103 took 2 tablets by mouth. R103's POS AND MAR showed in part: Sudafed Oral Tablet 30 MG (Pseudoephedrine HCl) Give 1 tablet by mouth as needed for Congestion Once daily. V4 administered 2 tablets instead of 1 tablet as ordered. 4. R29's admission record showed initial admit date on 9/25/2025 with diagnoses not limited to Type 2 diabetes mellitus, Iron deficiency anemia, Schizophrenia, Schizoaffective disorder, Essential (primary) hypertension. MDS dated [DATE] showed R29's cognition was intact.On 12/09/2025 at 12:57PM Medication administration conducted V11 (LPN) and checked R29's blood sugar = 300. R29 alert and verbally responsive, stated had lunch already. Observed V11 prepared and administered Insulin Aspart 20 units given to R29's abdominal area. R29's POS and MAR showed in part: Insulin Aspart (w/Niacinamide) Injection Solution 100 UNIT/ML (Insulin Aspart (with Niacinamide)) Inject 20 unit subcutaneously before meals. Ordered time at 6:30AM, 11:30AM AND 4:30AM. Insulin was given after meal as observed during medication administration. 5. R116's admission record showed initial admit date on 9/22/2009 with diagnoses not limited to Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Essential (primary) hypertension, Schizoaffective disorder, Unspecified asthma. MDS dated [DATE] showed R116's cognition was intact.On 12/09/2025 at 1:00PM Medication administration observation conducted with V11 (LPN) and checked R116's blood sugar = 196. R116 alert and verbally responsive, stated she had lunch already. Observed V11 prepared Insulin Aspart 2 units and injected to R116's right arm.R116's POS and MAR showed in part: Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units BS <80 or >350=CALL MD, subcutaneously before meals. Scheduled time: 6:30am, 11:30am and 4:30pm. Insulin was administered to R116 after meal. On 12/10/2025 at 11:23AM V2 (DON / Director of Nursing) stated he started working in the facility in August 2025. He said Nurses should follow the physician order in administering medications. V2 said nurses are expected to follow the 5Rs in giving medication (Right dose, right time, right medication, right route, right resident). Stated if nurse was not giving the right dose more than what was ordered could potentially overmedicate and resident could have an adverse reactions or side effects of the medication. He said nurse are expected to give medication as ordered at the Right time when insulin is ordered before meals then it should be given prior to meal. V2 said it is very important to give insulin at the right time and duration because the blood sugar might be higher if insulin is not given on time. V2 said Inhaler is supposed to be given as ordered by physician. He said nurse should wait in between puffs depending on the medication instructions or at least 2minutes to make sure that the resident get the right dose of the medication. Facility's administration procedures for all medications policy (undated) showed in part: To administer medications in a safe and effective manner. Review the 5 rights three times: Check MAR for order. Facility's short insulin administration policy (undated) showed in part: Ensure safe and accurate insulin administration following provider orders. Follow 6 rights of medication administration. Sliding scale insulin - administer as ordered. Facility's oral inhalation administration policy (undated) showed in part: to allow for safe, accurate, and effective administration of medication using oral inhaler. If another puff of the same medication is required, wait at least 1-2 minutes between.

Based on observations, interviews and record reviews, the facility failed to provide ADL (Activities of Daily Living) care assistance and ensure nail care was provided to one resident (R110) who is unable to carry out ADL independently of two residents reviewed for ADL in a sample of 23. The findings include: R110's admission record showed admit date on 7/14/2022 with diagnoses not limited to Type 2 diabetes mellitus, Unspecified dementia, Chronic obstructive pulmonary disease, Unspecified asthma, Epilepsy, Chronic kidney disease, Essential (primary) hypertension, Chronic ischemic heart disease, Schizophrenia. MDS (Minimum Data Set) dated 9/2/25 showed R110's cognition was moderate impaired. She needed supervision or touching assistance with upper body dressing; Partial / moderate assistance with personal hygiene and body dressing. On 12/9/2025 at 2:35PM Observed R110 sitting up on wheelchair, alert and verbally responsive. Observed clothes (sweater and pants) stained with food, brownish and reddish in color. Observed fingernails on both hands were long and dirty, with blackish debris / materials under nails. Observed both thumbs with redness / swelling, left thumb was more reddened and swollen, nail was thickened and brownish. Requested Nurse on duty V11 (LPN / Licensed Practical Nurse) and V3 (Wound care Nurse) and saw R110's thumbs reddened and swollen. V11 said she will inform the physician. V3 said fingernails are long, should be trimmed at least every week and as needed during shower. V3 said R110's left thumb nail is thickened and brownish. R110 said she would like her fingernails trimmed / cleaned. R110 said she does not know when it was last cleaned or trimmed. On 12/9/2025 At 2:38PM V16 (CNA / Certified Nursing Assistant) stated he has been working in the facility for more than a year and regularly assigned on the 3rd floor. He said he has been working with R110. V16 said R110 needed total assistance or dependent with lower dressing and personal hygiene; Partial assistance with upper dressing and transfer x 1 assist. He said Trimming nails usually done when shower is scheduled and as needed. He said part of Personal hygiene is to check nails and clean / trim it as needed. On 12/11/2025 at 11:23AM V2 (DON / Director of Nursing) stated he started working in the facility in August 2025. He said staff is supposed to assist resident with ADL (activities of daily living) care including grooming / dressing / nail care. He said resident's nails should be checked daily during care and should be trimmed and cleaned. V2 said resident's clothes should be free from food stain. He said nail care and clean clothes are part of resident's hygiene and should be always maintained. Care plan dated 12/9/25 showed in part: R110 has an ADL self-care performance deficit in grooming and personal hygiene related to poor hygiene awareness, lack of motivation r/t (related to) diagnosis (Dementia). Care plan interventions included but not limited to Evaluate R110's abilities to participate in daily care. Monitor to ensure ADL's are done daily - Oral care, Nail care, Grooming daily. Facility's activities of daily living (ADLs) policy dated 11/2020 showed in part: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene.

Based on observation, interview and record review, the facility failed to change oxygen nasal cannula and humidifier bottle as ordered for two (R11, R106) residents out of two reviewed for respiratory care in a final sample of 23. Findings Include:On 12/9/25 at 12:01 PM, Surveyor entered R11 and R106's room with V4 (Licensed Practical Nurse). R106 and R11 were not in their rooms and noted oxygen concentrators at R11 and R106's bedside not being used. R11 and R106's oxygen tubing and humidifier bottles were dated 12/1/25. V4 said they should have been changed on 12/7/25. V4 said that R11 and R106 uses oxygen as needed. On 12/10/25 at 12:57 PM, V2 (Director of Nursing) stated any respiratory tubing, and humidifier bottle are supposed to be changed every seven days and as needed. Even if it's an as needed order still needs to be changed. V2 said nurses should label it with the date it was last changed. V2 said changing oxygen tubing and humidifier bottle is important to prevent infection and growth of bacteria and to prevent residents getting sick.R11 and R106's order summary reports printed on 12/9/25 document in part to change humidifier bottle and oxygen nasal canula weekly. The facility's Policy: Oxygen Use and Storage with a handwritten date of 11/21/25 documents in part: Oxygen Supply Use and Storage - Replace every 7 days, when visibly soiled, or per policy. Change humidifier bottle weekly.

Based on observation, interview, record review the facility failed to properly discard a multi-dose insulin 28 days after opening for one (R86) resident and properly store multidose insulin vials that require refrigeration for one (R16) resident reviewed for medication storage and labeling in three of five medication carts and storage rooms. The findings include: R16's admission record showed initial admit date on 2/5/21 with diagnoses not limited to Type 2 diabetes mellitus, Presence of other cardiac implants and grafts, Unspecified right bundle-branch block, Chronic kidney disease stage 3, Essential (primary) hypertension, Schizoaffective disorder, Unspecified sequelae of cerebral infarction. R86's admission record showed initial admit date on 6/5/2020 with diagnoses not limited to Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Chronic systolic (congestive) heart failure, Essential (primary) hypertension, Schizoaffective disorder, Other seizures. On 12/9/2025 at 10:33 AM 4th floor medication cart inspected with V12 (RN / Registered Nurse) and observed multidose insulin Glargin for R86 with open date on 11/4/25 and discard date on 12/2/25 but was not discarded and was keep inside the medication cart. Observed with opened multidose insulin glargin for R86 with no open date and discard date labelled. Pharmacy sticker showed discard 28 days after opening. On 12/9/2025 at 1:52PM 3rd floor medication cart inspected with V11 (LPN / Licensed Practical Nurse) and observe unopen insulin pen for R16 inside the medication cart. Pharmacy sticker showed refrigerate. On 12/11/2025 at 11:23AM V2 (DON / Director of Nursing) stated nurses are expected to store / keep unopen insulin in the refrigerator to follow recommendation of the pharmacy and to maintain the potency of the medication. V2 said Insulin should be discarded after 28 days from opening. Stated insulin is not good after 28 days so it should be discarded and it is not supposed to be in the medication cart. Facility's medication storage in the facility policy (undated) showed in part: Medications are stored safely, securely and properly to ensure patient safety and assist in maintaining medication integrity. Special care should be taken to ensure medications requiring special storage (i.e. refrigerated items) are stored properly to ensure patient safety and medication integrity. Outdated medications are immediately removed from inventory, disposed of according to medication disposal guidelines. Certain medications require an expiration date shorter than the manufacture's expiration date to ensure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. Facility's insulin administration policy (undated) showed in part: Storage - Refrigerate unopened insulin. Label opened insulin with date; discard per manufacturer guidelines.

