Every finding on record at Montgomery Place

Based on interviews and record reviews, the facility failed to assess one [R1] resident risk of an accident, identify, implement interventions measures to reduce the hazards or risk as much as possible consistent with R1's needs, goals, care plans and current professional standards of practice to reduce the risk of an accident out of four residents reviewed.These failures resulted in R1 sustaining a right elbow dislocation with mildly displaced fracture of the tip of the coronoid and olecranon process from an unknown origin. Findings Include R1's clinical record indicates the following in part. R1 is a ninety-five-year-old admitted [DATE] with the following medical diagnosis of dementia with mood disturbance, major depression disorder, anxiety disorder, Alzheimer's disorder, dislocation of right ulnohumeral joint, subsequent encounter, essential hypertension, overactive bladder, and chronic kidney disease. R1's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score indicates R1 is cognitively impaired, care plans, medication administration record, treatment administration record, and progress notes were reviewed. R1's hospital notes documented in part:(Page #13) R1 arrived at the hospital at 7:11AM. admission 7/11/26, discharged on 7/13/26.Diagnosis: Right elbow dislocation with mildly displaced fracture of the tip of the coronoid and olecranon process. Dementia with behavioral disturbances. R1's, minimum data set [MDS] in part:R1 is dependent on toileting hygiene, bathing, dressing, personal hygiene, rolling left and right, sitting to lying, and transferring. Nursing staff does all the effort. R1 makes no effort to complete the task. R1's Care Plans reviewed, behavioral care plan and interventions were not documented. Elbow dislocation and interventions were not documented. Reviewed completed care plan with V1 [Administrator], V2 [Director of Nursing] and V15 [MDS Coordinator] all said there was no care plan for behaviors nor R1's dislocated elbow documented. R1's Progress Notes documented in part:V11 [Licensed Practical Nurse] 7/10/26 at 3:55PM Health Status Note Text: Writer called to R1's room by V8 [Certified Nurse Assistant] made writer aware that R1 right arm was swollen. R1 was observed lying in bed, R1 assessed and writer observed right elbow. R1's right elbow red, swollen, warm and painful to touch. Writer administered PRN dose of Tylenol and right arm elevated, NP paged and returned call, orders given for STAT x-ray of right elbow. V2 [Director of Nursing] and family made aware. V15 [Licensed Practical Nurse] 7/10/26 at 10:39 PM Health Status Note Text: Writer received a report regarding R1 X-Ray. R1 has dislocation on the right elbow. V15 [Licensed Practical Nurse] 7/11/26 at 6:04 AM Clinical Note: R1 was sent out to the hospital. Writer notify the V2 [Director of Nursing], V1[Administration] and family. V11 [Licensed Practical Nurse] 7/13/26 at 6:22PM, admission Summary R1 returned from the hospital. R1 with splint to right arm, no weight bearing until follow up appointment. 7/29/26 and 7/30/26, observed R1 resting in bed with right arm in sling. Call light and personal items in reach. On 7/29/26 at 10:40AM, R1 stated, I am okay. A witch hurt my arm, I don't remember. I am hungry for lunch. On 7/31/26 at 10:57AM, V7 [Certified Nurse Assistant] stated, I worked at the facility for three years. I worked on 7/9/26 night shift from 11PM to 7AM, I was assigned to R1 that night shift. R1 is alert and oriented x1 and confused. R1 is usually woke all night watching television. R1is combative, calls you out of your name, saying she hopes I die, holding her hands like claws, scratching, biting, spitting, and kept talking about the devil. R1 is able to roll from side to side and hold on the side bars on the bed. On 7/9/26, I checked R1 every two hours and she was dry. R1 did not urinate, did not have a bowel movement. I did not have to change her under brief all night for the entire shift. I did not report that R1 did not have any output. I usually chart on my residents every shift, but I have not had access to chart for over two months, V1 [Administrator] was made aware, and the administration has not done anything about it. I did not change R1's night gown, it was clean.[Surveyor asked how could R1 hold on the to side bar and her right hand is contracted] V7 stated, V7 stated, I did not know R1's right arm was contracted. I took care of her at night so did not know. I was suspended one day pending investigation due to R1's injury. In the past I was suspended two more times for abuse allegations. On 7/30/26 at 11:38 AM, V8 [Certified Nurse Assistant] stated, I started working here in May 2026. I am familiar with R1. R1 is alert and oriented x1 and confused most of the time. Usually during ADL/incontinence care R1 becomes combative. R1 yells out she wants to kill you, hitting, and scratching with the left arm. Since I started working here in May, R1 has not been able to move her left arm. R1's left arm is contracted. I worked on 7/10/26 day shift from 7AM to 3PM. R1 was assigned to me on my set of residents to care for. I made rounds and R1 was resting in bed with a clean gown on and I checked her front of the under brief and R1 was dry. I checked on R1 around 9:30 AM, during breakfast. I assisted R1 with her meal and she was still clean and dry. After lunch around 2PM, R1's gown was dirty from eating lunch and she was wet and needed to be changed. While performing care, I asked V4 [Certified Nurse Assistant] for assistance. R1 is a two-person assist while performing ADL/incontinent care, due to not being able to move well and her combative behaviors. V4 and I entered R1's room I explained to R1 that we were going to change her under brief and gown. I went to remove R1's gown and R1 began to yell out, no! My arm is broken. I gently lifted up her sleeve, and R1's right arm by the elbow was swollen big as two soft balls, hard and dark red. I immediately got the nurse. The nurse assessed her and the three of us got R1 cleaned up and her gown changed. R1 did not complain about any pain, until I went to remove her night gown. I knew R1's right arm was contracted. When I first started working here, the nurse told me to be careful of her right arm because it was fractured in January. When R1 becomes combative, I stop and talk to R1 to distract her and one of us will hold her hand and talk about different things while the other aide cleans R1. On 7/30/26 at 11:45AM, V4 [Certified Nurse Assistant] stated, I worked night shift on 7/9/26 11PM-7AM, continued to work into 7/10/26, 7AM to 3PM. On 7/9/26 night shift I did not have R1's room, she was not my resident to attend to. R1 was on V7's assignment. I did not see R1 during the night shift on 7/9/26. It was only V7 and I was working as certified nurse assistant. It always takes two nurse assistants to change R1, because she is confused and combative. R1 always needs multiple changes during the night due to her overactive bladder disorder. R1 is woken all night long eating snacks and drinking water. On 7/9/26, V7 did not ask me for assistance to clean R1, I had no contact with R1 that night. On 7/30/26 at 2:38 PM, V5 [Agency Registered Nurse] stated, I worked 7/9/26 night shift from 7PM to 7AM. I was R1's nurse. I did not receive any reports from V7 [Certified Nurse Assistant] that anything was wrong with R1's elbow. When I made rounds R1 was at her usual baseline. I worked several times with R1, and she requires two persons assist, due to R1 being combative. That night V7 did not ask me for assistance to clean R1. On 7/30/26 at 1:18PM, V11 [Licensed Practical Nurse] stated, I worked on 7/10/26 day shift 7AM to 7PM. I was R1's nurse. V4 [Certified Nurse Assistant] was R1's nurse assistant. Around 2PM, V4 came to get me and said R1's right elbow was swollen. I went immediately and assessed R1. I observed R1's right elbow. R1's elbow was swollen a lot, red, warm and hard to touch. R1 was yelling out saying 'my arm is broken'. I gave R1 pain medication and notified R1's nurse practitioner, Director of Nursing and R1's family. The nurse practitioner ordered a STAT Xray of R1's arm. The mobile Xray service came and took R1's X Rays but by the time the results came in, I was gone. On 7/30/26 at 3:44PM, V15 [Licensed Practical Nurse] stated, I worked on 7/10/26 from 7PM to 7AM, I was R1's nurse. I received a report of R1's elbow. R1's Xray results came around 11PM. R1 was sent to the hospital shortly after that, maybe around 1AM. I was busy helping the agency nurse and then I sent R1 to the hospital, I don't remember what time it was. I did notify the physician, director of nursing and administrator.[R1's hospital documented in part: (Page #13) R1 arrived at the hospital at 7:11AM.] On 7/30/26 at 11:25 AM, V12 [Medical Director] stated, I am familiar with R1. I made wound rounds the wound physician and I assessed with R1 skin assessment. On 7/9/26, early afternoon, I assessed a skin rash on R1's back. There was no swelling or discoloration to R1's right arm elbow area. R1 was being combative, grabbing and hitting, I crossed R1's arms in front of her chest and I wrapped her torso with a sheet. We were able to roll R1 gently over to her side for the assessment. During the assessment, there were no signs of pain or distress and no evidence that R1 had an injury at that time. I am positive R1 was not abused. When R1 was in the hospital emergency department, R1 had the type of dislocation they used to call the injury a nursemaids' elbow known as a pulled elbow injury. I think it was an incident that someone pulled R1's arm and did not know it was contracted. I cannot say for certain, that's what happened, because I was not there. On 7/30/26 at 3:50 PM, V2 [Director of Nursing] stated, On 7/10/26, I was called to R1's room around 1PM and I saw R1's right arm was swollen and tender to touch. R1 could not explain what happened. I was notified of R1's results on 7/11/26 early morning I don't remember the time. R1 sustained a right elbow dislocation. V1 [Administration] was made aware and started the investigation. R1 does have combative behaviors. The nursing staff should always give R1 time to calm down and there is always two nursing staff during care due to her behaviors. [Surveyor and V2 reviewed R1's complete care plan together]. V2 stated, There is no care plan for R1's combative behaviors. There is no care plan regarding R1's elbow dislocation. The team comes up with the interventions, and the MDS coordinator is responsible for placing them in the resident's care plan. There should have been a care plan for R1's combative behaviors and interventions, and for the dislocated elbow. I have not in-serviced staff about R1's incident. On 7/30/26 at 4:35PM, V1 [Administrator] stated, On 7/10/26, I was made aware that R1's elbow was swollen and was getting a Xray. On 7/10/26 around 11PM, R1's X Ray results came in. On 7/11/26 R1 was sent to the hospital early that morning.I don't know what happened to R1's elbow. I could not rule out abuse nor say it was abuse. The medical director and wound care physician assessed R1 on 7/9/26 during the day shift, and there was no swelling to R1's arm. The injury occurred between 7/9/26 day shift to 7/10/26 around 2PM. I interviewed all the staff and residents and could not identify any concerns. V7 was suspended one day and brought back to work. I had no evidence that any particular staff did any harm to R1. I know R1 did not fall out of bed, she is not mobile in and cannot roll or get up with assistance. I do not recall care plans for R1's behaviors or her dislocated elbow. The care plans are in place to hopefully prevent and minimize recurring incidents by placing in interventions. To allow staff to have a resource document staff can review to understand what to do for the residents. I did not come to any conclusion about what happened to R1's elbow. I have not in-served staff regarding R1's incident. Policy in part:Injury of Unknown Origin PolicyAny injury observed on a resident for which the cause cannot be immediately determined shall be treated as an injury of Unknown Origin until an investigation is determined otherwise. The facility will promptly assess the resident, provide necessary treatment, investigate the circumstances, notify appropriate individuals, and implement interventions to prevent recurrence.Such as bruises, swelling, fractures, and unexplained pain or tenderness.Procedures:Care Plan: Review contributing factors, update the care plan, implement interventions to reduce the risk of future injury.Educate staff regarding any identified concerns.