Based on observation, interview, and record review, the facility failed to follow physician order to provide specialized rehabilitation therapy post-fall for one (R102) resident reviewed out of a total sample of 23 residents. Findings include:On 12/11/25 at 12:22 PM, observed R102 sitting in the dining room in a wheelchair waiting for his lunch tray to be delivered. R102 said he used to walk around with a walker before he fell but now, he uses a wheelchair because he hurt his leg when he fell. R102 stated he does not know if he is getting therapy or not. Per R102's EHR (Electronic Health Record) R102 had an unwitnessed fall in his room on 11/10/25 and sprained his right ankle per discharge hospital records dated 11/10/25. Per R102's nursing progress noted R102 went for a follow up appointment with an orthopedic on 11/12/25 with recommendations for weight bearing as tolerated (WBAT) in a gym shoe and PT/OT (Physical Therapy/Occupational Therapy) to work on ROM (Range of Motion) and gait mechanics. Per R102's Physician Order Summary on 11/12/25 the following orders were entered:1.) WBAT (Weight Bearing as Tolerated) in a Gym Shoe re: right ankle sprain order date 11/12/25.2.) PT/OT to work on ROM and Gait Mechanics re: right ankle sprain order date 11/12/25. On 12/11/25 at 12:15 PM, V38 (Certified Occupational Therapy Assistant) stated she looked through the therapy screens and gave R102's Physical Therapy (PT) screen that was completed on 11/11/25 to administration. V38 looked up R102's name in the therapy computer system and stated that R102 was last receiving therapy in January 2025 and is currently not on any therapy program that she is aware of.On 12/11/25 at 12:47 PM, via telephone interview V36 (Director of Therapy/Certified Occupational Therapy Assistant) stated therapy gets notified about referrals verbally by nursing and a physician order is required for a therapist to see a resident. V36 stated even if there is a physician order for therapy if the resident does not want to receive therapy, then they honor the resident request. V36 stated if the resident initially does not want to work with therapy, then the therapist would return multiple times to see if the resident changes his mind and get social services involved to see if they can educate the resident because sometimes a different approach with a different person can make a difference. V36 stated the PT (physical therapist) screened R102 on 11/11/25 and R102 told the PT that he did not want to use the walker and was comfortable using the wheelchair, so the PT referred him to restorative. V36 stated she is not sure if the PT revisited with R102 after the initial screening date on 11/11/25. V36 stated if R102 was seen by ortho on 11/12/25 and if there was a new order for PT/OT evaluation then PT and OT should do another screen and evaluate R102 further as needed. V36 stated PT/OT did not pick him up and she does not know if a screen was done or not. V38 stated if the screen was done it would be in the therapy office, all the screens are done by hand and kept in one location. V38 stated if the PT and OT screen are not in that location then it was not done. V36 stated it may be that since R102 refused therapy on 11/11/25 it was figured he would refuse again. V36 stated someone should have revisited the topic and tried doing ROM (range of motion) before referring to restorative. V36 stated the potential problem if R102 stays in the wheelchair is a decline in independence.On 12/11/25 at 1:30 PM, via telephone interview V35 (Restorative Director/Registered Nurse) stated the last time a restorative assessment was completed for R102 was 10/21/25. V35 stated prior to R102's fall he was walking with a walker but now he is using a wheelchair. V35 stated restorative has not reassessed R102 since his fall because R102 has a physician order for PT/OT. V35 stated PT/OT did not give V35 a record of treatment or instructions so there has been no change in R102's restorative program since R102's fall. V35 stated restorative therapy has continued to do general ROM (range of motion) exercises with R102 except that restorative does not touch R102's ankle. V35 stated restorative is not doing anything with the ankle because of the sprain from the fall. V35 stated PT/OT are the ones who are qualified to assess R102 for safety and then they tell V35 what to do. V35 stated he does not want restorative to hurt R102 by mistake or make his injury worse in any way. V35 stated he relies on therapy to tell him what restorative can and cannot do with a resident especially one with a recent injury. V35 stated since R102's fall he has not received any new recommendations or instructions from PT/OT verbally or in writing for R102. V35 stated he does not know why PT/OT has not picked R102 up and that he does not want R102 to lose function or strength of his legs.On 12/11/25 at 2:20 pm, via telephone interview V37 (Physical Therapist) stated she is the only PT covering the facility and is onsite twice a week and as needed. V37 stated prior to R102's fall he was walking using a walker. V37 stated she did a PT screen for R102 on 11/11/25 but he was refusing therapy and did not want to walk so she gave him a wheelchair for safety and referred him to restorative. V37 stated that is the last time she screened him, and she has not worked with him since then. V37 stated she saw R102 in the hallway a couple of weeks ago in passing and noticed he was still using a wheelchair. V37 stated if she was given a physician order for PT after her initial screen was done, she would have rescreened R102 again. V37 stated range of motion exercise can be done with a resident even if they are sitting in a wheelchair to try to move the ankle. V37 stated gait mechanics is when you try to walk the resident. V37 stated if R102 was continuing to refuse to walk and wanted to still stay in the wheelchair range of motion exercises is something therapy can do with him if he is willing. V37 stated the long-term goal would be for him to return to his prior level of functioning which is to be walking with a walker because he will become more dependent in a wheelchair. V37 stated but if he is refusing to walk therapy cannot force him to walk. V37 stated there should be a follow up.On 12/11/25 at 2:30 PM - spoke with V2 regarding request for OT/PT screen based on physician order from 11/12/25. V2 stated PT and OT should have evaluated R102 based on the order to ensure R102 does not lose function and independence.On 12/11/25 at 2:35 PM, no one was in the therapy office and surveyor was told that everyone had left for the day.On 12/11/25 at 4:25 PM, V1 (Administrator) emailed surveyor a handwritten screen completed by a OTR (Registered Occupational Therapist) for R102 dated 11/14/25 saying no therapy indicated. On 12/11/25 at 5:39 PM, surveyor emailed V1 and V2 to request the name and contact information for the OTR who completed the screen form dated 11/14/25. On 12/12/15 at 9:13 AM, surveyor emailed V1 and V2 again to request the name and contact information for the OTR who completed the screen form dated 11/14/25. On 12/12/15 at 10:01 AM, V2 emailed the name and contact information for V36. Surveyor responded that V36 is not a OTR and did not complete the screen and again requested for the name and contact of the OTR who completed the screen on 11/14/25. On 12/12/15 at 10:26 AM, V2 emailed the name and contact information for V37. Surveyor responded that V36 is not a OTR and did not complete the screen and again requested for the name and contact of the OTR who completed the screen on 11/14/25. On 12/12/15 at 4:35 PM, surveyor did not receive a response to the email requesting the name and contact for the OTR who completed the screen dated 11/14/25. R102's MDS dated [DATE] documents in part, intact cognition, supervision/touching assistance required for self-care and transfers and R102 able to independently walk 10 feet and 50 feet with two turns. Facility provided policy titled Physician Orders dated 01/01/19 which documents in part, it is the policy of (name of facility) to follow physician orders for resident care including medications, diet and treatment plans as mandated by state law.

Based on observation, interview and record review the facility failed to provide a prescribed treatment to one resident (R3). This failure affected one out of three residents reviewed for treatment services.Finding include:R3's medical diagnoses include but are not limited to chronic obstructive pulmonary disease, localized edema, cellulitis of unspecified part of limb, essential hypertension, heart failure.R3's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, indicating R3's cognition is intact.On 08/18/25 at 11:48am R3 observed in first floor dining area with no bandages to bilateral lower legs.On 08/18/25 at 1:51pm R3 stated that the nurses wrap her legs sometimes. R3 stated that she did not get her legs wrapped today on 08/18/25.Review of R3's treatment administration record shows documentation of R3's legs being wrapped with ace bandages.On 08/19/25 at 10:23 am R3 observed in first floor dining are with no bandages to bilateral lower legs.On 08/19/25 at 10:23am V2 (Director of Nursing/DON) stated that R3 does not have bandages on R3's legs. V2 stated that the nurse documented that R3's bandages were applied, but R3 does not have the ace wraps on R3's legs. V2 stated that the nurse should not have documented that the bandages were placed if she did not apply the bandages. V2 stated that a nurse documenting something is done but they did not do it is falsification of documentation.On 08/19/25 at 10:56am V11 (Licensed Practical Nurse/LPN) stated that she did not apply R3's bandages yet. V11 stated that she should not have documented on something that she did not do.R3's care plan dated 04/30/25 documents in part, R3 has impaired skin integrity d/t (due to) recurrent lower extremity cellulitis .provide treatment as ordered.Facility's job description titled Licensed Practical Nurse dated 07/04/24 documents in part, General Description: The purpose of this position is to provide general nursing care, working collaboratively with physicians and multidisciplinary team members. The LPN will promote and restore patient's health as they prescribe, provide, delegate, evaluate and coordinate comprehensive professional nursing care through the use of nursing process for patient of all ages, gender, cultures, and background; provide physical and psycho-social support to patients, friends, and families. Facility's policy dated 11/2018 titled Residents' Rights documents in part, Your rights to safety .Your facility must provide services to keep your physical and mental health at their highest practical levels.

Based on observation, interview and record review, the facility failed to ensure the right of the resident to be free from physical abuse in 1 (R1) of 3 residents reviewed for abuse in a sample of 8. The findings include: R1 is a [AGE] year old male with a diagnosis including COPD, Dementia, Major depressive disorder and History of falling. R1 has a BIMS (Brief Interview for Mental Status) score of 13/15. R1 ambulates independently by wheelchair. R1 is care planned for being a potential risk for Abuse/Neglect. R1 was first admitted to the facility on [DATE]. Facility Incident Report Form dated 6/6/25 includes statement that on 6/4/25 corporate staff were reviewing video recording that shows V3 ( Housekeeper) moves R1's wheelchair unnecessarily and forcefully. R1 places his foot on the ground appearing to be non verbally communicating that he does not want to move. Despite this V3 lifts the front wheels of the wheelchair and moves R1 whose feet are visibly hanging. On 6/20/25 at 10:39AM R1 stated yes I remember when V3 (Housekeeper) spun my wheelchair and moved me from area when I came out of the elevator. He tilted my wheelchair back because I tried to put my feet down to stop him. Nothing else happened. I am fine and I feel safe in the building. I don't see that housekeeper anymore. On 6/20/25 at 9:55AM V1 (Administrator) stated on 6/4/25 V2 (corporate staff ) reported to me he witnessed abuse to a resident while reviewing facility security camera footage. V2 showed me the camera footage. At around 7:30 AM on 6/4/25 V3 (Housekeeper) was mopping the floor and R1 was coming out of the elevator. R1 went on the floor that V3 was mopping. V3 spun the resident around aggressively. R1 was resisting by putting his foot down on the floor. V3 tilted the chair backwards and moved resident from area. I suspended V3 and terminated him after my investigation. R1 was not physically abused but R1 was mentally abused as concluded by the investigation. I followed the facility abuse prevention policy. This investigation and termination was reported to corporate. There were no other witnesses to this event. On 6/20/25 at 10:25 AM Surveyor and V1 (Administrator) observed the 6/4/25 incident surveillance footage on V1's laptop. V3 (Housekeeper) was mopping the 1st floor immediately outside the elevator on the first floor. Three residents were standing in front of elevator. The elevator door opened. The three residents entered the elevator. R1 exited the elevator and rolled his wheelchair next to the wet caution sign. V3 put his mop in the bucket and grabbed the back of R1's wheelchair. V3 aggressively spun R1 around attempting to remove R1 from the area. R1 put his feet down on the floor. V3 snapped back the wheelchair tilting R1 and the chair pushing R1 from the area in an aggressive manor. Footage did not show any potential witnesses to the incident. Review of facility inservices show that on 5/7/25 V3 (housekeeper) attended and signed the attendance sheet of inservice titled Topic : Abuse and Neglect (Dated 5/7/25 ). Facility policy titled Abuse Policy 1/4/24 states including It is the policy of MADO Healthcare Uptown that each resident will be free from Abuse. Abuse can include verbal , mental , sexual, or physical abuse , misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion.