Based on interviews and record reviews, the facility failed to follow their Injury of Unknown Origin Policy and report an injury of unknown origin within two hours of the incident to IDPH [Illinois Department of Public Health] for one [R1] out of four residents reviewed. Findings Include R1's clinical record indicates the following in part. R1 is a ninety-five-year-old admitted [DATE] with the following medical diagnosis of dementia with mood disturbance, major depression disorder, anxiety disorder, Alzheimer's disorder dislocation of right ulnohumeral joint, subsequent encounter, essential hypertension, overactive bladder, and chronic kidney disease. R1's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively impaired, care plans, medication administration record, treatment administration record, and progress notes. R1's hospital notes documented in part:(Page #13) R1 arrived at the hospital at 7:11AM. admission 7/11/26, discharged on 7/13/26.Diagnosis: Right elbow dislocation with mildly displaced fracture of the tip of the coronoid and olecranon process. Dementia with behavioral disturbances. On 7/30/26 at 1:18PM, V11 [Licensed Practical Nurse] stated, I worked on 7/10/26 day shift 7AM to 7PM. I was R1's nurse. V4 [Certified Nurse Assistant] was R1's nurse assistant. Around 2PM, V4 came to get me and said R1's right elbow was swollen. I went immediately and assessed R1. I observed R1's right elbow. R1's elbow was swollen a lot, red, warm and hard to touch. R1 was yelling out saying 'my arm is broken'. I gave R1 pain medication and notified R1's nurse practitioner, Director of Nursing and R1's family. The nurse practitioner ordered a STAT Xray of R1's arm. The mobile Xray service came and took R1's X Rays but by the time the results came in, I was gone. On 7/30/26 at 3:44PM, V15 [Licensed Practical Nurse] stated, I worked on 7/10/26 from 7PM to 7AM, I was R1's nurse. I received a report of R1's elbow. R1's Xray results came around 11PM. R1 was sent to the hospital shortly after that, maybe around 1AM. I was busy helping the agency nurse and then I sent R1 to the hospital, I don't remember what time it was. I did notify the physician, director of nursing and administrator.[R1's hospital note documented in part: (Page #13) R1 arrived at the hospital at 7:11AM.] On 7/10/26 at 4:35PM, V1 [Administrator] stated, On 7/10/26, I was made aware that R1's elbow was swollen and was getting a Xray. On 7/10/26 around 11PM, R1's X Ray results came in. On 7/11/26 R1 was sent to the hospital early that morning. I sent the initial IDPH report on 7/11/26 at 8:08 AM. According to the facility's policy on injury from unknown origin, I should have sent the report on 7/10/26 due to the swelling from an unknown source. Policy in part:Injury of Unknown Origin PolicyTo ensure all injuries of unknown origin are promptly identified, assessed, investigated, documented, and reported in accordance with facility policy and applicable to federal and state regulations to protect the health, safety, and rights of residents. Any injury observed on a resident for which the cause cannot be immediately determined shall be treated as an injury of Unknown Origin until an investigation is determined otherwise. The facility will promptly assess the resident, provide necessary treatment, investigate the circumstances, notify appropriate individuals, and implement interventions to prevent recurrence. Such as bruises, swelling, fractures, and unexplained pain or tenderness. Abuse policy:Immediately report any reasonable suspicion of a crime committed against a resident of the facility to the state survey agency in fulfillment of the statutory directive. Immediately means not later than two hours after the allegation is made if the events that cause the allegation result in serious bodily injury.

Based on observations, interviews, and record review, the facility failed to protect a resident's right to be free from physical abuse by a staff member and failed to immediately report an allegation of abuse to the designated abuse coordinator. As a result, Resident (R1) remained fearful, and the alleged perpetrator continued to be assigned to provide care after the allegation was reported to the nurse. The failure to promptly report the allegation had the potential to delay the investigation and place residents at risk for further abuse. This deficient practice affected one (R1) of three residents reviewed for abuse. Findings include:R1 had diagnoses including dementia, mood disorder, chronic pain, seizures, and other chronic conditions. The Minimum Data Set (MDS) dated [DATE] indicated R1 had moderately impaired cognition, with a Brief Interview for Mental Status (BIMS) score of 12 out of 15, placing R1 at increased risk for vulnerability related to abuse and reporting concerns.On 7/10/2026 at 11:10 a.m., R1 stated that a Certified Nursing Assistant (CNA) entered her room during the night, abruptly pulled her covers off, and startled her, causing her to fear for her life. R1 further reported previous interactions with the same staff member where the care provided was so rough that she felt as if her bones were being crushed. R1 stated she was so frightened following the incident that she could not remember her son's phone number and reported the concern to V6, R1's son, the following day.On 7/10/2026 at 11:31 a.m., V3, Licensed Practical Nurse (LPN), stated she received a text message from V6, R1's family member on 6/7/2026 reporting that R1 had complained about a staff member who treated her harshly. The following day, V6 further reported that R1 stated a staff member entered her room, threw her bedding off, and that there had been a prior incident involving the same individual. V3 acknowledged she did not immediately report the allegation to the Administrator on 6/7/2026 and instead waited for clarification from the family member and reported the allegation of rough handling to V1 on 6/8/2026.Facility staffing records showed V2, Certified Nursing Assistant/CNA, was assigned to provide care to R1 on 6/4/2026, 6/5/2026, and 6/7/2026 during the 11:00 p.m. to 7:00 a.m. shift and continued to be assigned to R1 after the abuse concern was initially reported.On 7/10/2026 at 1:20 p.m., V1, Administrator, stated the allegation was reported to her on 6/8/2026. V1 stated she was not aware of what V6 (R1's son) texted to V3 (LPN) on 6/7/2026, V1 was only shown the text message dated 6/8/2026 and not the one from 6/7/2026.V1 stated the investigation determined V2's approach toward R1 was inappropriate and that R1 was legitimately afraid. V1 further stated that if the information received from V6 on 6/7/2026 represented an abuse allegation, the nurse should have reported it immediately. V2 was later terminated on 6/9/2026 due to a positive drug test related to a separate workplace incident; however, V1 confirmed V2 was not terminated due to R1's allegation.The facility Abuse Prevention Policy and Procedure dated 9/15/2024 states the facility will not condone abuse or neglect of any resident by any person.The facility failed to ensure R1 was immediately protected from potential abuse, failed to ensure the allegation was promptly reported for investigation, and failed to prevent continued assignment of the alleged perpetrator. As a result, R1 experienced actual psychosocial harm, including fear and distress related to the alleged abuse.