Based on observation, interview, and record review, the facility failed to follow their policy by failing to notify the nurse on duty of a resident fall and failed to ensure that a resident was immediately assessed by a nurse after sustaining a fall. This failure effected 1 resident (R1) out of 5 residents reviewed for falls in a total sample of seven residents. Findings include: Facility Final Incident Investigation (dated 04/25/2025) documents in part: The certified nursing assistant stated that in the morning he went to the room of R1 and he was sitting on the floor. He tried to get him up from the floor. Staff denied being physically aggressive towards R1. He denied causing any harm to R1. The facility is unable to substantiate the allegation of physical abuse. There was no ill-intentions or intentional act towards R1. R1 sustained a close fracture of the right shoulder. Staff were in-serviced on 04/22/2025, on appropriate transfer practices. Fall Prevention Policy (undated) documents in part: It is the policy of this facility to provide the highest quality care in the safest environment for the individuals residing in the facility. Immediate action when a resident is found on the floor: do not move the individual; Call for assistance. Do not leave the individual alone; The nurse will immediately assess the individual for injury. R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: nondisplaced fracture of surgical neck of right humerus, initial encounter for closed fracture, pain in right shoulder, bipolar disorder, primary osteoarthritis left shoulder. Minimum Data Set Section (MDS) section C (dated March 04, 2025) documents that R1 has an Interview for Mental Status (BIMS) score of 14, indicating that R1's cognition is intact. Care plan (03/04/2025) documents that R1 has potential for joint pain/discomfort due to diagnosis of osteoarthritis left shoulder. On 05/03/2025, at 10:14 AM, surveyor observed R1 lying in bed on his left side. R1 was observed with a bruise on the right arm. Surveyor interviewed R1 about the fracture of the right shoulder that R1 sustained from a fall on 04/21/2025. On 05/03/2025, at 12:09 PM, V3 (S1/certified nursing assistant) stated, I was the certified nursing assistant that was assigned to R1 on 04/21/2025. R1 is a resident that I care for regularly. Around 9:00 AM, I gave R1 a towel because R1 was going to shower. That day was not R1's scheduled shower day, but I shower R1 every day. R1 is ambulatory and walks to the bathroom independently. When R1 has a bowel movement, R1 does not wipe his buttocks after the bowel movement. I was going to shower R1 because he just finished having a bowel movement and he did not wipe his buttocks. After I handed R1 the towel, I told him to go to the shower room and I told him that I'm coming. I had to go and attend to another resident who could not walk. I was with the other resident about 8 to 10 minutes and then I went to the shower room to meet R1, but R1 was not in the shower room. I went to R1's room, I observed R1 sitting on the floor with his legs straight. R1 was wearing pants and gym shoes while R1 was sitting on the floor. When I walked out of R1's room to check on another resident, R1 was sitting on the bed. When I returned to R1's room, R1 was sitting on the floor. I asked R1 why he was still in his room. R1 told me that he is suffering from his right arm. I grabbed R1's pants from the back and I got him up. R1 stood up. When R1 stood up, I pulled R1's pants and diaper down and R1 was full of poop. R1 said that he is not going to shower because R1's right arm hurts too much. I cleaned R1 up while R1 was standing up. After I changed R1, I told R1 to sit on the bed. R1 eats downstairs, so I told R1 to go and eat downstairs. R1 said that R1 does not want to go because his arm is in too much pain. When R1 told me that he's not going to go eat downstairs, I told my nurse. I told the nurse on duty, V7 (licensed practical nurse), that R1 cannot go downstairs to eat and that R1 broke his arm. I went downstairs and brought R1 his tray. I asked R1 what he was doing on the floor, but he did not respond to me, so I asked him what he was still doing in his room. He said that his right arm hurts. R1 did not tell me how he fell . I would always go and supervise R1 in the shower room because R1 would go and wet the towel and pretend that he was taking the shower. R1 is needs supervision in the shower room. Normally I go with R1, but I needed to mop the floor because another resident peed in the hallway. When I see the resident on the floor, I am not supposed to pick up the resident from the floor without a nursing assessment. Picking up R1 from the floor was the mistake I made. I informed the nurse that R1 had a fall after R1 was already in bed and after R1 told me that R1 is going to stay in bed for breakfast due to his right arm pain. When a resident has a fall, the policy is to inform the nurse right away, which I did not do. After I informed the nurse that R1 had a fall and that R1's arm was hurting, V7 went to assess the resident. R1 was sent to the hospital. The mistakes I made is that I transferred R1 post fall without informing the nurses and without the nurse's assessment. R1 slipped off the bed and fell on his right arm. I never stretched is arm and never pulled on his shoulder when I was getting R1 up. I just pulled R1 by his pants. I did not ask for assistance from other staff to transfer R1 to bed post fall, I lifted him by myself. On 05/03/2025, at 2:41 PM, V1 (administrator) stated, I investigated the incident that occurred on 04/21/2025. I got a call from the hospital that R1 was claiming that R1 was physically abused by the staff. I immediately initiated the investigation. V3 (S1/certified nursing assistant) was the certified nursing assistant that was assigned to R1. V3 was immediately suspended and sent home, pending investigation. R1 was not in the building at the time that the investigation was started, R1 was in the hospital. Then I got another call around 4:30 PM from R1's V12 (primary physician). He verbalized what the resident was claiming about the incident. I explained to the physician that I initiated the investigation and the physician shared that he had spoken to the emergency room doctor. The emergency room doctor had concluded that R1's right arm fracture was not as a result of physician abuse. V12 recommended that we in-service nursing staff and certified nursing assistants on proper transfer techniques. We spoke to the physical therapist to initiate the in-services. The resident was readmitted to the facility later that day. The following day on 04/22/25, I interviewed R1. R1 shared that he was on the floor and V3 lifted him up from the back. His hand gave out when the C.N.A. lifted him up. When he was asked if he feels it was an intentional physical aggression, R1 said no, it was not intentional. R1 was re-interviewed by me. He stated that he was sitting on the edge of the bed and the C.N.A tried to lift him up by his arm and that's how R1 sustained the fracture. He again said that he doesn't think it was intentional. We interviewed other residents and residents never accused this particular C.N.A. of being abusive or aggressive towards the resident. Staff were interviewed on abuse and reporting of abuse. All the staff in the facility receive abuse prevention training monthly and as needed. A C.N.A should not pick up a resident after a resident sustained a fall because it can cause injury without a nursing assessment. V3 should have first notified the nurse on duty to assess R1 when R1 fell . Based on the recommendation from the nurse, we can get then get the resident up from the floor. It is never ok for a C.N.A to pick up a resident from the floor post fall without notifying the nurse and without nursing assessment. On 05/03/25, at 3:03 PM, V2 (director of nursing) stated, After interviewing V3 (S1/certified nursing assistant), we educated V3 about proper transfers. V3 says that R1 was sitting on the floor, however, V3 and other staff should never assist a resident from the floor alone without notification of the nurse. The nurse must complete an assessment first to see if it is safe to transfer the resident from the floor post fall. We educated V3 on never assisting a resident post fall alone, without other staff assistance. All the nursing staff were educated about proper transfers and therapy demonstrated proper and safe transfers. On 05/03/2025, at 3:12 PM, V13 (restorative director) stated, R1 transfers independently with stand-by supervision. R1 requires stand-by assistance for showers. R1 is moderate assistance with shower. R1 requires staff encouragement for showers. R1 did not have any prior falls, prior to 04/21/2025. R1 did not tell me that he had a fall. I asked R1 if he had a fall, but R1 did not confirm that R1 fell . R1 just told me that he went to the hospital. On 05/03/2025, at 3:34 PM, V7 (licensed practical nurse) stated, On 04/21/2025, I was working on the 4th and 5th floor. While I was on the 5th floor, V3 (S1/certified nursing assistant) alerted me that a resident is hurt. I went to assess R1. R1 was sleeping in his bed. I opened the resident's chart to see if he has any pain medications. I see that R1 has a prescription for pain medications for shoulder pain. I got the pain cream and I went to R1's room to apply the cream. That's when R1 told me that the shoulder that the cream is prescribed for is not what was causing the pain. I was not told that the resident had a fall. I was told by V3 that R1 is having pain. When the resident told me that his right arm is hurting, that's when I did the assessment. While I was assessing R1, that's when R1 alleged that V3 twisted his arm. I was still not informed about a fall; I was only informed by the resident that the C.N.A twisted R1's arm. R1's right arm was visibly swollen. R1 was not able to do range of motion and move his arm due to excruciating pain. I asked R1 how long R1 was having this pain. R1 told me that he was having pain since this morning. I followed the facility protocol and if there is an alleged abuse allegation, we report it to the abuse coordinator who is the administrator. From there the administrator will give me the directives on what to do next. The whole time during R1's assessment, I was not informed at all that a had had taken place. R1 only reported an alleged abuse allegation that V3 twisted his arm, but the C.N.A never told me that a fall occurred. V3 only told me that R1 is having difficulty moving his arm. R1's Progress Note (dated 04/21/2025) documents, Resident complained of right arm swelling. Assessment done. Swelling noted on said arm. He admits to excruciating pain. Range of motion is limited. Resident cannot abduct right arm. Physician notified and responded with order to send resident to community hospital for medical evaluation. Nurse to nurse report given and an estimated time of arrival of 30 min obtained from ambulance. Resident left the facility accompanied by 2 EMT (emergency medical transport) staff without incident. Family member notified via voice mail. R1's Progress Note (dated 04/21/2025) documents, Follow up call made to community hospital regarding patient's status. Spoke with the nurse. That resident will be returning to facility. That patient will be on a sling. Incoming to follow up with return. R1's Progress Note (dated 04/21/2025) documents, Resident returned back to the facility via medical transport. Arrived with 2-person assist on a stretcher. Received alert and oriented at baseline. emergency room discharge documentation confirmed fracture to the right arm with sling in place. Assessment of swelling noted around the scapula region, resident denies pain at this time. No facial grimacing observed. Discharge order for resident is to schedule an appointment with physician (Orthopedic surgery). Physician notified of resident's return, new order for Tylenol 325mg; take 2 tabs by mouth every six hours hours as needed for pain. Order received and carried out. Director of nursing notified. Message left for emergency contact (daughter). Monitoring in place. Vitals stable. R1's Emergency Record (dated 04/21/2025) documents that R1's diagnosis was closed fracture of right shoulder.

Based on interview and record review, the facility failed to protect resident's right to be free from physical abuse. This failure affected one (R1) out of three residents reviewed for abuse. Findings include: On 04/22/25 at 11:30 AM, R1 stated R2 tried to choke him when R1 was in the 1st floor dining room doing activities. R1 stated, R2 came up from behind R1 and grabbed R1 around the neck with R2's arm. R1 stated he was not expecting it, so he was surprised when R2 did that. R1 stated one of the staff got R1 off R2 and R2 was removed from the room. R1 does not remember if R2 said anything as he was trying to choke R1. R1 stated R2 did not look angry and I don't know why he did that. On 04/22/25 at 11:10 AM, observed R2 sitting in his bedroom looking at an opened bible on his bedside table. V21 (Business Office Manager) acted as translator because R2's primary language is Spanish. R2 stated via V21 that God, told me to choke him (R1) so I did and God told me to do this because he (R1) was going to try to choke me first. R2 stated via V21 that R1 never touched or threatened R2 and the only reason R2 tried to choke R1 was because God told R1 to do it. On 04/23/25 at 11:10 AM, via phone interview V3 (Former Activity Aide) stated he was running the activity group in the morning in the 1st floor dining room on the day R2 tried to choke R1. V3 stated that on that day R2 walked into the 1st floor dining room and came up from behind R1 and got R1 in a head lock using his arms. V3 stated he could see that R2 was trying to choke R1. V3 stated he had to pull R2's arm off from around R1's neck. V3 stated once he separated them, R2 told V3 that God told R2 to kill somebody, not specifically R1, just somebody. V3 stated he was the only staff in the room when this happened, and he does not remember the names of the other residents in the room at the time. On 04/23/25 at 12:22 PM, V21 (Business Office Manager) stated on 02/04/25, the former administrator called her downstairs to translate for R2 after the altercation had occurred between R1 and R2. V21 stated R2 told her that he (R2) was trying to kill R1 because God told him to. V21 stated R2 said he put his arm around R1's neck to choke him. V21 stated R2 said R2 did that because R1 was going to hurt R2, so God told R2 to hurt R1 first. V21 stated R2 said he was trying to kill R1, not just hurt R1. V21 stated R2's story on 02/04/25 was the same he told us yesterday (04/22/25), no changes. On 04/22/25 at 10:51 AM, V5 (Licensed Practical Nurse) stated on 02/04/25, she was notified that there had been an altercation between R1 and R2 and she assessed each of them. V5 stated R1 told her, R2 grabbed me from behind. V5 stated R1 denied being in pain anywhere and there were no signs or symptoms of any injury. V5 stated R1 told her I don't know, muchacha, I don't know, muchacha and R2 was calm, not agitated. V5 stated R2 does have a history of schizophrenia and does hallucinate saying things like God told me I need to drink water or God told me On 04/23/25 at 11:45 AM, V1 (Administrator) stated he is the abuse coordinator at the facility and has been working at the facility for two months. V1 stated the main goal is to prevent abuse and to keep the residents free from abuse. V1 stated the residents living at the facility are a vulnerable population and it is the staff/facilities responsibility to advocate for the residents and keep them safe from abuse. V1 stated R2 choking R1 is physical abuse. V1 stated he does not think the action was intentional, but it was willful on R2's part because R2 was responding to the inner voice inside his head telling R2 to take the action of trying to choke R1. R2's nursing progress note dated 02/04/25 entered by V5 documented, Writer was notified at about 11am that resident was aggressive and meet criteria for psychiatric evaluation. Resident is to be sent to St Mary's Hospital for psychiatric evaluation and indicated that R2's son, primary care provider, and psychiatric nurse practitioner were notified. R2's Petition for Involuntary/Judicial admitted d 02/04/25, 11:30 AM documented in part, client is presenting below baseline. Displaying socially intrusive and aggressive behavior directed toward people in immediate environment secondary to psychosis. Client choked a co-peer believing God told him to. In need of immediate hospitalization for psych evaluation and to prevent harm to others. Facility reported incident written witness statement received 02/04/25 at 11:00 AM documented in part, I, (V3) witnessed R2 choking R1 around the neck in a choke hold yelling, God told me to kill him. The written statement also the incident happened in the dining room during morning group at 10:15. R1's admission record indicates admitted on 01/03/25 with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Chronic Sinusitis, Dysarthria and Anarthria, Schizophrenia, Osteoarthritis of Knee, Insomnia, Slurred Speech, Essential (Primary) Hypertension. R1's MDS ([NAME] Data Set) dated 01/21/25 indicates intact cognition. R1 has care plan in place stating R1 is at risk for abuse/neglect. R2's admission record indicates admitted on 11/24/21 with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance, Mild Cognitive Impairment of Uncertain or Unknown Etiology, Essential (Primary) Hypertension, Unspecified Schizophrenia, Schizoaffective Disorder, Bipolar Type, Alcohol Dependence, In Remission. R2's MDS dated [DATE] indicates intact cognition. R2 has care plans in place for audio hallucination/preoccupation with religion, felony history for aggravated stalking and risk for abuse/neglect. Facility provided document titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities dated 11/18 documents in part, your rights to safety: You must not be abused, neglected, or exploited by anyone- financially, physically, verbally, mentally, financially or sexually. Facility provided document titled, Abuse Policy dated 01/04/24 which documents in part, that each resident will be free from Abuse Abuse can include verbal, mental, sexual, or physical abuse . Additionally, resident will be protected from abuse, neglect, and harm while they are residing at the facility.

Based on interview and record review, the facility failed to (a) assess and document pressure ulcer characteristics and measurement on a weekly basis and (b) ensure that the orders provided by wound nurse practitioner (NP) were performed to 1 (R3) out of 3 residents reviewed for Improper nursing care. The findings include: R3's admission record showed initial admitted on 5/19/2021 with diagnoses not limited to Acute respiratory failure with hypoxia, Pressure ulcer of right heel stage 3, Morbid (severe) obesity due to excess calories, Chronic respiratory failure with hypoxia, Pressure ulcer of right buttock stage 2, Unspecified diastolic (congestive) heart failure, Acute embolism and thrombosis of unspecified deep veins of right lower extremity, Unspecified urinary incontinence, Type 2 diabetes mellitus, Schizoaffective disorder, Chronic obstructive pulmonary disease. R3 was discharged from the facility on 4/15/2025. On 4/22/25 at 10:25AM V5 (LPN / Licensed Practical Nurse) stated wound treatment is done by nurse on duty, had regularly worked and provided treatment to R3's wounds (Sacrum and Right heel). She said R3 had wound on sacrum area and treatment was Santyl and Foam dressing. V5 said R3 's wound to right heel, treatment was Xeroform. On 4/22/25 at 11:22am V10 (MDS coordinator, LPN) stated R3 had 2 pressure ulcers, 1 Stage 2 to sacral / right buttock and 1 Stage 3 to Right heel and were present upon readmission. On 4/22/25 At 1:04PM V8 (Wound NP) stated has been servicing the facility for 2 years and seeing wounds in the facility. Stated he has been following R3's wounds. Surveyor reviewed R3's EHR (Electronic health record) with V8 and said R3 had pressure ulcers, Stage 2 to sacrum and Stage 3 to right heel. Reviewed V8's wound documentation dated 4/8/25 and said treatment for sacrum and right heel was Hydrofera. V8 stated is it important to follow treatment order to promote wound healing and prevent complication like worsening or deterioration of wound. V8 stated the purpose of Hydrofera treatment is to keep the wound moist and promote healing. He said Santyl is a chemical debriding agent. V8 said Santyl to Right buttock / Sacrum should have been discontinued and changed to Hydrofera. He said R3's wound visit was on 3/1/25 then 3/26/25 and 4/8/25. V8 stated no wound visit on 3/8/25, 3/15/25, 3/22/25 and 4/1/25. He said it is important to assess wound and document at least weekly to monitor if treatment is appropriate and if need to be changed, it will also monitor progress of the wound and if the wound is not improving treatment should be changed. On 4/22/25 At 2:36pm V2 (DON / Director of Nursing) stated it is important to carry out and follow wound NP's order for wound treatment. She said wound NP's order should be placed in POS (Physician order sheet) and TAR (Treatment administration record). V2 said purpose of wound treatment is to promote healing of the wound. She said if wound treatment is not followed, potentially can lead to wound deterioration / complications. V2 said it is important to assess and document wound at least weekly to monitor the progress of the wound. MDS (Minimum Data Set) dated 3/4/25 showed R3's cognition was intact. She needed Substantial / maximal assistance with oral hygiene, upper body dressing; Dependent with toileting and personal hygiene, shower / bathe self, lower body dressing, chair / bed and toilet transfer. R3 was always incontinent of bladder and frequently incontinent of bowel. MDS showed R3 had 1 Stage 2 and 1 Stage 3 pressure ulcers that were present upon admission. V8 (Wound NP/Nurse Practitioner) follow up wound documentation dated 4/8/25 showed in part: - Sacrum pressure ulcer Stage 2 orders: cleanse wound using normal saline solution, pat dry using gauze. Apply Hydrofera on wound bed. Apply ABD pad on wound and secure with tape. - Right heel pressure ulcer Stage 3 orders: cleanse wound using normal saline solution, pat dry using gauze. Apply Hydrofera on wound bed. Apply Hydrofera on wound bed. Apply rolled gauze and secure with tape. R3's order summary report dated 4/22/25 with order not limited to: - Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Sacrum topically one time a day related to pressure ulcer of right buttock Stage 2. Cleanse sacrum with NS, apply Santyl ointment, cover with gauze, secure with ABD pad. - Xeroform Petrolat Patch 2 (Bismuth Tribromophenate-Petrolatum) Apply to Right heel topically one time a day related to pressure ulcer of right heel, stage 3. Apply to right heel topically every day shift for wound treatment on the right heel post saline cleansing then cover with gauze dressing and wrap with kerlix until healed. R3's TAR (Treatment Administration Record) schedule for April 2025 showed in part: - Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Sacrum topically one time a day related to pressure ulcer of right buttock Stage 2. Cleanse sacrum with NS, apply Santyl ointment, cover with gauze, secure with ABD pad. Start date 3/26/25. Discontinue date 4/16/25. - Xeroform Petrolat Patch 2 (Bismuth Tribromophenate-Petrolatum) Apply to Right heel topically one time a day related to pressure ulcer of right heel, stage 3. Apply to right heel topically every day shift for wound treatment on the right heel post saline cleansing then cover with gauze dressing and wrap with kerlix until healed. Start date 3/6/25. Discontinue date 4/16/25. Care plan dated 3/18/2025 showed in part: R3 has alteration in skin integrity related to Breakdown (right buttock wound, right heel wound). Conduct wound assessment and observation per facility protocol Facility was not able to provide R3's weekly wound assessment / documentation on 3/8/25, 3/15/25, 3/22/25, and 4/1/25. Facility's skin management guidelines policy dated 3/2016 documented in part: Document findings, wound characteristics, stage (if applicable), wound measurements in centimeters (cm), pain associated with wound on the weekly wound documentation form. Notify the physician, obtain treatment orders and document orders on TAR (Treatment administration record). Facility's wound care / prevention policy dated 1/2025 showed in part: Ensure that the orders provided by physician are performed as ordered.