Based on interview and record review the facility failed to ensure that one resident R2 was free of medication error. This failure affected 1 of 3 residents reviewed in the facility.On 06/22/2026 at 1:55 PM, R2 was observed in bed. On the door the names that were labeled read R5(A), R2(B). When surveyor entered the room and observed the bed B empty, the resident in the first bed asked me who I was looking for and stated she was R2 and that R5 had discharged home. R2 stated she feels safe in the facility despite receiving the wrong medication from a nurse a few weeks ago. R2 stated that the nurse entered her room and gave her a cup of pills that she took. Then a few moments later the nurse returned back and said that she had pills for R2, when I stated to the nurse that you already gave me pills that is when the nurse said oops, I thought you were R5 because the way the door is labeled. R2 states she is only here temporarily for therapy and will be going back home and she has not seen that nurse since.R2 stated after receiving the wrong medications she was feeling tried and drowsy for a few days.R2 instructed me to speak with her daughter further related to the wrong medication administration. R2's face sheet dated 06/23/2026 documents, in part, readmitted to facility on 05/07/2026 with diagnoses of anemia, diabetes mellitus, idiopathic aseptic necrosis of right femur, fracture of rib on left side, pleural effusion, hypertensive heart, heart failure, chronic kidney failure, atrial fibrillation, muscle weakness, cognitive communication deficit, history of falls, obstructive sleep apnea. R2's Minimum Data Set (MDS) for Cognitive Patterns dated 05/13/2026 documents, in part, R2's Brief Interview for Mental Status (BIMS) score is 13, indicating cognitively intact.R2's Care plan dated 04/07/2026 documents in part that R2 is at risk for decreased cardiac output[Intervention: staff to monitor R2 for orthostatic blood pressure and if positive, alert physician, evaluate blood pressure, evaluate for change in level of consciousness, evaluate heart rate, evaluate pulse oximetry].On 06/22/2026 at 2:02 PM,V6 ( Licensed Practical nurse) stated she is the nurse for R2 and that R2 is alert x 4 and able to make all needs known to staff. V6 stated when she came to work on 06/08/2026 V13(Occupational therapy assistant) informed her that R2 told her she received the wrong medication and she immediately informed the V2 ( Director of Nursing). V6 stated she was not the nurse that performed the medication error but that she monitored the patient closely during her shift and observed that R2 was having altered mental status which she relayed to the physician and received orders for urinary culture. V6 did not document in medical record a blood pressure or vitals for R2 on 06/08/2026. V6 stated she is not sure if the medication error contributed to R2's change in condition, but after a medication error administration R2 should be monitored for three to seven days and documentation should be done.On 06/24/2026 at 11:43 AM,V13 (Occupation therapy assistant) stated on 06/08/2026 she was providing room therapy to R2 and R2 reported that she was not feeling well because she received the wrong medication on 06/06/2026.V13 stated she clarified with R2 that she meant that the medication she received was not for R2,at that point V13 went and got the nurse V6. V6 came into the room and asked R2 the same questions about the medications being administered to her that were not for R2 and that is when V2 entered the room.V13 stated that she observed R2 with tremors that was different from any other time she had provided therapy to R2.On 06/23/2026 at 2:50 PM, V15 (Registered nurse) stated she has been working at the facility through agency staff for over one year now.V15 stated when she started a year ago the names on the door were confusing to her because the way the doors are labeled, bed two is actually bed A and bed one is bed B.V15 states she uses other residents identifier to identify a resident such as photo in chart, wrist band if they have one or ask another staff member.On 06/23/2026 at 11:02 AM, V11(Registered nurse) interview on phone . stated the medication error occurred on 06/06/2026 on a Saturday evening. V11 stated she worked 7pm-7am on 06/06/2026 and she went into the room of R2, V11 stated she called out for R5's name 3 times and then R2 answered, R2 did not have on wrist band. V11 stated that the resident's door name tags are confusing because R2(B) and R5(A). V11 stated after R2 swallowed the medication that is when R5 woke up and stated she was R5. V11 stated that R5 told her she was confused and that is why she responded to R5's name but at that point it was too late because she has swallowed the medications already. V11 stated she informed R2 to let her know if she was having a change in condition to inform V11. V11 stated she completed an assessment on R2 and monitored R2 over the night. V11 stated she did not call the physician on call or use the facilities on call physician service because she was capable of monitoring R2 and that R2 was fine. V11 stated that since R2 did not require hospitalization then she would have called the doctor.V11 stated she attempted to reach V2 but there was no answer and no message was left.V11 stated she informed R2 to call her daughter and inform her of the medication error because she didn't think to call the family and no number was in chart. V11 stated there is no supervisory staff over the weekend available. V11 stated she was in contact with the facility on Monday, 06/08/2026 by V2 who informed me to send her a text message of what occurred on 06/06/2026. V11 stated that R2 has no adverse reaction and vital signs were fine and she felt that the medications would not cause any harm. V11 stated she did not complete a medication error report. V11 stated that V2 called her on 06/22/2026 (the day the surveyor entered the facility) to inform her that her employment status was being placed on open window status from 06/06-07/06, she did not call it a suspension but told me that I could not pick up any shifts at the facility within that time frame.On 06/23/2026 at 11:54 AM, V12( Family of R2) stated when she came to visit R2 on 06/08/2026,R2 informed her that she was given the wrong medication by a nurse, V12 stated R2 was shaking at that time so she informed the nurse she needed to speak to V2. V12 stated V2 informed her she has to investigate and track down who was the nurse. On 06/09/2026 V12 stated she spoke with V2 and informed her that R2 has on two name badges on her wrist and also the photo is on the computer. V12 stated she told V2 that R2 has a pacemaker and kidney issues and that she was informed by her primary care physician that R2 should not receive more that 200mg Gabapentin daily. V2 informed V12 that the staff would receive in-service regarding medication error and that V11 would be suspended. V12 stated she has asked several times for the incident report and the nurse documentation. V12 stated what if R2 had a stroke. V12 said R2 told her V11 stated oops, I gave you the wrong medications. V12 stated that V2 informed her that the medication error was that R2 only received multivitamins that she was not prescribed.On 06/23/2026 at 12:48 PM, V2 stated she is not sure what date and time she informed the NP/MD because she did not chart it. V2 stated her expectations of the nurse is to notify the family, physician and place an incident report in the system. V2 stated the nurses should monitor and document for 72 hours the condition of the patient and contact physician for any further orders. V2 stated she was not familiar with the on call video physician system but she thinks that is who the nurses are to contact. V2 stated she should have documented. V2 stated that her number is not placed in the electronic system or at nursing's station and there are no steps posted on how to complete an incident report at the nursing station. V2 stated she contacted V12 on 06/09/2026 but was not sure of the time because she did not document the conversation. V2 stated even if she would have charted the nurses would not follow up with charting because they are not good about charting at this facility. V2 stated that V11 has not been back to the facility since incident occurred and that she called V11 on 06/08/2026 after discovering she was the nurse who performed the medication error. V2 stated there was no documentation in the medical record of R2 related to medication error or monitoring from time of incident. V2 stated that she was made aware of the incident from V6 on 06/08/2026. V2 stated that there are no instructions posted on the electronic medical record dash board or at the nursing station on how to complete an incident report and that her (V2's) phone number is not posted at the nursing station either. V2 stated that the nurse should have called the physician and the family to inform them both regarding the medication error. The family should have been notified, and the physician should have been immediately notified of further orders.On 06/23/2026 at 1:59 PM, V1 (Administrator) stated her expectation of the nursing staff when a medication error is discovered is to immediately check was medications were given to the patient and reactions could be called and called the physician right away because the physician is the person who understands diagnosis and they are the experts on medications and the physician would decide the course of treatment from there. V2 should also be notified of the medication along with the family because the family should be notified of anything that may have an impact on the resident's condition. The nurse is expected to monitor the residents' vital signs.On 06/23/2026 at 2:45 PM, V2 stated that Mirtazapine oral tablet 15 milligrams( mg) at 2100 could cause R2 to become drowsy. Azo D-Mannose 500 mg 2 tablets at 2100,Carvedilol oral tablet 6.25 mg at 2100 could cause R2's blood pressure to drop. Eliquis oral tablet 5 mg at 2100, could cause R2's blood to thin and cause her to bleed. Gabapentin capsule 300 mg at 2100, could cause R2 to be drowsy because higher dose. V2 stated that the nursing staff have other ways to identify a resident besides the name on the door. The staff should use name badges or photo that is in chart, or the staff can ask another colleague for verification of the resident.On 06/22/2026 at 2:09 PM, V8 (Nurse practitioner) stated she was not made aware that R2 received the wrong medications by any staff member at the facility.On 06/24/2026 at 11:49 PM,V17 (Medical director) via phone stated that she comes to the facility every Thursday and she was informed on Thursday 06/11/2026 (greater than 48 hours later) by V2 when she was in the facility. V17 stated it is the policy and expectation that the physician is notified with 24 hours of and change in condition of a resident or medication error so the medical team could implement corrective actions. V17 stated she conducts a weekly meeting on Wednesdays with the facility to discuss sentinel events and discuss concerns. V17 stated the discussion and implementation for today will be for the facility to correct the names on the doors to reflect that bed A is the resident in the first bed to decrease confusion and errors. V17 stated Gabapentin, Eliquis, and Mirtazapine would leave the residents system in 24 hours and Remeron could cause some sleepiness. V17 stated Carvedilol would be a concern if the nurse did not monitor the blood pressure for any drops.On 06/24/2026 at 11:56 PM, V2 stated she is not sure why she did not attend the weekly Wednesday meeting on 06/10/2026 to inform V17 of the medication error. V2 stated she is not sure why she was until 06/11/2026 to inform v17 in person of the medication error.On 06/24/2026 at 12:06 PM, V2 reviewed the vital sheets for the blood pressures of R2 from 06/06/2026 through 06/11/2026 and stated there are no blood pressures recorded in the medical record. V2 also reviewed the 24-hour reports from 06/06/2026 through 06/11/2026 no documentation regarding change in condition, medication error or vital signs monitoring.Reviewed medical record from 06/06/2026- 06/10/2026 no documentation related to medication error or monitoring R2's condition or blood pressure. No vital signs from 06/06/2026-06/10/2026 on any shifts.Reviewed R2's Vital summary report dated 06/24/2026 at 12:15 pm documents in part that from 06/06/2026-06/10/2026 there were no documented blood pressures recorded.Review of medication list for R5 displayed on 06/06/2026 that R2 received from V11 include:Mirtazapine oral tablet 15 milligrams( mg) at 2100Azo D-Mannose 500 mg 2 tablets at 2100Carvedilol oral tablet 6.25 mg at 2100Eliquis oral tablet 5 mg at 2100Gabapentin capsule 300 mg at 2100Reviewed R2's medication error-wrong resident form dated 06/08/2026 which documents that R2 had a medication error on 06/06/2026. Incident description: R2 received the wrong medication from nurse. Resident in bed received resident A medication. R2 is listed as B.Immediate action taken Description: R2 was assessed per nurse, vital signs received per nurse. Monitored per nurse. R2's family did not want R2 to go to the hospital. Form does not display that the primary care physician was notified of the medication error. Form was completed by V2(Director of nursing).Facility policy titled Change in condition which is undated documents in part that; Intent: The purpose of this policy is to ensure the facility promptly informs the residents' physician and notified residents representative when there is a change requiring notification. Situations requiring notification include: 1)accident involving the resident which has the potential to require physician intervention.4).upon identification of a change in condition in a resident the nurse will complete an evaluation of the resident's status and document the findings on the change in condition form in the resident's electronic medical record.Facility policy titled medical errors occurrence reporting which is undated documents in part ; Intent: It is the policy of the facility to evaluate any concerns related to medical and or medication errors. Procedure: 1). In the event that a medication error is detected, the individual detecting it will complete the medication variance event form.3). The completed medication error occurrence record will be reviewed the next business day by the signed risk manager, administrator and director of nursing. 4). The completed medical error occurrence record will be reviewed by the medical director. Point of emphasis: all errors will be reviewed and evaluated with the goal of identification of risk and or gap analysis to determine correctio, systematic changes when indicated, in-service and education with appropriate follow-up and monitoring.Facility policy titled Medication administration, general undated documents in part 5). that medication administration should consist of identifying the resident before administering any /all medications.

Based on interview and record review, the facility failed to ensure that a resident (R1) remain free from physical abuse and verbal abuse. This failure affected R1 who was physically (aggressively bear hugged and pushed) abused by V7 (Registered Nurse, RN) and verbally abused (aggressively yelled at) by V7 out of a sample size of 3. Finding include:R1 had diagnosis of but not limited Cerebral Infarction, Acute Respiratory Failure with Hypoxia, Pneumonia, Aphasia, Chronic Kidney Disease, Stage 4 (Severe), Hypertension, Dementia and Alzheimer's Disease.R1 has a Brief Interview of Mental Status Score of 07 that indicates severe cognition impairment. R1's Care Plan focus titled Altered Neurological Status, dated 4/08/2025, documents, in part, Interventions: Monitor for behavioral changes.R1's Care Plan focus titled Elopement risk/wanderer, dated 4/08/2026, documents, in part, Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.R1's Care Plan focus titled Impaired Cognitive Function/dementia or impaired thought processes r/t (related to) Dementia, Impaired decision making, dated 2/15/2026, that documents, in part, Interventions: Cue, reorient and supervise as needed.Initial Reportable to the state agency, dated 5/18/2026, documents, in part, V7 (RN) came from behind him (R1) and grabbed R1's shoulders and walked R1 to his bed. He (V7) loudly told him (R1) to sit down on the bed and not come back out. On 5/18/2026 at about 1:04pm R1 stated that no one abused him. On 5/18/2026 at 1:40pm V4 (Registered Nurse-RN) said, Yes, I have observed physical abuse from a staff member (V7, RN) to a resident (R1). V4 stated on 5/12/2026 at about 7:30pm she observed V7 pull R1's hands behind R1's back and aggressively pushed R1 into his room. V7 stated that she was waiting for the elevator on the 2nd floor and had a clear sight of the interaction that occurred by the exit door by R1's room, on the right side of the hallway. V7 stated R1 had pushed the exit door, and the alarm was going off and V7 pulled and held R1's hands behind R1's back as he was forcibly pushing R1 into R1's room. V7 stated we should not redirect or guide a resident in this manner. V4 stated that V8 (Certified Nursing Assistant) witnessed the entire incident between V7 and R1.On 5/20/2026 at 8:11am V8 (Certified Nursing Assistant) stated on 5/12/2026 at about 7:30pm or so, V8 observed V7 (RN) aggressively bear hug R1 and pulled R1 back into the hallway from the stairwell. Once V7 had R1 in the hallway, he aggressively pushed R1 to his room and was yelling at him and saying, Don't come out, don't come out. V8 stated that V7 was standing by the door saying what is wrong with this guy (R1), he (R1) is going to make me hit him (R1). Surveyor reviewed email documentation to V1 from V10 (Chief Executive Officer), dated 5/18/2026, that documents, in part, follow up interviews from V8 that states: While still on the landing V7 took over redirecting R1, but V8 indicated that V7 was rough with R1; V7 alleges that V7 put his arms around R1's shoulders from behind in what she described as a bear hug. V8 stated that V7 was upset and yelling, allegedly saying things like What's wrong with this guy and He's going to make me hit him; V8 also alleged that V7 yelled at R1 once back in the room, Don't come out.On 5/18/2026 at 2:05pm V5 (Health Services Executive Assistant) stated V4 called her and reported that V4 witnessed rough housing with R1, and V4 said she was standing at the elevator and saw V7 pull R1's hands behind his back and pushed R1 to his room. On 5/19/2026 at 1:04pm V7 (RN) stated that day (5/12/2026), I (V7) came into work, and the exit door alarm was going off because R1 had pushed the door and was trying to leave. The CNA (V8) was trying to get R1 back into the hallway from the stairwell, so I rushed over to assist. V7 stated he went to help V8 because R1 was being combative and swinging his arms and telling us that he wanted to go home. V7 said, I (V7) did shout at him (R1) and told him (R1) to go back to his room. V7 said, No, I did not put my hands on (R1); I held my hands out in front of me as I guided (R1) as I walked behind him.On 5/20/2026 at 3:08pm V2 (Director of Nursing, DON) stated it is not appropriate to aggressively grab, touch or yell at a resident that has dementia or trying to elope and doing this may startle or make the resident fearful. V2 stated you should gently guide them and talk to them softy to redirect their behavior. On 5/202/2026 at 1:32pm V12 (Physician) stated yes, I (V12) was aware of the abuse allegation (towards R1 from V7) and did see R1 yesterday. R1 has dementia with some behavioral disturbance. V12 stated of course, yelling and being physically aggressive to a resident can create more problems and cause the resident to be fearful, withdraw, and refuse care or food. Abuse Prevention Program with no date documents, in part, this facility affirms the right of our residents to be free from abuse, the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment or abuse of our residents and immediately protecting residents involved in identified reports of possible abuse.Job description titled Staff Nurse with a revision date of November 10, 2020, documents, in part, maintain the physical safety of each resident.