Based on review of records and interview, the facility failures are the following: Failed to follow interventions in the care plan, review and/or revised the fall prevention care plan of 1 out of 4 residents (R1) reviewed for accidents and hazards. Failures affected 1 resident (R1) who had an incident of fall resulting to right hip/pelvic fracture that required surgery in the hospital. Finding includes: R1 is [AGE] years old, a resident in the facility since 10/08/2020. R1 has moderate impairment of cognition based on brief interview of mental status (BIMS) dated 10/15/2024, with a score of 12. R1 was not in the facility during review, per V10 (Registered Nurse) nursing notes dated 12/28/2024. R1 was transferred to the hospital due to vomiting. On 12/31/2024, at 11:21 AM. V8 (Licensed Practical Nurse) stated that R1 used to be in the current floor that she is working. R1 was admitted on a different floor after hospitalization . V8 stated that R1 underwent hip surgery. R1 was ambulating without any help before the fall. V8 cannot remember if R1 was using any device like walker when ambulating. R1's notes related to the incident are documented as follows: - V3 (Licensed Practical Nurse) nursing notes dated 11/28/2024, documents that R1 was noted limping while ambulating in the hallway. V5 (Medical Doctor) was informed and ordered an x-Ray to the right hip to pelvic area. - V5 (Medical Doctor) medical notes dated 12/02/2024, documents that R1 has pain in the right hip. R1 does not know what happened but think that she fell . V5 noted right leg showing extended and rotated. V5 documents that he suspects right hip fractures upon examination although portable x-Ray does not indicate fracture or dislocation. - V6 (Licensed Practical Nurse) nursing notes dated 12/02/2024, documents that R1 was scheduled to be transferred to the hospital. V7 (Registered Nurse) nursing notes dated 12/02/2024, documents that hospital nurse called informing her that R1 has been admitted with closed right hip fracture that needs surgery. Per Incident Report of the facility related to R1 fall incident, it documents as follows: During R1's admission to the hospital (12/02/2024), the facility received a call from the hospital that R1 will be undergoing right hip surgery due to fracture and that the R1 said she fell in the facility. On 01/02/2025, at 9:57 AM, V2 (Director of Nursing) stated that a nurse tried to tell her that R1 was supposed to use the walker but did not and got up. When asked who was the nurse that told her? V2 said that she was not sure. She (the nurse) may have mixed R1 from other residents. After reviewing R1's printed progress notes, V2 said (reading the notes), On 11/28/2024, she (R1) was limping when ambulating in the hallway. V2 then said, Yes, she (R1) was allowed to ambulate. V2 was asked about the current status of R1 after the incident? V2 stated that R1 is now chair or bed bound when R1 came back from the hospital after the incident. V2 after review of R1's care plan noted that R1 needs extensive assist during transfer. R1 requires a gait belt. R1 needs to be assessed and evaluated before transfer, and to prompt R1 to stand, pivot and transfer to chair or wheelchair. V2 stated that those questions can be best answered by V12 (MDS Coordinator / Licensed Practical Nurse). V2 stated that she only knew that R1 was verbalizing that she fell when the hospital called and informed her that R1 said she fell here in the facility. V2 was made aware that per V5 (Medical Doctor) physician notes dated 12/02/2024, it was documented that R1 verbalized to V5 that she may have fall. V2 said, I was not aware that R1 verbalizing to V5 that she (R1) may have fall. On 01/02/2025, at 11:16 AM, V12 (MDS Coordinator / Licensed Practical Nurse) stated that R1 ambulates by herself without using any equipment like walker. After review of R1 fall care plan, V12 stated that R1's fall care plan was not reviewed since 2022. V12 stated, Yes, the care plan should be reviewed quarterly. V12 was asked how can R1's fall care plan reflects her current fall prevention needs when it was not reviewed since 2022? V12 stated, I know what you mean. That it needs to be updated. V12 was also asked that R1 has a care plan for extensive assist, to use a gait belt, and assess when being transferred. R1 was also identified in her care plan for decline in physical ability. V12 stated that restorative has their own scope. A He (V12) does not know about R1's decline on physical ability. Currently, the facility does not have restorative nurse. Per R1's care plan it provides as follows: - R1 is unable to transfer independently and requires assistance to supervision as evidenced by R1's medical diagnosis. The goal is for R1 to be able to transfer safely from bed to chair/wheelchair with extensive assist. Intervention for R1 includes application of gait belt, evaluation, or assessment of R1's sitting and standing ability prior to transfer, and prompt R1 to stand, pivot, and transfer to chair/wheelchair. - R1 has decline in physical ability that will affect her (R1's) activity pursuit daily. - R1 is at risk for decreased upper and lower extremities strengthening and range of motion as evidence by R1's medical diagnosis that includes mild cognitive impairment, bipolar disorder, and lack of coordination. - R1 assessment reveals a reasonable risk for falls secondary to difficulty of walking, unsteadiness on their feet, and generalized weakness. R1 was observed with weakness in the legs three (3) to four (4) times a week. R1 is observed and is at risk for fall. Fall care plan for R1 was initiated on 03/08/2022 and was last reviewed/revised on 06/01/2022. After 06/01/2022 there was no record of review/revised of R1's fall care plan. MDS (Minimum Data Set) comparison between assessments dated 10/15/2024 annual assessment (prior to fall) and 12/11/2024 significant change (after the fall). R1's functional abilities substantially declined from able to walk/ambulation to dependent or chair bound due to the fall. Hospital documentation are as follows: Dated 12/02/2024, documents, R1 chief complaint: I fell and hurt my hip. R1 sustained a mechanical fall from standing. X-Ray of the right hip reviewed. R1 has a displaced femoral neck fracture. Right hip surgery was done on 12/03/2024. Facility provided Post - Fall Protocol policy and procedure dated 09/01/2023, that focus on guidance related to resident after the fall. After request for policy and procedure of the facility prior to fall or fall prevention. V2 (Director of Nursing) stated that the facility has only post fall policy and procedure that was already provided. V11 (Director of Operation) stated that although facility has no specific policy for fall prevention. The facility has training and in-service related to fall prevention.

Based on interview and record review, the facility failed to have a qualified licensed nurse oversee the facility's restorative nursing program. The failure has the potential to affect all 120 residents that receive restorative programming. Findings include: On 11/17/24 at 10:25 AM, V5 (Restorative Director) stated that V5 is the restorative director and that V5 is a COTA (Certified Occupational Therapist Assistant). On 11/18/24 at 9:55 AM, V1 (Administrator) stated that V5 supervises the restorative programming in the facility. On 11/18/24 at 12:22 PM, V5 stated that V5 creates and evaluates all restorative programs in the facility. V5 explained that V5 is responsible for assessing residents for restorative need and creating a restorative care plan. V5 stated that all restorative certified nursing assistant aides report to and are supervised by V5 and V5 completes all the training on restorative for staff members. V5 stated that V5 was qualified to supervise the restorative nursing program because V5 had taken a course on restorative nursing. On 11/19/24 at 10:09 AM, V2 (Director of Nursing) stated that the facility does not have a restorative nurse. V2 affirmed that V5 oversees the restorative nursing program. V2 stated that V2 isn't familiar with restorative nursing services so V2 does not provide supervision to V5. V2 stated that V2 was unsure if a restorative nursing program could be supervised by a staff member that was not a licensed nurse. On 11/19/24 at 10:27 AM, V1 stated that V5 oversees and supervises the restorative nursing program in addition to assessing and completing restorative assessments. V1 affirmed that V5 was a COTA and not a licensed nurse. V1 affirmed that V5 is qualified to supervise the restorative nursing program because V5 has taken a class in restorative nursing. V1 affirmed that the facility uses the RAI (Resident Assessment Instrument) to guide resident assessment and care. Record review of list of residents on restorative program documents in part that 120 residents receive restorative nursing programming. Record review of job description titled, Restorative Director (dated 1/21/24) documents in part . the Restorative Director plays a critical role in providing superior customer service and nursing care to all residents. The Restorative director implements and directs the facility's restorative nursing program with the goal of helping residents reach and maintain their full mobility potential. Essential Functions -Develops, implements directs and evaluates the facility's Restorative Nursing Program. -Meets and consults with the facility's interdisciplinary team on a regular basis to develop and maintain restorative care standards. Ensures restorative nursing program complies with applicable laws, regulations, and national restorative nursing standards and requirements . Record review of CMS's RAI Version 3.0 Manual Chapter 3 MDS Items [O] (10/2024) Page O-51 documents in part, .A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents . Although therapists may participate, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs.

Based on observation, interview, and record review, the facility failed to ensure window blinds are not missing blind panels/slats in an effort to provide a homelike environment to residents. This failure affected 5 (R53, R74, R76, R82, R91) residents reviewed for homelike environment in the total sample of 57 residents. Findings include: On 11/17/2024 at 10:27 AM, inside R82's room, the vertical window blinds have missing panels/slats. There were no panels/slats on the floor. On 11/17/2024 at 10:29 AM, inside R91's room, the vertical window blinds have missing panels/slats. There were no panels/slats on the floor. On 11/17/2024 at 10:35 AM, V12 (Certified Nursing Assistant) was requested to check R82's window blinds. V12 stated the window blinds should have more coverage to provide privacy; there were missing panels (slats). I don't know how long it has been like that. No, I don't see any window blind panels (slats) on the floor. On 11/17/2024 at 10:38 AM, V12 (Certified Nursing Assistant) checked R91's window blinds and stated there's a lot of missing panels. I don't see panels on the floor. On 11/17/2024 at 10:41 AM, V12 checked R74's window blinds and stated the vertical window blind has missing panels/slats. No panels on the floor. On 11/17/2024 at 10:46 AM, V12 checked R76's window blinds and stated the window blinds has no panels/slats at all. I don't see any panels/slats on the floor. ON 11/17/2024 between 10:52am and 11:11am, V13 (Maintenance Supervisor) checked R74's, R76's, R82's, and R91's window blinds and corroborated the observations done by this surveyor with V12. On 11/17/2024 at 11:11 AM, V13 (Maintenance Supervisor) stated we are expected to provide a homelike environment to our residents. If something is broken in my home, I will fix it right away. I knew about the missing panels (slats) on the window blinds about two months ago now. I have a lot of work to do and it is just me and the Maintenance Director. Every day, I have to fix something; like a broken toilet, leaking water, and clogged drain. I never get the chance to fix all the window blinds that are broken or with missing panels. On 11/18/2024 at 11:16am, V2 (Director of Nursing) stated we are not providing a homelike environment if there are missing panels on the window blinds. Window blinds are used for privacy. If missing, we are not providing coverage or privacy to the residents. R74's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) bipolar disorder, major depressive disorder, copd (chronic obstructive pulmonary disease). R74's (Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R74's mental status as cognitively intact. R76's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) dysphagia and gastrostomy status. R76's (08/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 00. Indicating R74's mental status as severely impaired. R82's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus, essential hypertension. R82's (10/01/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R82's mental status as cognitively intact. R91's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Obsessive Compulsive disorder and epilepsy. R91's (10/22/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R91's mental status as cognitively intact. The (undated) Residents' rights for people in Long-term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections, and privileges according to state and federal laws. Your rights to safety. Your facility must be safe, clean, comfortable, and homelike. The Resident Right - Safe/clean/comfortable/Homelike dated 01/01/2024 documented, in part Intent: It is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights. Procedure: 1. The resident has a right to a safe, clean, comfortable, and homelike environment. 2. The facility must provide a safe, clean, comfortable, and homelike environment. 3. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 41611 On 11/17/2024 at 10:30am surveyor observed the blinds in room [ROOM NUMBER] to be tethered and bent. On 11/17/2024 at 10:50am surveyor observed the blinds in room [ROOM NUMBER] to be tethered with a brown substance that had been spilled on the blinds. On 11/19/2024 at 12:17am R53 stated that the blinds are broken, and it would be nice to have them fixed. On 11/19/2024 at 12:22pm V21 (Licensed Practical Nurse) stated that when blinds need to be changed we call maintenance and make them aware. Policy dated 1/21/2024 titled Maintenance Department documents, in part, it is the policy of the maintenance department to provide for maintenance and other equipment. Job Description for Maintenance Director dated 1/04/2024 documents, in part, the Maintenance Worker is responsible for the maintenance and repair of the facility and grounds and perform troubleshooting and repairs for items/structures. Surveyor: [NAME], Criselda

Based on interview and record review, the facility failed to ensure oxygen signs were placed on the resident's door and failed to properly label and date oxygen tubing. This failure affects 3 residents (R86, R93, R25) and has the potential to affect all 25 residents that reside on the 5th floor. Findings include: On 11/17/24 at 10:47 AM, R25 was observed lying in bed with nasal cannula in R25's nostrils. R25 had an oxygen concentrator on next to R25's bed, delivering oxygen to R25. No oxygen in use signage was observed on the resident's door or in any place of high visibility on the unit. On 11/17/24 at 10:52 AM, V10 (Agency Licensed Practical Nurse) affirmed that there was no sign on R25's door. V10 stated that V10 was unsure if there is supposed to be oxygen signage on the door to alert others to R25's oxygen use. V10 stated that oxygen is flammable and can combust if exposed to flames. On 11/19/24 at 10:27 AM, V1 (Administrator) stated when residents are undergoing oxygen therapy, the facility standard is that the resident should have a sign on their door stating that oxygen is in use. V1 affirmed that 25 residents reside on the 5th floor. R25's physician orders document in part an order for 2 liters of oxygen via nasal cannula as needed for shortness of breath. Facility policy titled OXYGEN Storage (updated 1/4/2024) documents in part, .7. And Sign should post on resident door when use. 45196 R86's face sheet shows that R86 has a diagnosis which includes but not limited chronic obstructive pulmonary disease, vitamin D deficiency, bipolar disorder, disorder of bone, and history falling. R86's Brief Interview for Mental Status (BIMS) dated 09/24/24 shows a BIMS score of 15 which indicates that R86 is cognitively intact. On 11/17/24 at 10:40 am, R86's room was observed with a nasal cannula (NC) concentrator that had NC oxygen tubing undated, and uncontained next to R86's bed. R86's Physicians Order Sheet (POS) dated 03/15/2024 shows that R86 has orders for Oxygen (2 L) (2 liters) per minute via nasal cannula as needed for Shortness of breath. R93's face sheet shows that R93 has a diagnosis which includes but not limited chronic obstructive pulmonary disease (COPD), unspecified asthma, osteoarthritis of knee, pure hypercholesterolemia, paranoid schizophrenia, essential primary hypertension, atherosclerotic heart disease, and urinary incontinence. R93's Brief Interview for Mental Status (BIMS) dated 10/15/24 shows a BIMS score of 15 which indicates that R93 is cognitively intact. On 11/17/24 at 10:48 am, R93's room was observed with a NC concentrator that had oxygen tubing undated, and uncontained next to R93's bed. R93 stated that R93 uses oxygen as need for shortness of breath every day at the facility. When R93 was asked how often R93's oxygen tubing is changed R93 stated, Whenever It (referring to R3's humidifier bottle) gets empty. R93's Physicians Order Sheet (POS) dated 10/09/2024 shows that R93 has orders for Oxygen (2 L) (2 liters) per minute via nasal cannula as needed for Shortness of breath d/t (due to) COPD. On 11/18/24 at 2:11 pm, V2 (Director of Nursing, DON) was asked regarding oxygen tubing and V2 stated, Oxygen tubing is changed daily. It should be dated with a date and placed in a plastic bag when not in use. When V2 was asked regarding the importance of labeling oxygen tubing with a date and placing the oxygen tubing in a bag when not in use and V2 stated, For infection control. The facility's document dated 01/04/2024 and titled Oxygen Storage documents, in part: Procedure: 1. When the Oxygen is at bedside, not in use, tubings (tubing) must be contained in a clear plastic bag. 2. Tubing must be discarded and replace every 72 hours and prn (as needed). 5. Label all tubings and bubble humidifier with a date and nurses initials.