Based on interview and record review, the facility failed to timely submit an initial abuse report to the state agency within 2 hours which affected one resident (R1) in the sample of 3 residents reviewed for abuseFindings include: On 5/15/26 at 1:50 PM, V4 (Registered Nurse) stated that she has worked at the facility for 11.5 years, and V4's regular work area is R1's floor and hallway. V4 stated that last 5/12/2026 at 7:17 PM that she immediately reported to V5 Health Services Executive Assistant via phone call the abuse incident she witnessed between V7 and R1. V4 stated that V7 pulled R1's arms behind his back and started to push R1 back to the hallway towards R1's bedroom. V4 stated that it is not a form of redirection and V7's voice was loud telling R1 to go back to his room. V4 stated that's the reason the incident was reported immediately due to aggressive actions by V7 towards R1. V4 stated that on the next day, 5/13/26, she reported the incident again to V1 (Administrator), and V4 provided a signed witness statement to V1. On 5/19/2026 at 2:53 PM V1 (Executive Director) stated that when she (V1) was notified about the abuse incident from V7 (Registered Nurse, RN) towards R1 that occurred on 5/12/26, V1 did the investigation but did not report in a timely fashion and that's her fault. V1 stated that she should report any abuse incident to Illinois Department of Public Health (IDPH) within 2 hours and have 5 working days to submit the final report. On 5/19/2026 at 1:04 PM V7 (Registered Nurse) stated they (V1 {Executive Director}, V2 {Interim Director of Nursing} and V11 {Human Resource Manager}) called him on 5/13/2026 and asked me what happened with R1. Facility document dated 5/18/2026 at 3:30 pm, indicates that V1 (Executive Director) submit the preliminary report for R1 to the state agency via fax. The facility document dated 09/05/2024 and titled (Facility) Abuse Prevention Policy and Procedure documents, in part, Purpose: This policy provides guidelines that aims to prevent, protect, and prompt reporting and interventions in response to alleged, suspected or witnessed abuse, neglect, mistreatment, misappropriation of property, or exploitation of any resident. All residents have the right to be free from mental, physical, sexual, and verbal abuse, neglect, mistreatment, misappropriation of property, and exploitation and to be treated with dignity and respect. Responsibility: Facility will not condone the abuse/neglect of any resident by anyone, including, but not limited to, Registered Nurse (RN), Nurse Practitioners (NP), Licensed Practical Nurses (LN), Certified Nursing Assistant (CNA),. Abuse: is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish. Mental/Verbal Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The facility document undated and titled Reporting Reasonable Suspicion of a Crime in a Long Term Care Facility documents, in part, It is our facility's responsibility to report to IDPH(Illinois Department of Public Health) incidents involving serious physical harm or injury to a resident, in accordance with IDPH licensure requirements Section 300.690 or allegations or reasonable suspicion of abuse, neglect or misappropriation of property, in accordance with licensure regulation 300.3240 and OBRA(Omnibus Budget Reconciliation Act) F326. Facility employees have the obligation to report incidents or suspicion of abuse to the Administrator. If the allegation or suspicion of abuse involved serious bodily injury or sexual abuse, the suspected crime must be reported to IDPH and local law enforcement within two hours of the event. Federal policies make a distinction. Incidents are a facility and facility administrator's responsibility to report to IDPH. The facility document dated 04/29/2026 and titled (Facility) Executive Director of Healthcare Services Job Description documents, in part, Position summary oversees all activities of the nursing home and assisted living business units at Facility in accordance with established policies and federal and state guidelines. Essential duties and responsibilities: Investigates allegations of abuse, neglect and complies with reporting requirements.

Based on interviews and records review, the facility failed to keep protected health information secure for one (R4) of three residents reviewed in a sample of 9. Findings include:R4's medical diagnosis includes but is not limited to mixed hyperlipidemia, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's MDS (Minimum Data Set) section C-Functional Abilities dated [DATE], documents R4's Brief Interview for Mental Status as 7/15, indicating severe cognitive impairment.R4's Physician Order Sheet (POS) dated 12/30/2025 documents: Atorvastatin Calcium Oral Tablet 20 MG (Atorvastatin Calcium). Give 20 mg by mouth one time a day for antihyperlipidemia.R2's Physician Order Sheet (POS) dated 11/15/2025 documents: Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for LIPITOR.On 04/07/2026 at 11:26AM, V3 (R2's family member/Power of power of attorney -POA) stated via phone that R2 was discharged with one packet of medication Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) 30 pills in her name and another packet of (Atorvastatin) 20MG in R4's. V3 provided R4's information on the packet which included R4's personal identifying information which included R4's, name, date of birth , dose to be given which was different from what R2 receives. V3 stated she noticed the wrong medications belonging to R4 when she got home with R2. On 04/08/2026 at 12:25PM, V9 (Registered Nurse-RN (Agency) stated she discharged R2 with all medications as prescribed in the discharge order. V9 stated a resident's medication Bingo card has the resident's name, date of birth , name of medication, dose and time medication is taken. It would be a HIPAA (Health Insurance Portability and Accountability) violation to discharge a resident with another resident's medication because the Bingo cards contain resident's personal protected information. On 04/08/2026 at 12:35PM, V2(Director of Nursing-RN) stated the nurse should review discharge medications with the resident being discharged to make sure they are the right medications. Each resident's medication Bingo cards contain the resident's name, date of birth , name of medication, dose and time to be taken. If a resident is discharged with medication belonging to another resident, that is a HIPAA violation because the medication contains the other resident's personal protected identifying information.Policy titled HIPAA dated 02/02/2026 documents:-This policy establishes the standard and procedures for protecting the privacy, security, and integrity of Protected Health Information (PHI) in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations.