Based on observation, interview, and record review the facility failed to ensure that the controlled drugs-count record form was not prematurely signed by in and outgoing nurses. These failures have the potential to affect all residents on the second, fourth, fifth, and six floors receiving medications. Findings Include: On 11/17/24 at 12:40 pm, on the second floor the controlled drugs- count record sheet was prematurely signed for the outgoing nurse. On 11/17/24 at 12:41 pm, surveyor inquired to V9 LPN (License Practical Nurse) why is the controlled drugs- count sheet prematurely sign for the outgoing nurse? V9 stated, I always sign for outgoing when I sign for incoming because there are no medications in there. Surveyor inquired to V9 if it is checked with the incoming nurse at the beginning and ending of each shift. V9 stated, that's how I do it, I sign both when I come in because nothing is in there. On 11/17/24 at 1:45 pm, surveyor requested the controlled drug-count records for all resident floors. V2 DON (Director of Nursing) gave the third, fourth, fifth and six floor's sheets. The fourth, fifth and six floors were all prematurely signed for the outgoing nurse. On 11/19/24 10:48 am, V2 (DON) stated, The narcotic sheet should be sign when the nurses come in and when they go out. They (Nurses) should not sign the sheet before the end of their shift. The nurses should look in the narcotic box even if nothing is there. They should not sign before their shift is over because they still need to confirm that there is nothing in the box and to also make sure the count is right if there is something there. Facility's policy (2/21/24) titled Medication and Narcotic Storage documented in part, Procedure: 10. Narcotic count will be done every shift with in and outgoing nurse and sign by the nurses. Facility's policy (1/21/24) titled Medication Narcotic Count Policy documented in part, Narcotic count will be done every shift with in and outgoing nurse and sign by the nurses. In the event that there's no narcotic on that floor nurses still have to sign that there's none. Facility's (undated) job description titled Registered Nurse, RN documents in part, Essential Duties and Responsibilities: 2. Ensure that the written policies and procedures that govern the day-to-day functions of the nursing department are followed by all nursing personal assigned .

Based on observation, interview, and record review the facility failed to discard an expired medication. This failure has a potential to affect one resident (R74) in a sample size of 57 residents. Findings Include: On 11/17/24 at 12:20 pm, the third-floor medication cart had R74's Breo Ellipta (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) that was labeled to use by 11/14/24. R74's admission diagnosis includes but not limited to asthma, COPD (Chronic Obstructive Pulmonary Disease), and congestive heart failure. R74's active orders as of 11/18/24 documents in part, Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT 1 puff inhale orally one time a day for Antiasthma. R74's MAR (Medication Administration Record) documented in part, (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath) had a check mark indicating administered on 11/15/24, 11/16/24 and 11/17/24. On 11/17/24 at 12:21 pm, V15 RN (Registered Nurse) stated, I cleaned the cart and missed that. Observed V15 take the inhaler out of the medication cart. On 11/19/24 10:48 am, V2 DON (Director of Nursing) stated that expired medications should not be in the medication cart. The nurse on duty should take the medication out of the cart. Facility's policy dated 1/21/24 and titled Medication Discard and Labeling documented in part, Expired medications will be removed from the cart or refrigerator and returned to the pharmacy. Nurse on duty or supervisor will re-order expired meds as needed. Facility's (undated) job description titled Register Nurse, RN documents in part, Essential Duties and Responsibilities: 10. Prepare and administer medications as ordered by the physician. 11. Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies. Facility's (undated) job description titled Licensed Practical Nurse documents in part, Characteristic Duties: 10. Order prescribed medications, supplies, and equipment as necessary, and in accordance with our established policies.

Based on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier precaution (EBP) sign is posted for a resident on EBP and failed to ensure a PPE (personal protective equipment) bin is available for resident on EBP. These failures affected 1 (R76) resident reviewed for infection control. Findings include: On 11/17/2024 at 10:25 AM on 3rd floor, there was an EBP sign posted by the door with R76's room identifier. A PPE bin was also available outside of the room with R76's room identifier. The room was located at the end of the hallway. This surveyor knocked on the door. No one was in the room. On 11/17/2024 at 10:46 AM, R76 was in a room located right across the 3rd floor's nurse's station in the middle of the hallway. The room identifier did not indicate R76 was residing in that room. There was no EBP sign nor PPE bin on site. ON 11/17/2024 at 11:36 am, on the end hallway on 3rd floor with V15 (Agency Registered Nurse) this surveyor pointed to the EBP sign posted on the door and the PPE bin outside of the room and inquired who was the resident on EBP. V15, looking at the name identifiers on the door frame, stated the only resident I could think of on EBP is (R76) because she has a g-tube. But she was moved to a new room. I don't know when. ON 11/17/24 at 11:39 AM, by room right across the nurse's station where R76 was observed, this surveyor requested V15 to check for EBP sign and PPE bin. V15 stated there was no EBP sign posted and no PPE bin outside of (R76)'s room. When she moved to a different room, the EBP sign and the PPE bin should move with her so the staff would know the precautions. Anyone caring for her and in contact with her g-tube will take precautions. The main purpose is prevention of infection. ON 11/19/2024 at 12:22 pm, V13 (Maintenance Supervisor) stated we have to paint her (R76) room that's why we moved her (R76) last Friday (11/15/2024) and moved her back last Sunday (11/17/2024) around 5pm. On 11/18/2024 at 11:19 am, V2 (Director of Nursing) stated I think they were doing something in her (R76) room that's why they had to move her. The policy is to move the EBP sign and PPE bin with her. The purpose of moving the EBP sign and the PPE bin is to make the staff aware that the resident is on precautions; so, anyone who is taking care of the resident is taking precautions. Main purpose of moving the EBP sign and the PPE bin with her is for infection control. R76's (Active Order as Of: 11/18/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) dysphagia and gastrostomy status. Order Summary: Feeding formula six times a day. 1 can per feeding PGT (per gtube). Active. Order Date: 08/20/2024. Enhance(d) Barrier Precautions to be observed and utilized when providing high-contact resident care activities to prevent spread of infectious germs secondary to risk colonization due to resident having indwelling devices. Order Date: 08/10/2024. PEG tube flush with 250ml Q6 (every 6) hours for routine order. Order Date: 08/19/2024. R76's (08/23/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 00. Indicating R74's mental status as severely impaired. Section GG. Functional Abilities and Goals. GG0130. A. Eating -1 dependent. E. Shower - 1 dependent. F. upper body dressing - 1 dependent, G. Lower body dressing - 1 dependent. I. personal hygiene - 1 dependent. R76's (08/10/2024) care plan documented, in part Focus: at an increased risk for spreading possible multi-drug resistant organism (MDRO) secondary to indwelling medical devise regardless of MDRO colonization status. Goal: will decrease risk of spreading possible MDRO to other staff or residents through use of recommended precautions and PPE (personal protective equipment). Interventions: ensure proper signage to inform staff of precautions. The (11/17/2024) Residents on Enhance(d) Barrier Precautions indicated R76 was on the list. Of note, the room listed for R76 was not where R76 was observed on 11/17/24. The (undated) Enhanced Barrier Precautions from CDC (Centers for Disease Control and Prevention) documented, in part Providers and staff must: wear gloves and a gown for the following High-Contact Resident Care Activities: Device care or use: feeding tube. The Enhanced Barrier Precautions (EBP) policy and procedure dated 2/12/2024 documented, in part the purpose of enhanced barrier precautions is to prevent opportunities for transfer of MDRO's (multi drug resistant organism) to employees' hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or bod fluids. Policy: it is the policy of this facility that enhanced barrier precautions, in addition to Standard And Contact Precautions will be implemented during high contact resident activities when caring for resident with indwelling medical devices. High Contact Resident Care Activities include: Device care or use: feeding tube. When initiating EBP: post EBP signage at the door. Ensure PPE and disinfectant are present, ordered, and restocked routinely and placed at the entrance of room.