Based on interview and record review, the facility failed to maintain resident safety during a mechanical sit to stand lift transfer and failed to use a two person assist when transferring a dependent resident at high fall risk for one (R1) of three reviewed for safety and mechanical lift transfer. This failure resulted in R1 sustaining a right femoral fracture.Findings Include:R1 is a [AGE] year-old initially admitted to the facility on [DATE] with a diagnosis of fractured tibia/fibula after sustaining a fall. R1's diagnosis include but not limited to Unspecified Fracture of Shaft of Left Tibia, Subsequent Encounter for Closed Fracture with Routine Healing, Fall From or Off Toilet Without Subsequent Striking Against Object, Subsequent Encounter, History of Falling, Pain in Left Lower Leg, Spinal Stenosis, Cervical Region, Polyosteoarthritis, Pain In Left Shoulder, Presence of Artificial Knee Joint, Bilateral, Unspecified Urinary Incontinence, Muscle Weakness (Generalized), Other Reduced Mobility, Need For Assistance With Personal Care, Encounter for Other Orthopedic Aftercare, Pain In Right Hip, Pain In Left Hip, Unspecified Fracture Of Upper End of Right Tibia, Subsequent Encounter for Closed Fracture with Routine Healing.R1's Minimum Data Set (MDS) assessment dated [DATE] indicates R1 has functional limitations in range of motion to one side of upper extremity and both sides of lower extremity and is dependent (the assistance of two or more helpers is required for the resident to complete the activity) for transfers.R1's care plan include that R1 had an actual fall prior to admission during transfer with son, R1 is at risk for falls related to gait/balance problems and has impaired physical mobility.R1's Fall Risk Evaluation completed 08/30/24 indicates R1 is at high risk for falls.Initial facility reported incident with date of occurrence 02/09/26 documents in part, fall with physical harm or injury. V8 (Certified Nursing Assistant) attempted to get R1 out of bed using the sit to stand (lift). V8 stated R1 was strapped in and ready to be moved when R1 pushed forward and began to slip. R1's buttocks (came) off the bed and her feet came off the foot base and (R1) released the handrails causing her to fall down into a kneeling position. R1 sent to hospital emergency room and diagnosis listed as femur fracture.R1 remains in the hospital. R1's hospital records were requested but were still pending receipt upon exit.On 02/14/26 at 11:40 AM, V8 (Certified Nursing Assistant) stated via telephone interview that she has been working in the facility for three years and has been a CNA for eight years. She works at the facility full time and usually works the 3rd shift from 11PM-7AM. V8 stated the overnight shift gets R1 out of bed daily. V8 stated R1 was dependent on care and incontinent bowel/bladder. V8 stated when she first started working with R1, R1 could stand and pivot to transfer but sometime during the summer of 2025 R1 was transitioned to using a sit to stand lift. V8 stated she does not remember the last time she received training on how to use the sit to stand lift and she had no issues using the sit to stand lift with R1. V8 stated R1 does not have very good trunk control, she cannot sit on her own for very long she would lean backwards. V8 stated on Monday, 02/09/26 R1 was up and alert, she changed and dressed her and put the belt support of the sit to stand lift on R1, tightened the belt to fit tightly, connected the hooks on the sit to stand lift, positioned her feet on the base of the list and positioned R1's wheelchair close by in the locked position. V8 stated she pressed the up button on the sit to stand remote and as R1 started to lift up off the bed R1 jerked forward and threw herself toward the sit to stand lift. V8 asked R1, What's going on? Are you okay? V8 stated she started to lower R1 back down to the bed and as she did this R1's buttocks slid off the bed and R1 took her right foot off the base of the sit to stand lift. R1 was still attached to the lift but her toes were touching the floor and R1 was sliding forward. V8 stated she realized she needed help so she had to lower R1 to the floor so she could go get someone to help her. V8 stated when she pressed the down button on the lift to lower R1 to the floor, R1's legs were not out in front of her, they were twisted underneath her body. V8 stated as she lowered R1, her right leg bent inward and was tucked underneath her body, so she was in a seated position on her buttocks with her right leg bent underneath her. V8 stated as soon as she lowered R1 to the floor she went into the hall to get help. V8 asked another CNA (V10) to help her with R1 and when they came back into the room R1 was still in the same seated position on the floor upright with right leg folded underneath her and her left leg was straight out with her back resting on the side of the bed. V8 stated R1 told her that R1's foot hurt and she was in pain. V8 stated she and V10 got on each side of R1 and put their arm under R1's arms with the sit to stand lift to get her up off the floor and put her back into bed (bed was in the lowest position). V8 stated R1 kept saying her right foot was hurting her so V8 ran and told the nurse (V9) to come check R1 out. V8 stated V3 (Registered Nurse) was coming in on duty at that time and she was the one who called the R1's physician. V8 stated R1 kept saying her foot was hurting, her foot was hurting. V8 stayed with her but had to leave before the ambulance arrived to take R1 to the hospital.V8 stated the staff was instructed to use the lifts with two people but she has been using the sit to stand on her own because people are not always available to help her. V8 stated she has never had a problem with doing it on her own before with R1. V8 stated the reason there should be two staff assisting during mechanical lift transfers is so someone can guide the residents and help in case something does happen during the transfer. V8 stated if there were two CNAs there that morning with R1 it could have prevented R1 from getting injured. V8 stated two CNAs could have prevented R1 from sliding off the bed and with two people they would have been able to get R1 back onto the bed instead of having to lower R1 to the floor.On 02/14/26 at 12:57 PM, V10 (Certified Nursing Assistant) stated via telephone interview that she has been working at the facility for one year four months, a CNA for five years. V10 stated she works part-time at the facility on the 11AM-7PM shift. V10 stated she does not use the sit to stand lift by herself, she always goes and gets another CNA to assist her. V10 stated if there is not another CNA available, she leaves the resident in bed because she does not want to risk an injury to the resident or to herself. V10 stated she usually works with V8 and V13 (Certified Nursing Assistant) and V13 asks for her help with transfers but V8 routinely gets R1 up out of bed by herself using the sit to stand lift. V10 stated she knows this because she has never been asked to help V8 transfer R1 using the sit to stand lift. V10 stated on 02/09/26 she was coming out of one of the rooms and V8 asked if she could help her with R1. V10 stated when she came into the room, she saw that R1 was attached to the belt/sling but her butt was on the floor and both of her legs looked twisted underneath her. V10 stated R1 was not suspended in the air she was all the way down on the floor. V10 stated R1 was screaming about her knee and leg. V10 stated it looked like R1 had slipped off the bed maybe when trying to raise the lift R1 slipped off the bed and her legs got caught underneath her. V10 stated R1 does not do well sitting up on her own and does not have good trunk control. V10 stated R1 is very heavy, like dead weight and cannot bear any weight on her legs. V10 stated R1 is anxious and scared of falling so, V10 thinks R1 slid forward as she was getting ready to go up in the lift. V10 said, R1 was screaming really bad. V10 stated they (V8 and V10) each got under one side of R1 and slid her onto the bed. V10 stated R1 was screaming the entire time I'm in pain! and kept complaining about her knee and leg I'm in so much pain, help me, help me! The nurse (V9) came in to assess R1 and then V10 had to go home because it was the end of her shift. They were sending R1 to the hospital. V10 stated she thinks if there was another CNA in there during the transfer R1 would not have hurt herself. V10 stated if there was another staff behind R1 to support her during the transfer R1 may not have been able to slide off the bed.On 02/14/26 at 1:42 PM, V3 (Registered Nurse) stated on 02/09/26 when she came on shift she observed R1 was lying in the bed and her toes were pronated outward. V3 stated R1 verbally told her that R1 was in pain and the pain was coming from legs. V3 called R1's doctor and told them that R1 went down on her legs while she was in the sit to stand lift and she was complaining of pain. The doctor told V3 to send R1 to the hospital and the ambulance was called. V3 stated when staff is using the sit to stand lift there should be two CNAs during the transfer so one can staff can provide assistance while the other one is moving the lift. V3 stated this is a safety measure so the staff assisting can act quickly in the resident needs help to prevent the resident from getting injured. V3 stated R1 cannot sit on her own because she has poor trunk control and cannot bear weight. V3 stated the injury may have been prevented if two staff were there but because she was not there she does not really know. V3 stated having two staff is a preventative measure to prevent injuries like that from happening.On 02/14/26 at 3:30 PM, V2 (Director of Nursing) stated she called the hospital and was told R1's admitting diagnosis was right periprosthetic femoral shaft fracture and that is why on the initial IDPH reportable she put femur fracture as R1's diagnosis. V2 stated it sounds like when V8 was trying to fix R1's feet they got tangled and when V8 lowered the sit to stand lift R1's legs buckled and that is probably what caused R1's injury. V2 stated V8 should have pulled the sit to stand upwards instead of downwards because that is what caused her weight to be on her legs, tangled underneath her. V2 stated if two staff members were there, they could have potentially pulled R1 back onto the bed and therefore may have prevented her from getting injured. V2 stated a fall is change of plane and therefore by the formal definition R1 had a fall. V2 reviewed R1's most recent MDS assessment and saw that R1 was coded for being dependent for transfers. V2 stated by definition of dependent meaning two-person assistance of two or more helpers required then R1 should have had at least two staff assisting with the sit to stand lift. V2 stated the goal is to keep the residents safe and free from any injury.On 02/14/26 at 3:52 PM, V15 (Therapy Director/Occupational Therapist) stated via telephone interview that when the staff are using any type of mechanical lift there should be two people. V15 stated anything is possible so it is better to have two people with you, even if it is just to have one on standby so they can be there to spot for positioning and safety so they can intervene needed. V15 stated she usually sees two CNAs when they are transferring residents using the sit to stand lift. V15 stated she heard about R1 having a fall while using the sit to stand lift. V15 stated if there had been two staff members present when R1 was being transferred R1 may not have sustained the injury, but she does not know the specifics about the fall. V15 said, the hope is that if someone else was there that would not have happened.On 02/14/26 at 3:40 PM, V16 (Facility Medical Director) stated via telephone interview R1 was admitted to the hospital with a right hip fracture, and it was her understanding that the fracture was caused by R1 falling to the floor during a transfer using the sit to stand lift and tragically R1 was injured. V16 stated if R1 is dependent on staff for mobility and transfers then there should have been two staff members present during the transfer.Facility provided a written statement signed by V8 (Certified Nursing Assistant) dated 02/11/26 which reads in part: On 02/09/26 at 6:30AM (V8) was transferring the resident in room (R1's room number) from the bed to her wheelchair in her room using the sit to stand lift. (V8) had properly applied the sling and jacket to the resident. As the lift was transferring the resident from a sitting position to a standing position the resident jerked herself and thru (though) herself forward making her buttocks slide off the bed while still being attached to the lift. (V8) lifted the resident back up the resident removed her right foot from the foot base and (V8) assisted her (R1) with placing her foot back on the base. The resident removed her foot again and positioned her foot in an angle where her toes were touching the floor. As (V8) lowered the resident to the floor her right leg went inwards and the resident sat on her buttocks. Then (V8) and another CNA lifted the resident back up and placed in bed and reported the incident to the nurse.R1's electronic health record (EHR) progress note dated 02/09/26, 7:09 documented by V9 (Licensed Practical Nurse) while transferring on sit to stand and strapped in the resident threw herself forward and took her foot off the base and put one leg behind the other and the CNA had to lower the Mechanical Lift and she sat on her legs and upon laying back in bed both feet were pointed outward and small skin tear was observed on anterior right calf and she complained of pain in right lower extremity.Attempts were made to contact V9 (Licensed Practical Nurse), V11 (Agency Certified Nursing Assistant), V13 (Certified Nursing Assistant) because they were working on 02/09/26 however they were not able to be interviewed as there was no answer and/or returned messages.Facility provided policy titled, Safe Lifting and Movement dated 01/10/26 which documents in part this policy provides guidelines that aim to protect the safety and well-being of the staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Facility provided policy titled, Fall Policy Overview undated which documents in part,definitions of fall: loss of upright position that results in landing on the floor, ground or an object or furniture, or a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor/ground or hitting another object like a chair or stair; excluding falls resulting from violent blows or other purposeful actions.Any injurious fall is any fall in which physical injury occurs, regardless of severity.

Based on observations, interviews and records review, the facility failed to follow their food storage and labeling policy and failed to follow kitchen dress code to prevent food contamination. This failure has the potential of affecting all 31residents receiving food from the facility's kitchen. On 09/02/2025 at 10:20AM, during tour of the kitchen, V4 ([NAME] Director for Dinning) and surveyor observed an opened bag of carrots and an opened bag of peeled garlic in the cooler with no opened-on date. V4 stated all opened foods should be labeled with date when opened to notify kitchen staff which items to use first. V4 stated this is to prevent stale food that can cause foodborne illnesses being served to residents. Observed an open bag of vanilla wafers (Cookies), a 25 pounds (lb.) bag of breadcrumbs, 25lbs bag of cake mix open to air and not label with opened on date in the dry food storage room. V4 stated this is not our standard. V4 further stated all opened dry foods should be transferred to a self-sealing food container to preserve freshness and should be labeled with the opened-on date. V4 stated storing dry opened foods properly will prevent stale or spoiled foods from being cooked and served to residents which can make them sick. Observed a dented can of pumpkin puree on the can rack in the dry food area. V4 stated dented food cans should be placed outside the dry food storage area on the rack marked return for the vendor to pick it up. V4 stated foods in dented food cans can cause serious illnesses such as botulism. On 09/04/2025 at 11:09AM, V12(Server) was observed in the kitchen without wearing a hair net arranging to go ice-cream/soup cups. V12 stated he should have worn his hair net when he came back to the kitchen from break. V12 stated working in the kitchen without a hair net can cause hair to fall into residents' food contaminating the foods which can cause the residents to get sick.On 09/04/2025 at 11:20AM, V4 stated all staff working in the kitchen should wear hair nets to prevent food contamination which can cause foodborne illness to residents. Facility policy titled Food and supply storage dated 1/25 documents:-Cover, label and date unused portions and open packages.-Maintain designated area for items that are damaged (Such as dented cans) that are to be returned for credit. Facility policy titled Uniform Dress Code dated 1/25 documents: -Associates working with food-Wear approved hair restraint when on duty regardless of length of hair.

Based on interview and record review, facility failed to follow their policy to provide pneumococcal vaccination with its education and their consent for 4 residents (R4, R6, R8 and R21) out of 5 reviewed for immunizations in a sample of 13. Findings include: On 09/03/2025 at 12:15 PM, V2 (Director of Nursing) stated that she is currently the Infection Preventionist.On 09/03/2025, V2 stated that the facility has not ordered the pneumococcal vaccinations yet. V2 stated pneumococcal vaccine is offered all year around. We order the pneumococcal vaccine with influenza for this year. V2 stated that the facility orders it together when they order the influenza vaccine to save on costs. V2 stated that flu season begins in October till April. V2 stated that they screen residents for the influenza immunization in September and administer the vaccine in October. V2 stated that she has not screen or educated R4, R8 or R21 for their pneumococcal vaccination. V2 stated that R4, R8 and R21 do not have their pneumococcal vaccine, nor do they have education or consent. V2 stated that it is important for these residents to have their vaccination to protect them from pneumonia related infections. V2 stated that R6 received her influenza vaccine on 9/1/2025 but no education was provided. V2 stated that it is important to provide education and receive consent prior to administering immunization. This allows residents and/or family member make a well informed decision to consent to receiving the immunization. R4's immunization record documents in part: No up to date pneumococcal vaccine administered. No documentation of education or consent. R8's immunization record documents in part: No pneumococcal vaccine administered. No documentation of education or consent. R21's immunization record documents in part: No pneumococcal vaccine administered. No documentation of education or consent.R6's immunization record documents in part: Influenza vaccine administered on 09/01/2025 but no education provided.Facility's Influenza and Pneumococcal policy (07/2024) documents in part: Before offering the pneumococcal immunization, each resident and or resident representative receives education regarding the benefits and potential side effects. The resident's medical record includes documentation that indicates, the resident or representative was provided education regarding the benefits and potential side effects of pneumococcal and that the resident either received the pneumococcal immunization or did not receive the influenza immunization due to medical contraindications or refusal. Before offering influenza immunization, each resident and or the resident representative receives education regarding the benefits and potential side effects of the immunization.

Based on observations interviews and records review, the facility failed follow their policy to prevent aspiration during feeding for one (R1) of 13 residents reviewed in a sample of 31.R1's current face sheet document's R1's medical diagnosis to include but not limited to: Dysphagia, oropharyngeal phase, Parkinson's disease with dyskinesia, without mention of fluctuations, muscle weakness (generalized). MDS (Minimum Data Set) Section C - Cognitive Patterns dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) as 12/15, indicating R1 has moderately impaired cognation. Section K - Swallowing / Nutritional Status documents R1 Coughing or choking during meals or when swallowing medications and Complaints of difficulty or pain when swallowing.On 09/02/2025 at 1:00PM, V5(Certified Nursing Assistant-CNA) was observed by R1's bed side assisting R1 with eating his lunch. R1 was observed with food in his mouth trying to eat. R1's bed was observed to be slightly elevated. V5 stated the bed is elevated at about 30-40 degrees. V5 stated she is aware R1's bed is supposed to be elevated to 90 degrees when feeding to prevent choking. V5 stated she tried to elevate R1's bed but at about 40 degrees, R1 complained of pain so she left the bed at 40 degrees angle and continued to feed R1. V5 stated she did not notify V6(Licensed Practical Nurse-LPN), R1's nurse about R1's pain when bed was elevated.On 09/02/2025 at 1:05PM, V6 observed R1's bed and stated R1's bed was elevated at approximately 35-40 degrees. V6 stated when R1 is eating, his bed should be elevated to 90 degrees to prevent choking which can lead to aspiration pneumonia. V6 further stated V5 should have informed V6 that R1 was experiencing pain when his bed was elevated and V6 could have assessed and provided pain management for R1 and inform R1's provider. V6 stated feeding R1 with the bed elevated at 40 degrees is a choking hazard. On 09/03/2025 at 12:05PM, V2(Director of Nursing-DON) stated when a resident is eating in bed, the head of the bed should be elevated to 90 degrees to prevent choking. V2 further stated if the head of the bed is not elevated to 90 degrees when R1 is feeding, R1 can choke on his food and develop aspiration pneumonia. V2 stated V5 should not have continued feeding R1 in a low elevated bed and should have notified V6 R1 was experiencing pain with bed elevation. Facility polity titled Assisting Resident with feeding, dated 09/05/2024 documents: -Check to see that resident is sitting in an upright (90-degree) position.

Based on observations, interviews and record reviews, the facility failed to follow their infection control policies and procedures by ensuring appropriate hand hygiene was completed by staff upon exiting and entering a residents' rooms for 2 (R4, R8) out of 6 residents reviewed for infection control out of sample of 13.Findings include: On 09/02/2025 at 11:30 AM, surveyor observed V10 (Housekeeper) clean R8's bathroom. V10 then came out of the bathroom, exited R8's room without removing her gloves or washing her hands. Immediately right after surveyor observed V10 enter R4's room without sanitizing her hands and enter R4's bathroom. On 09/03/2025 at 12:48 AM, V2 (Director of Nursing) stated all staff members including housekeepers are expected to sanitize their hands and wear gloves prior to entering a resident's room. V2 stated that prior to exiting the room the staff member is expected to remove their gloves in the room and wash their hands. This prevents the spread of infection. V2 stated housekeepers should not go from room to room wearing the same gloves because this can spread infection.Facility's infection control policy (4/20/2025) documents in part: Handwashing is the single most important means of preventing the spread of infections. When handwashing is not available, employees shall use an alcohol-based hand sanitizer to prevent the spread of infections. The use of gloves does not eliminate the need for hand hygiene. Examples when to wash hands with soap and water: Before contact with each individual, his/her environment, and things that come in contact with the individual and after contact with each individual, his/her environment, and things that come in contact with the individual. After you go to the toilet.

Based on review of records and interviews the facility failed provide ostomy plan of care to 1 out of 4 residents (R1) reviewed for person centered care plan. This failure is not in accordance with professional standards guidelines. And has a potential to affect 1 resident (R1) ostomy quality of care needs.Findings include: R1 is [AGE] years old, initial admission date 05/11/2024. R1 was seen able to express clearly her thoughts during conversation. On 08/05/2025 at 10:55 AM, R1 stated that V3 (Registered Nurse/Agency) came to her room took her ostomy supplies and ran out of her room. At 12:18 PM, V1 (Administrator) clarified that R1 went for an appointment for her ostomy and came back with change or new ostomy size. After ostomy supplies for new size were used. R1 does not want to use her old ostomy supplies although R1 kept on asking for her ostomy to be changed multiple times a day. V1 stated that Medicare Part B will not cover premature order of supplies. Per V1, R1 was informed that she can go to the hospital to put the ostomy size she like but she refused. V1 said, The main problem was that her new size was run out and Medicare Part B will not cover if the supply does not last that long. And she refuses to use the old size. At 01:22 PM with V2 (Director of Nursing), V2 confirmed that R1's urostomy size was changed after appointment. V2 said, It took a lot of people to calm her down. We told her that new ones need to be ordered. V2 reviewed electronic health record of R1 full care plan. After review V2 cannot find care plan related to ostomy care. V2 said, We have missed it. V2 confirmed that R1 kept on asking her ostomy to be change not as scheduled. Per physician order dated 05/14/2025 ostomy (urostomy) needs to be changed on Monday and Friday one time a day. V2 stated that urostomy care plan needs to be in place and care plan needs to be reviewed quarterly. R1's MDS assessment dated [DATE] under Section H documents that R1 has ostomy. Per CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2017: Care plan should be individualized, and resident centered. Planning of care requires implementing appropriate, individualized interventions and modifying them as appropriate.

Based on interview and record review the facility failed to ensure the resident right to receive services in the facility with reasonable accommodation of resident's needs in 1 (R1) of 3 residents in a sample of 8. Findings include: R1 is a [AGE] year old male with a diagnosis including Heart Failure, Obesity and Multiple Myeloma. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) 10/15, moderate cognitive impairment. On 4/28/25 at 12:30PM R1 stated they run out of the proper size diapers for me on the weekends and night shift. The CNAs put a small size diaper on me, and it is very uncomfortable. My wife had to go to the store on several occasions to buy the right size diaper for me to wear. This has happened several times. The CNAs just say they are out of the extra large size. On 4/28/25 at 12:50PM V6 (family member) stated two times I had to buy diapers for R1 because they ran out of size 3XL. The CNAs used the diapers I purchased. On 4/28/25 at 12:41PM V5 (CNA, per phone) stated yes last night I took care of R1. We did not have the 3XL diapers needed for R1. I had to put a 2XL on him instead. I am not aware of any supply in the basement for diapers. I was never told that. I have had other instances where R1's wife had to go buy diapers for him because we didn't have the correct size. On 4/28/25 at 12:35PM V4 (CNA, per phone) stated on last Saturday I ran out of 3XL size diapers for R1. I had to use 2XL size. I ran to the basement and they did not have 3XL diapers for him. Facility resident concern form dated 4/21/25 shows including statement, He was also told that 3X depends are not available. Concern/Follow-up /Resolution includes statement I explained to the resident that clean linen is always available it is located in another location and staff should have escalated to supervisors for location. This includes 3X depends, security should be called to open basement storage. On 4/29/25 at 10:50AM V2 (DON) stated I addressed the issue of the concern that R1 was given the wrong size diapers. I had to explain to the CNAs that if they run out of diapers on the floor that they are to notify security. Security will open the basement storage room to retrieve the diapers. The staff failed to do this and that is the reason they say there is no supply.