Based on interview and record review, the facility failed to establish a system of accounting for resident's funds and safeguarding resident's funds against theft, failed to follow their system of updating resident's belongings, and failed to ensure shipping address of online purchase for the resident was to the facility. These failures resulted on R1 and R6 incurring fraudulent debit card transactions on R1's and R6's bank accounts. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 03/25/2024 when V14 (R1's family member) completed a concern form regarding unexplained activities on R1's bank account. On 09/16/2024 at 10:45am, V1 was notified of the Immediate Jeopardy. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 09/23/2024. Although the immediacy was removed, the deficiency remains at a level 2 until the facility can determine the effectiveness of the implementation of removal and effectiveness of the in-service trainings. Findings include: 1. On 09/04/2024 at 10:15am, with V11 (PRSC Psychiatric Rehabilitation Services Coordinator) R1 stated I felt less safe this month than last month. This surveyor requested R1 to elaborate. R1 stated I don't want to talk to you anymore. On 09/04/2024 at 2:58pm, V4 (Business Office Manager/Payroll Specialist) stated (R1)'s wallet was given to (V4) by (V6- Admissions Coordinator) on 06/19/2023 for safekeeping. On 09/17/2024 at 12:02pm, V6 (Admissions Coordinator) stated it was (V27 R1's Former PRSC) who gave me (R1)'s wallet and I told (V27) it is not my department; it was (V4). I wrote the date it was handed to me by (V27). I handed it to (V4) the same day. I did not take anything from the wallet. I did not check what's in the wallet. I just handed it to (V4). (V4) and I did not check what was in the wallet. On 09/03/2024 at 12:46pm, V4 stated when residents come with their wallet and IDs, I keep them in my office right away. I have (R1)'s wallet unless he needed the wallet to go to the bank to withdraw money himself and buy stuff from the store. The social service will go with him to withdraw money from the bank or go to store to buy clothes or snacks from the store. For (R1) it was (V5- PRSC Psychiatric Rehabilitation Services Coordinator). On 09/05/2024 at 10:05am, V4 (Business Office Manager/Payroll Specialist) stated I don't have a log for the cabinet where I keep (R1)'s and other resident's wallet. I and (V1 - Administrator) have access to the wallet. We both have keys. When (R1) needs his wallet, I don't take the wallet out of the manila envelope. I give the whole manila envelope to (V5- PRSC). When they (R1 and V5) bring the manila envelope back, I don't look if (R1)'s debit and credit cards are there. Only (V5) takes the manila envelope from me. (V5) was in charge of 3rd and 4th floors, so whenever (R1) goes to store it falls on (V5) to take him. (V11- PRSC) is now assigned to 4th floor and (V5) continues to still go with (R1) to the store and it is also (V5) who would bring the whole manila envelope back to me. I did not check to make sure everything is in the wallet when the manila envelope was returned to me and when I gave it to (V5), I did not show (V5) what was in the wallet. I should have made a binder, so they sign what they take to avoid any theft, honestly to avoid theft of residents' items. I never took (R1)'s wallet and made ATM withdrawals. It is possible the debit card was not in the wallet when it was returned to me because I did not check the contents of (R1)'s wallet. On 09/04/2024 at 3:22pm, this surveyor showed V5 (PRSC Psychiatric Rehabilitation Services Coordinator) R1's Release of Responsibility For Leave Of Absence Forms, dated 02/2024 to 08/2024, and inquired if (V5) recognized the signature/staff on the space provided for PATIENT OR NEAREST RELATIVE. V5 stated that's me. This surveyor requested V5 to review the PRSC notes on 03/07/2024. V5 stated these (items) are something that we (V5 and R1) got from R***. We (V5 and R1) went out on that day. Some of them were returned because it was too big or not his style. I can't recall how many were returned. On 09/04/2024 at 3:35pm, V5 stated (R1) made withdrawals mostly at (R1's bank). I never recall any withdrawals outside of (R1's bank). I always keep an eye on (R1) because he did not have a steady gait and I don't want (R1) to fall. When I went out with (R1), there was never a time (R1) withdrew money from outside of (R1's bank). I was with (R1) all the time. I am probably 5 feet away from (R1). (R1) would put the money in his wallet, then inside the manila envelope. I don't know how much (R1) takes from the ATM. This surveyor showed V5 R1's bank statement and pointed out to V5 the transaction that was done on 03/07/2024 at (non R1's Bank) ATM withdrawal in the amount of $244.80 and asked if (V5) could explain the transaction. V5 stated I have no explanation for that, I don't know. This surveyor inquired if V5 has knowingly purchased any items using R1's debit card. V5 stated No. This surveyor inquired if he threatened a resident to get what he needed from the resident. V5 stated I am a very nice guy. R1's Admission Record documented that R1's diagnoses include but not limited to bipolar disorder, essential hypertension, and depression. R1's untitled (complaint) form, dated 03/25/2024, documented, in part Person sharing the concern: (V14, R1's family member). Nature and description of the concern: (R1)'s bank account has some unexplain(ed) activity. Description of investigation: Bank was called (to) investigate and replace(d) most of the funding. R1's State Initial Reportable, dated 09/03/2024, documented, in part It was reported by state surveyor that resident's family member reported unusual activity on bank account. R1's State Final Reportable, dated 09/09/2024, documented, in part Investigation revealed that electronic payment method/debit card was used for what appear to be unauthorized charges. R1's A***** Order Details, dated 03/06/2024, documented, in part Shipping Address. (V5 and non-facility address) Payment method. (R1)'s bank account number ending in (last 4 numbers). Of note, shipping address was not of the facility. On 09/05/2024 at 11:26am, V15 (PRSD Psychiatric Rehabilitation Services Director) stated not sure if R1 has an A***** account. PRSC's ordering for residents online, the shipping address should be the facility's address and not the PRSC address. Why ship stuff to the PRSC address if we are open for 24 hours. The expectation is everything should be shipped to this building (facility). On 09/17/2024 1:18pm, V15 (PRSD (Psychiatric Rehabilitation Services Director) stated I know for sure (R1) has no A***** account. (R1) is not that tech savvy. He refused to use the smart phone provided by 'T****y. R1's Bank statement, dated 01/27/2024 - 02/27/2024, is marked with a handwritten note documenting PIN # (4-digit number). R1's Bank statement, dated 02/28/2024 - 03/26/2024, documented the following, in part. Deposit and Addition: 03/07 Purchase Returns (bank card last 4 digits) in the amount of $252.29 3/14 ATM Cash deposit in the amount of $400.00. 3/19 Card Purchase Return (bank card last 4 digits) in the amount of $15.24 3/26 Reversal: (Pet Store) in the amount of $119.06. The total amount returned was $786.59. ATM and Debit card withdrawals: 1. (12x) Non-(Bank) ATM withdrawals (bank card last 4 digits) with a total amount of $2,881.05. 2. (2x) ATM Withdrawals (bank card last 4 digits) with a total amount of $400.00. 3. (6x) Online food orders on 03/10/24, 03/12/24, 03/14/24, and 03/18/24 (bank card last 4 digits) with a total amount of $367.44. 4. (2x) W****** purchases (bank card last 4 digits) with a total amount of $187.33. 5. (2x) C**part purchases (bank card last 4 digits) with a total amount of $264.84. 6. (1x) T***** purchase + cash back (bank card last 4 digits) with a total amount of $67.98. 7. (11x) A***** purchases (bank card last 4 digits) with a total amount of $413.97. 8. (1x) Card purchase with pin (Pet Store) (bank card last 4 digits) in the amount of $119.06. Of note, the total amount of purchases and withdrawals without receipts = $4701.67. 9. (7x) purchases (bank card last 4 digits) with receipts provided by the facility with a total amount of $4,483.60. The (09/06/2024) email correspondence with V1 in response to the inquiry of this surveyor Do you have additional receipts for (R1) aside from the 03/07/24 and 03/11/2024 R*** Receipts; 3/7/24 U****n A** hardware receipt; 03/11/24 (x2) E** L*** CEMETERY RECEIPTS; 03/07/24 (x2) and 03/25/24 A****n receipts? V1 wrote in response No I gave you everything we have. On 09/17/2024 1:18pm, V15 (PRSD (Psychiatric Rehabilitation Services Director) stated (R1) has no car and has no pet. The R*** receipt dated 03/07/2024 at 10:46am, documented 19 sold items. The R*** receipt dated 03/07/2024 at 1:52pm, documents 16 returned items. The R*** receipt dated 03/07/2024 at 2:12pm, documents 6 sold items. Of note, 9 items were retained by R1. R1's Additional Items (Patient's Clothes and Personal Belongings) list, dated 03/12/2024, documented in part Clothing Retained by Patient: Shoes x 2 and 1 magic shine sponge. Of note, 6 items were missing. R1's Personal Belonging list, dated 09/05/2024, documented in part 2 trousers and 1 Polo. Of note, no additional belonging list after 03/12/2024 and before 09/05/2024 was provided by the facility to this surveyor. The Daily Staffing dated 03/10/24, 03/12/24, 03/14/24, and 03/18/24, documented that V12 (Administrator Assistant/Front Desk), V19 (Security/Front Desk), V20 (Security/Front Desk) and V21 (Security/Front Desk) worked on these days either the 8am - 4pm shift or the 4pm-12pm shift or 12am - 8am shift. On 09/05/2024 at 9:49am, V12 stated I started in October 2022, I work Monday thru Friday, 7am-4pm. Part of my job is to call up the floor and tell the resident to pick up food order. I never had any circumstance calling (R1) to pick up his food. On 09/06/2024 at 11:57am, V19 (Security/Front Desk) stated I have been working at the facility for [AGE] years as security or front desk staff. I work different shifts; 8am-4pm, 4pm-12am, and 12am-8pm shifts. I know (R1). I never received any online food order from G*****b for (R1). On 09/06/2024 at 4:43pm, V22 (Security/Front Desk) stated I started here in 2021 or 2022. I am familiar with (R1). I never received any food order from G*****b or any A***** packages for him (R1). On 09/17/2024 at 4:12pm, V21 (Security/Front Desk) stated I have never received any online food order or any A***** packages for (R1). On 09/03/2024 at 3:34pm, V1 (Administrator) stated I called (V14 - R1's family member). V14 said it would take the bank 8-10 weeks before he could hear from them. I would be mad if I were not able to touch my money for that long. On 09/05/2024 at 11:54am, V1 (Administrator) stated no one should be stealing the resident's money. I am the Administrator; I have the key to (V4)'s office. There was never a time I took (R1)'s wallet from (V4)'s office. I spoke with him (V14 - R1's family member) and he said he will not hear from the bank for 8-10 weeks. This surveyor inquired how would V1 feel not having access to her money in the bank for 8-10 weeks. V1 stated, I would be mad. On 09/05/2024 at 12:02pm, reading the charges on R1's March 2024 bank statement, this surveyor inquired if V1 could explain the withdrawals in the statement, V1 stated I cannot explain them. On 09/16/2024 at 11:03am, V1 (Administrator) stated I hired an outside team of Private Investigator to check on the situation, on anything that has to do with financial abuse. On 09/16/2024 at 11:27am, V25 (President - (Private Investigator's) Group) stated they (V1) did searches of (V5)'s office, and they saw (R1)'s bank statement with a PIN written on it. On 09/16/2024 at 2:38pm, V1 (Administrator) stated I have to search (V5)'s office regardless. I ended up searching his whole office. There was a bank statement for R1. I know it is a PIN number because it has word PIN written on it. The (09/18/2024) email correspondence with V1 (Administrator) documented, in part Here is the list of residents' items retrieved from (V5)'s office. (R1) Assurance wireless notice, bank statement dating January 27th thru February 27th. 2. On 09/16/2024 at 11:27am, V25 (President-(Private Investigator's) Group) stated another resident (R6) gave her debit card to (V5) who told her he will take care of her finances for her. On 09/16/2024 at 2:48pm, R6 stated I have about $2000 on my bank card. I gave my bank card to (V5) probably in December of last year. (V5) is keeping my bank card in case I need something from the store. (V5) did not tell me I could have (V4) keep the bank card for me. (V5) said let me have your bank card and I will take care of your financial stuff. (V5) knew I have a bank card because whenever I need stuff from the store, I would give him my bank card. I never received my bank statement here because I don't want these people to know my finances. I called the bank today and they said I have a dollar in my account. Surveyor inquired how R6 felt about her missing bank card and having a dollar in her (R6) account. R6 stated, I am so pissed I can pee. It means I am very mad; (V5) took all my money. This surveyor inquired who was sending money to R6. R6 stated I get a pension every month. I wrote my PIN on a piece of paper and handed it to (V5). On 09/17/2024 at 1:20pm, V15 stated I have never seen the card; but (R6) is not going to say falsely about it. I know from time to time (V5) would go to the store to buy whatever miscellaneous things (R6) needs. When I asked (R6) does anybody have access to your card? (R6) said yes, (V5) has access and he knows the pin to the card. I asked why and (R6) said because (V5) is going to take care of my finances for me. At that point, I told (R6) Stop we are going down to (V1)'s office. In (V1)'s office, I made (V1) aware of the situation and called (R6)'s bank. We (V1, V15, and R6) canceled the card and we asked for 90 days' worth of bank statements. I asked for the last 10 transactions. Most of them occurred on 09/03/2024. (R6) was shocked because she had a deposit made on 09/03. The customer service mentioned that some of the transactions were (Person to Person mobile payment application), there were at least 2 transactions of $200. It appeared, whoever is doing it, is just cleaning out the account, emptying the bank account. There were couple A***** transactions. (R6) said she did not consent to those transactions. While (R6) was listening to this, she was so shocked. (R6) was saying Oh, my God! Oh, my God! Oh, my God! It is not expected of PRSC or staff, per se, to take the card with them without the resident present. (V5) was trying to help (R6) out but he has too much access to resident information like the resident's PIN number. On 09/23/2024 at 2:29pm, V15 stated we just received (R6)'s bank statement. V15 showed this surveyor the transactions on R6's (07/2024- 09/2024) bank account. V15 stated (R6) has $750 deposit on 09/03. On the same day (09/03) there were multiple (Person to Person mobile payment application) transactions to K*****h C****. According to (V1), K*****h is (V5's) middle name. There were 9 transactions on 9/03 and 1 transaction on 09/04. (R6) will not make those transactions because she had not realized that she has that money yet on the 09/03. Obviously, (R6) is getting $750 at the beginning of the month. I don't think (R6) has (Online Music Streaming Service). That is an online streaming app for music. I can guarantee you, (R6) did not have a (Online Music Streaming Service). R6's Bank statement dated 07/10/24, documented, in part Deposits and credits: 7/01 benefit payment deposit - $750. Checks and other debits: 7/01- (Online Music Streaming Service) $10.99. Checking account Summary and Detail: ending balance: $65.29. R6's Bank statement dated 08/09/24, documented, in part Deposits and credits: 8/01 benefit payment deposit - $750. Checks and other debits: 8/01 - ATM W/D Card # $408.00. 8/08 (Online Music Streaming Service) - $11.99. Checking account Summary and Detail: ending balance: $60.13. R6's (09/10/24) bank statement documented, in part Deposits and credits: 9/03 benefit payment deposit - $750. Checks and other debits: 9/03 Cash App * K*****h C**** - $15.00. 9/03 (Person to Person mobile payment application), K*****h C**** $80.00. 9/03 (Person to Person mobile payment application), K*****h C**** $200.00. 9/03 (Person to Person mobile payment application), K*****h C**** $200.00. 9/03 (Delivery and Ride Service Subscription) $96.00. Checking account Summary and Detail: ending balance: $1.85. R6 Admission Record documented that R6's diagnoses include but not limited to chronic obstructive pulmonary disease, unspecified; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R6's census list documented that R6 was moved to the 6th floor on 11/29/2023. R6's Minimum Data Set, dated dated dated [DATE], documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 14. Indicating R6's mental status as cognitively intact. Section GG. GG0170. Mobility. J. Walk 50 feet with two turns: 88 - not attempted due to medical condition or safety concerns. R6's State initial reportable dated 09/10/2024, documented, in part Resident reported that her bank card is missing. R6's State Final reportable dated 09/17/2024, documented, in part The following is a response to an incident that occurred on 09/10/24 whereby a resident (R6) reported that her bank card was missing. (R6) stated last person that had (the bank card) was (V5). Investigation revealed that electronic payment method/debit card was used for what appear to be unauthorized charges. R6's PRSC Progress note dated 12/25/2023 at 9:16, documented, in part Resident present with a history of frivolous money management. PRSC will educate resident on setting goals to handle finances, savings, possible investing. R6's Care plan dated 09/16/2024, documented, in part Resident is at increased risk or has experienced financial abuse secondary to psychological and/or medical diagnosis. Will be free of any financial abuse occurrences. Assist resident with addressing financial situations with business office. The (09/06/2024) email correspondence with V1 (Administrator) in response to the inquiry of this surveyor Do you have Ethics policy and procedure in reference to receiving gifts (monetary/kinds/goods) from residents? If you do not have a policy, what are your expectations? V1 wrote in response In our employee handbook it is said that no personnel or persons associated with the facility will accept gifts of money or goods of material value, favors remuneration or other compensation from any client. The CNA Supervisor job Description dated 4/21/23, documented, in part Ensure that Resident Belonging is completed upon admission and as needed and up to date. The PRSC (Psychiatric Rehabilitation Services Coordinator) Job Description (Undated) documented, in part Summary: In keeping with our organization's goal of improving the lives of the Guests we serve, the PRSC is responsible for the overall administration, coordination, and evaluation of the social services function to meet and maintain the mental and psychosocial well-being for (of) each Guest. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 4. Coordinates the inspection of guests belongings to ensure they are properly labeled and inventoried. The Front desk/Security Job Description dated 1/26/2024, documented, in part Summary: The front desk/security staff attend to visitors by greeting, welcoming, and directing them appropriately; notifies company personnel of visitor arrival; maintains security and telecommunications system. Essential Responsibilities: 5. Monitor entrance and departure of employees. This includes overseeing the log-in and log-out books. Ensure staff and responsible party are signing resident out when leaving the facility. The Personal Property Policy and Procedure dated 01/24/2024-4163, documented, in part It is the policy of the (Facility) to permit residents to retain personal property items as long as they do not infringe upon the rights of other residents or affect the safety and well-being of the residents. Procedure. 5. The belonging list shall be updated as needed upon receiving new item. The Signing Patients Out When Leaving the Building policy dated 01/01/2024, documented, in part Intent: Signing patients out when staff are taking residents out of the building. Procedure: This policy ensures that when any resident is taken out of the building by a staff member, that staff member is to sign the patient in and out at the front desk with a date and time. The Ordering Items for Residents policy dated 01/01/2024, documented, in part This policy ensures that items ordered for residents by staff in the facility are done properly and complies with any (Facility) Healthcare policies. Procedure: If staff orders items online for the residents, they are to be shipped and received to the facility. The Abuse Policy dated 1/4/24, documented, in part It is the policy of the facility that each resident will be free from abuse. Abuse can include misappropriation of resident property and exploitation. Additionally, residents will be protected from abuse while they are residing at the facility. No abuse or harm of any type will be tolerated. The facility presented a removal plan on 09/16/2024 at 3:18pm and was not approved. A revised Removal Plan was submitted on 09/17/2024 at 12:26pm and was not approved. A revised Removal Plan was submitted on 09/18/2024 at 2:52pm and was not approved. A revised Removal Plan was submitted on 09/18/2024 at 3:36pm and was approved. On 09/19/2024 at 12:37pm, further review of the revised Removal Plan that was submitted on 09/18/2024 at 3:36pm documented no in-services for abuse and resident's belonging which was previously noted on the revised Removal Plan submitted on 09/17/2024 at 12:26pm. On 09/19/2024 at 2:58pm, V1 was informed of the discrepancies on the removal plan provided to this surveyor. V1 stated I don't know what happened let me ask (V29 - Management Consultant). A revised removal plan was submitted on 09/20/2024 at 9:26am and was not approved. A revised removal plan was submitted on 09/20/2024 at 3:20pm and was approved. The Immediate Jeopardy that began on 03/25/2024 was removed and the deficiency remains at a level 2 on 09/23/2024. On 09/23/2024 at 4:29pm, V1 (Administrator) stated I initiated in-services again, and still ongoing about abuse and resident's belongings when you first came here on 09/03/2024. Surveyor confirmed the following: The (09/03/2024) Abuse in-service was reviewed with no issue noted. Attached documents 7signs of nursing home abuse, how to prevent abuse, and abuse policy and procedure. The (09/03/2024) Resident Belongings in-service was reviewed with no issue noted. Attached Resident belonging documented, in part No one is allowed to hold any resident's wallet, cards, or money. On 09/19/2024, V26 (Activities Aide), V30 (Maintenance Assistant), V31 (Maintenance Director), V32 (CNA), V33 (PRSC (Psychiatric Rehabilitation Services Coordinator), V34 (Housekeeping/Maintenance), V35 (Housekeeping/Laundry Supervisor), and V36 (Dietary Supervisor) all affirmed in-services were received in the month of September about abuse and resident belongings. The (revised 09/04/2024 and 09/09/2024) personal property policy and procedure, The (09/16/2024) new employee health care worker background check, and the (09/19/2024) Online Purchase for Resident were reviewed and appropriate revisions were made that were included in the removal plan. V1 Removed V5 from the facility on September 4, 2024, suspended without pay pending investigation as part of actions to mitigate risks to R1 and any other resident. Suspension status will remain until investigation concludes. If facts are founded, V5 will be terminated immediately with appropriate reporting to Health Care Worker Registry. On 09/19/2024 at 9:54am, V1 (Administrator) stated V5's time sheet and the write up are my proofs that he is not at the facility at this time. It still an ongoing investigation and we get outside help to make sure we thoroughly go through the situation, and it does not happen again and to find out who did it. V5's Employee Disciplinary Action dated 09/04/2024, documented, in part Type of offense: Possible fraudulent activities in multiple occasions. PRSC (V5) has taken resident out to the bank multiple times and on all these dates there are suspicious activities in which the patient (R1) states that he does not recognize. (V5) is suspended pending investigation. V5's Timecard from 09/01/2024-09/19/2024 indicated no entry since 09/05/2024. On September 4, 2024, V1 implemented a revised personal items log to account for resident personal items such as debit, credit, ID, and wallet. (see attached Exhibit F Personal Items Log which includes the date, personal items requested, resident name, employee name, date/time of personal item given to resident, date/time of personal item returned from resident, as well as the purpose of the request). The Resident In and out log (Debit card, ID, and Wallet), (undated), was reviewed with no issue noted. R7's Resident in and out log (Debit Card, ID, and Wallet) dated 09/12/24 and 09/16/24, provided date, employee name, resident name, out, in and purpose with attached [NAME] and bank withdrawal receipts. On 09/19/2024 at 11:44am, V4 unlocked the office on the 5th floor with a key. Inside the room, V4 showed her desk with 3 drawers on the left side. The 2nd drawer was locked. V4 stated only the administrator and myself have the key to the second drawer. V4 attempted to open the drawer with no luck. Unable to open the drawer by just pulling the door handle of the drawer. V4 opened the drawer using a key and showed this surveyor R1's and R6's valuables. On September 4, V1 Revised the resident personal property policy to include the following language regarding investigating misappropriation of resident funds/property (see attached Exhibit G - (Facility) Personal Property Policy and Procedure) In the event a claim is made regarding misappropriated funds or property, the Administrator will be made aware immediately and any potentially involved employees will be removed immediately from the building with an immediate independent investigation conducted to mitigate any potential risks to residents. All other prudent measures will be taken to mitigate risks including canceling accounts with questionable charges until investigations are complete. The revised personal items log in addition to the requirements of the new policy requiring witnesses and receipts, and a detailed log of community visits including the staff members who accompanied the resident, date and time will address concerns regarding not only accounting for resident and staff going out on community pass but also Accounting for resident belongings and safeguarding against theft. In addition, the revised policy includes that once the investigation is complete, the facility will assist the resident in retrieving any loss of value owed to the resident. The actions address a system of investigating the potential misappropriation of resident funds. The Personal Property policy and procedure dated 09/04/2024, documented, in part 9. In the event a claim is made regarding misappropriated funds or property, the Administrator will be made aware immediately and any potentially involved employees will be removed immediately from the building with an immediate independent investigation conducted to mitigate any potential risks to residents. once the investigation is complete, the facility will assist the resident in retrieving any loss of value owed to the resident. The actions address a system of investigating the potential misappropriation of resident funds. 10. All other prudent measures will be taken to mitigate risks including canceling accounts with questionable charges until investigations are complete.