Based on interview and record review, the facility failed to ensure to have a Registered Nurse (RN) staffed 8 hours with a 24 hour period on weekends to care for residents'needs based on the staffing scheduling and PBJ (Payroll Based Journal) staffing data report. This failure could potentially affect all 28 residents residing in the facility as of census 11/12/24. The findings include: On 11/14/24 at 10:40 am V2 (Director of Nursing/DON) stated that it is V2's expectation that there shall be a minimum of one Registered Nurse (RN) on duty in the facility for eight hours, seven days a week. V2 stated that V2 has four RNs and two of the RNs are as needed. V2 stated that V2 does not have a RN on duty some days and weekends especially in the month of April, May, and June, and V2 is interviewing more RNs for this position. V2 stated that the potential problem of not having RNs to take care of residents could result in poor outcomes to residents requiring specialized care that is beyond the scope of the Licensed Practical Nurse (LPN). On 11/14/24 at 12:15 PM, V1 (Administrator) stated V1 oversees staffing in the facility. V1 stated that it is V1's expectation that the facility meets the RN eight hours a day, 7 days a week. V1 stated that V1 has 2 nurses each shift and the nurses work 12 hour shifts (7am-7pm shift, and 7pm-7am shift). V1 stated that V1 has not been meeting the 8 hours of RN daily even on 11/11/24 and 11/12/24 and V1 has been utilizing V2 or agency at times, but V1 is looking into hiring more RNs. V1 stated that when there is a complex task like Total Parenteral Nutrition (TPN) that LPNs cannot perform this and it can lead to a delay in care. Reviewed facility's daily schedule with V1, showed the following: - On 4/6/24 (Saturday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 4/7/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 4/20/24 (Saturday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 4/21/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 5/5/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 5/18/24 (Saturday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 5/19/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 6/9/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 6/22/24 (Saturday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. - On 6/23/24 (Sunday) 2 LPNs worked for 7am-7pm shift, and 7pm-7am shift. V1 stated that having eight hours of RN daily, seven days a week including weekends should be maintained to provide adequate care and meet the needs of the resident. V1 stated if RN staffing is not met could potentially affect resident's care. CMS (Centers for Medicare and Medicaid Services) [NAME] report dated 11/07/24 documented in part: Triggered for no RN Hours. Facility's Daily Nursing Schedule dated 11/10/24 to 11/15/24 was reviewed. There was no RN scheduled to be working on the floor on 11/11/24 and 11/12/24. Facility's policy titled; Skilled Nursing Staffing Levels dated 1/1/2024 documented in part: There shall be a minimum of one (1) registered nurse on duty in the facility for eight (8) consecutive hours, seven (7) days a week.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedure for food and supply storage to ensure foods in the walk-in coolers, walk-in freezer and dry storage were properly covered, labeled and dated when they were opened and prepared, and discarded on the discard by date. The facility also failed to ensure kitchen staff was wearing hair restraint while in the kitchen, failed to ensure frozen foods were stored six inches above the floor in the walk-in freezer, failed to obtain temperature checks prior to serving the food to the residents, and failed to sanitize and air dry the blender and lid after staff washed during pureed preparation. These failures have the potential to affect 26 residents in the facility who are receiving oral diet. Findings Include: On [DATE] at 9:36 AM, during the initial kitchen observation conducted with V3 (Director Dining Services), the following were found in the main cooler for meat and dairy: opened foods with no labels when they were opened/prepared and when to discard such as, canned prunes in the container, two opened jars of low fat cottage cheese, a container of lettuce, a container of chicken salad, a container of olives, a container of coleslaw, a container of pears, a container of grilled chicken, a container of tofu, a container of spring mix lettuce, a container of romaine lettuce, a container of cranberries, a container of nuts, a container of spinach, a container of vanilla pudding, and a bag of Monterey jack cheese. Surveyor and V3 also found unwrapped and unlabeled opened parmesan cheese, an opened box of carrot cake, an opened box of double chocolate cake, an opened box German chocolate cake, and opened shredded mozzarella cheese with an opened date of [DATE] and discard by [DATE] written on the label. In the dry storage area, there was an opened box of cream of wheat mix that was not wrapped and not labeled with opened date. In the walk-in freezer, there were six boxes of frozen cods, a big box of bread buns, and a container of demi-[NAME] placed on the floor. V3 stated that there should not place anything on the floor per food storage policy and foods should be stored 6 inches about the floor. In the walk-in cooler for produce, Surveyor and V3 found a tray of [NAME] sandwiches not wrapped on the rack and no date when it was prepared, a container of sliced pineapples good thru [DATE] on the label, and a container of tomato paste with discard by date of [DATE] on the label. On [DATE] at 12:12 PM, food containers were placed on the steam table on the 2nd floor dining area. V20 (Dietary Aide) began serving lunch from the tray line and started plating the food. Surveyor asked for the food temperatures and V20 stated [V20] did not check food temperatures. V20 stated that food temperatures are done in the kitchen. On [DATE] at 1:13 PM, V5 (Cook) was preparing the foods to be served for dinner. V5 had short length hair on V5's head and was not wearing any hair restraint. On [DATE] at 11:06 AM, observed V6 (Support Chef) preparing pureed food for lunch service. When V6 finished pureeing the quinoa stuffed peppers, V6 rinsed the blender and lid in the sink with water. Observed that the blender container was still wet and still with residuals of the pureed quinoa stuffed peppers left inside the blender container. V6 then added 6 servings of 8 ounces boiled baby carrots then pureed in blender. On [DATE] at 10:40 AM, interviewed V3. V3 stated all opened foods are supposed to be properly covered, labeled and discarded by the date written on the labels for food safety. V3 stated expired foods should not be kept stored and should not be served to the residents. V3 stated prepared and opened foods should be completely wrapped, and must be labeled and dated for safety, to maintain freshness, and avoid bacteria. V3 stated, They are not supposed to be storing expired foods. They have to discard expired foods by the discard date. We did the in-service yesterday in regards to labeling, dating, expired foods, and food safety. We're going to be running that daily to train and enforce. They should never serve expired food. If it's opened and unlabeled it should be thrown out. After it's cooked here in the kitchen, they record the temperatures when it's put in the cart and it's taken upstairs and when the diet aide takes it upstairs and put in the steam table, they have to record temperatures in the beginning before serving the food meaning before food is placed on the tray and take temperatures also the end of serving. The temperature log is kept in a binder on each floor. It's important to temp the foods before serving. Hot food should be hot, and cold food should be cold. If it's below the hot of 141 degrees Fahrenheit, we need to reheat it or replace it to prevent bacteria in the food. We don't want it in the danger zone. We have a high-risk population that are prone to sickness. V3 also stated that staff entering the kitchen have to put on the hairnet to keep hair in the head and not on the food. The facility's MEAL QUALITY AND TEMPERATURE policy dated ,d+[DATE] documents in part: When bulk food is transported to a dining serving location, temperatures are taken and recorded in the kitchen before transport as well as at the final serving location. If temperatures are not optimal at the receiving location, corrective action is taken and documented on the taste and temperature log. The facility's [NAME] Job Description (undated) documents in part: Maintains basic food recipes, preparation, and service and storage sanitation principles. The facility's FOOD AND SUPPLY STORAGE policy dated ,d+[DATE] documents in part: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain in the safety and wholesomeness of the food for human consumption. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded. Cover, label and date unused portions and open packages. Refrigerated storage: unused portions of canned fruits and vegetables must be transferred to clean, approved storage containers. Label and date container. Frozen storage: store food items 6 inches above the floor, and 18 inches below sprinklers. Wrap food tightly to prevent cross contamination. The facility's Infection Control - Food Handling (undated) documents in part: Food should be properly labeled and expired foods will be discarded. The facility's roster dated [DATE] documents 28 residents residing in the facility with 2 residents who are NPO (Nothing By Mouth).

Based on observation, interview and record review, the facility failed to ensure the dumpster was properly covered and not overflowing to prevent the harborage and feeding of pests. This deficient sanitation practice has the potential to affect all 28 residents residing in the facility. Findings include: On 11/12/24 at 9:36 AM, during the initial kitchen observation conducted with V3 (Director Dining Services), observed 3 garbage bins with no covers filled with waste from the kitchen. V3 stated they all should be covered. On 11/12/24 at 9:55 AM, V3 (Director of Dining Services) brought surveyor outside to inspect the facility's dumpsters. Surveyor observed one dumpster with the lid not fully closed due to overflowing of garbage. V3 stated that all dumpsters should be fully closed to prevent rodents and other pests' infestation. On At 10:14 AM, V12 (Maintenance Director) that the lids of the dumpster should be closed when not in used so no rodents get in there and no debris would fly out. V12 stated that the lids should be closed for pest control, and if it's open the garbage would attract flies and rodents. V12 stated that it could cause pests in the building because all garbage from the building is being thrown there. V12 stated that if there are too many flies, the flies get in the building. On 11/14/24 at 10:49 AM, interviewed V13 (Facilities Director) and stated [V13] oversees waste management and environmental services in the facility. V13 stated that the lids of the dumpsters outside the facility should be closed when not in use and should not be overflowing to keep rodents and other pests away from the property. V13 also stated that it is also for the safety of the staff if the lids are not closed items could be tossed and hit staff or the workers. The facility's SOLID WASTE DISPOSAL policy dated 1/24 documents in part: Garbage containers are clean, lined and covered at all times. Keep lids closed on all outside trash receptacles. The facility's roster dated 11/12/24 documents 28 residents residing in the facility.

Based on observations, interviews and record reviews, the facility failed to follow their infection control procedures. The facility failed to: 1. Handle linen in a manner to prevent cross contamination. 2. Have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. These failures could potentially affect all 28 residents residing in the facility. Findings Include: On 11/12/24 at 12:55 PM, the laundry room was reviewed with V13 (Facilities Director) and V14 (Environmental Services Manager). Surveyor observed V14 and V17 handling clean linens on the folding table without proper hand hygiene. V13 stated V13 should have sanitized V13's hand and wear a pair of gloves before handling clean linens. V14 stated that the policy is to sanitize hands and put on gloves when handling clean linens. V14 stated that touching clean linens with dirty hands can result in cross contamination, spreading of bacteria to residents, and increase the risk for infection. On 11/12/24 at 1:05 PM, surveyor reviewed the water management area with V13. Surveyor asked V13 for measures in place to prevent the growth of Legionella. V13 stated V13 is not sure, and V13 could not provide any documentation. V13 stated V13 will follow up with V1 (Administrator) On 11/12/24 at 1:45 PM, V2(Infection Preventionist/IP) stated that staff should sanitize hands before touching clean linens to prevent cross contamination, and the water should be tested yearly for legionella to prevent growing of pathogens. On 11/13/24 at 9:55 AM, V1(Administrator) stated that Legionella should be checked yearly, and V1 has not checked for Legionella this year. V1 stated that V1 has no record when Legionella was last checked, and it was not checked last year. V1 stated that V1 will call the company to come over later. V1 stated that failure to perform an annual check for Legionella, is a potential for waterborne infection. The facility could not provide any policy on prevention of Legionella and other opportunistic waterborne pathogens in building water systems. The facility policy titled Hand Hygiene dated 08/27/2024 documents read in part: Failure to clean contaminated hands can result in the spread of these pathogens to residents, staff, and environmental surfaces. The facility policy titled Linen Management, documents read in part: Ensure linens are handling in a way to prevent cross contamination and the spread of infection in accordance with State and Federal Regulations, and national guidelines. The facility policy titled Infection Control, General Policy and Procedure dated 05/05/2024 documents read in part: This policy provides a comprehensive infection control program for distribution to, and by its employees and contractors.

Based on interview and record review, the facility failed to follow their policy to develop and implement a comprehensive person-centered care plan to meet preferences and goals and address the resident's needs that include measurable objectives and timeframes for 5 (R6, R17, R21, R22, R29) of 5 residents reviewed for comprehensive care plan in the sample of 15. The findings include: R17's Admission record showed admitted on 8/30/2024 with diagnoses not limited to Unspecified fracture of shaft of left tibia, Anemia, Spinal stenosis cervical region, Essential (primary) hypertension, Polyosteoarthritis, Pain in left shoulder, Presence of artificial knee joint bilateral, Unspecified fracture of upper end of right tibia, Unspecified glaucoma. R22's Admission record showed admitted on 5/11/2024 with diagnoses not limited to Other nontraumatic intracerebral hemorrhage, Malignant neoplasm of colon, Essential (primary) hypertension, Unspecified convulsions, Malignant neoplasm of bladder, Gastrostomy status, Dysphagia following nontraumatic intracerebral hemorrhage, Hemiplegia unspecified affecting left nondominant side. R29's Admission record showed admitted on 9/1/2024 with diagnoses not limited to Acute respiratory failure with hypoxia, Adult failure to thrive, Suicidal ideations, Pleural effusion, Essential (primary) hypertension, Squamous cell carcinoma of skin of right upper limb, including shoulder, Hyperlipidemia, Iron deficiency anemia, Benign prostatic hyperplasia, Sciatica. On 11/12/24 At 3:50 PM Reviewed R29's POS (Physician order sheet) showed active order not limited to: DNR (Do Not Resuscitate). No care plan found for advance directives or code status in R29's health record. On 11/13/24 at 12:55 PM Reviewed R17' POS showed active order not limited to: Full Code. No care plan found for advance directives or code status health record. On 11/14/24 at 9:10 AM Reviewed R22's physician order and showed active order not limited to Duloxetine HCl Capsule Delayed Release Particles 20 Give 2 capsule by mouth one time a day for depression. No care plan found for use of psychotropic medication use in R22's health record. At 10:09am V2 (DON / Director of Nursing) stated she started working in the facility March 2024. V2 said care plan should be done or developed by IDT (interdisciplinary team). Care plan serves as a guidance for the care of the resident that includes plan / goal, interventions and identified problem / concerns of the resident. If there is no care plan, could potentially miss opportunities of interventions or progress of the resident in going back to the community. Care plan should be individualized according to resident's needs. Advance directives, high risk meds such as psychotropic and anticoagulant medications and dementia care should be care planned. Reviewed R17, R22 and R29's records no care plan found for advance directives and psychotropic medication use. At 11:18 AM V17 (Social Services / SS) stated Advance directives would include code status, end of life issues and choices whether DNR or Full code. Code status is very important to know what the resident wishes are especially during emergency and staff would know what to follow whether to resuscitate or not. Stated she is not sure who should do the care plan for advance directives or code status. MDS (Minimum Data Set) dated 9/5/2024 showed R17 was cognitively intact. MDS ARD 8/15/2024 showed R22's cognition was moderately impaired. MDS dated [DATE] showed R29's cognition was moderately impaired. Facility was not able to provide person-centered comprehensive care plan for advance directives for R17 and R29 and care plan for psychotropic medication use for R22. Facility's comprehensive care plan policy and procedure dated 7/30/21 documented in part: each resident will have a person-centered comprehensive care plan developed and implemented to meet his / her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. It includes measurable objectives and timeframes to meet the resident's medical, nursing and mental / psychosocial needs that are identified in the comprehensive assessment. Facility's policy and procedure for psychotropic dated 8/12/21 documented in part: The resident's comprehensive care plan will reflect the plan for a gradual dose reduction or contraindications for same. 44103 On 11/14/24 at 1:14 PM, R6's clinical records were reviewed and showed an admitted [DATE] with included diagnoses but not limited to Ventricular Tachycardia and Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side. R6's physician orders with active orders as of 11/14/24 shows an order of anticoagulant Warfarin Sodium Oral Tablet 2 MG (Warfarin Sodium) Give 1 tablet by mouth in the afternoon for stroke (order date 11/5/24). R6's Minimum Data Set, dated dated dated [DATE] shows anticoagulant was marked. R6's comprehensive care plan does not address R6's anticoagulant medications use. On 11/14/24 at 12:56 PM, R21's clinical records were reviewed and showed an admitted [DATE] with included diagnosis but not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety. R21's Minimum Data Set, dated dated dated [DATE] shows active diagnoses section I marked Non-Alzheimer's Dementia. R21's comprehensive care plans were reviewed and no care plan for dementia was identified. The facility's Dementia policy dated 5/15/24 documents in part: Care plans and management will be individual and seen from the perspective of the client. Clients Care Plans will reflect diversity, gender, ethnicity, age, religion, sexuality and personal care needs and protected characteristics.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures by NOT (a) attempting to use appropriate alternatives prior to installing a side or bed rail, (b) assessing the resident for risk for entrapment from bed rails prior to installation, (c) reviewing the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and (d) developing and implementing a comprehensive person-centered care plan for 4 (R1, R17, R29 and R132) out of 4 residents reviewed for accidents and hazards in a sample of 15. The findings include: R1's Admission record showed admitted on 10/4/2019 with diagnoses not limited to Cerebral infarction, Vascular dementia, other seizures, Essential (primary) hypertension, Unspecified osteoarthritis, anxiety disorder. R17's Admission record showed admitted on 8/30/2024 with diagnoses not limited to Unspecified fracture of shaft of left tibia, Anemia, Spinal stenosis cervical region, Essential (primary) hypertension, Polyosteoarthritis, Pain in left shoulder, Presence of artificial knee joint bilateral, Unspecified fracture of upper end of right tibia, Unspecified glaucoma. R29's Admission record showed admitted on 9/1/2024 with diagnoses not limited to Acute respiratory failure with hypoxia, Adult failure to thrive, Suicidal ideations, Pleural effusion, Essential (primary) hypertension, Squamous cell carcinoma of skin of right upper limb, including shoulder, Hyperlipidemia, Iron deficiency anemia, Benign prostatic hyperplasia, Sciatica. R132's Admission record showed admitted on 10/17/2024 Chronic respiratory failure with hypoxia, Acute on chronic diastolic (congestive) heart failure, Essential (primary) hypertension, Chronic obstructive pulmonary disease, Alzheimer's disease, Hyperlipidemia, Gastro-esophageal reflux disease, Chronic embolism and thrombosis of unspecified deep veins of left lower extremity, Chronic pulmonary embolism, Chronic kidney disease, Unspecified osteoarthritis. On 11/12/24 at 11:28 AM Observed R132 lying in bed, on moderate high back rest, alert and verbally responsive with confusion, both upper side rails were up. At 11:31 PM R17 Observed lying in bed, alert and verbally responsive, appears comfortable, well groomed. Stated she has weakness on both lower extremities. Observed both upper side rails were up. At 11:39 AM Observed R29 sitting up on the side of the bed, alert and verbally responsive, appears comfortable and well groomed. Bed on lowest position, upper side rails were up. On 11/13/24 12:22 PM Observed R1 lying in bed, nonverbal, head of bed elevated, both upper bed rails were up. At 12:25 PM Observed R17 lying in bed, both upper side rails were up. V18 (Nursing Supervisor) requested to R17's room and stated side rails are up by staff to promote independence or help with turning and repositioning resident while in bed. On 11/14/24 at 10:09am V2 (DON / Director of Nursing) started working in the facility March 2024. She said there is no restorative nurse in the facility, she oversees side/ bed rail use. Stated upper side rails are used for residents to help them get out of bed, aid in mobility, turning or repositioning. V2 said use of side rails should be assessed and care planned but not sure if there should be an order for it. If not assessed properly the resident could be harmed by entrapment, risk for harm if side rail not functioning properly, resident could climb over it and risk for accident and hazards. V2 said the care plan should be individualized according to resident's needs. The care plan serves as a guidance for the care of the resident that includes plan/ goal and interventions and identified problem/ concerns of the residents. If there is no care plan, there could potentially be missed opportunities of interventions or progress of the resident. Reviewed R1, R17, R29 and R132's health record with V2, unable to find documentation for care plan, assessment and consent for use of side rails. MDS (Minimum Data Set) dated 9/13/2024 showed R1 was rarely or never understood. R1 needed total assistance or Dependent with eating, oral, toileting and personal hygiene, shower / bathe self, upper and lower body dressing. MDS dated [DATE] showed R17 was cognitively intact. R17 needed set up or clean up assistance with eating, supervision or touching assistance with oral hygiene; Partial/ moderate assistance with personal hygiene; Substantial / maximal assistance with shower / bathe self, upper body dressing; Dependent with toileting hygiene, lower body dressing, chair / bed and toilet transfer. MDS dated [DATE] showed R29's cognition was moderately impaired. MDS dated [DATE] showed R132's cognition was severely impaired. She needed set up / clean up assistance with eating; Supervision or touching assistance with oral hygiene; Dependent with toileting hygiene, shower / bathe self, upper body dressing, lower body dressing, chair / bed and toilet transfer; Substantial / maximal assistance with personal hygiene. Reviewed R1, R17, R29 and R132's health record with no order for side rails, no care plan, no assessment found for use of side / bed rails. R1, R17, R29 and R132's record did not show an attempt to use appropriate alternatives prior to installing a side or bed rail. Facility was not able to provide documents / records regarding care plan, assessment, consent for side rail use for R1, R17, R29 and R132. Facility's Bed rails policy and procedure dated 10/10/22 documented in part: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. Entrapment is an event in which a resident is caught, trapped, or entangles in the space in or about the bed rail. This facility will attempt to use appropriate alternatives prior to installing a side or bed rail. Assess the resident for risk for entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Documentation in the resident's record will reflect this assessment and related information, including how the alternatives failed to meet the resident's assessed needs. After the installation of bed rails, it is expected that the facility will continue to provide necessary treatment and care, in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's record, and include the following components, but are not limited to: the type of specific direct monitoring and supervision provided during the use of the side rails, including documentation of the monitoring. The identification of how needs will be met during use of the bed rails, such as for repositioning, hydration, meals, use of bathroom and hygiene. Ongoing assessment to ensure that the bed rail is used to meet the resident's needs. Ongoing evaluation of risks.

Based on interview and record review, the facility failed to provide R2 with the correct medication at discharge. This failure resulted in R2 being discharged with another resident's medication, ingesting the incorrect medication, resulting in urinary retention and hospitalization for urinary catheterization. This affected one(R2) of three residents reviewed for discharge. Findings Include: Facility Final Investigation Report (dated 06/01/2023) regarding R2 documents in part: R2 was admitted to facility on April 27, 2023, for short-term rehabilitation, and was discharged on [DATE]. He was alert and oriented x4. R2 had teaching completed upon discharge by agency nurse, patient verbalized understanding. We were notified by physician on June 01,2023 of a medication error with R2 after discharge from our SNF unit. Doctor had some communication with R2's primary care physician at hospital. Information was passed on that R2 received his medication upon discharge, but also two medication cards for another patient. The other medications were Oxybutynin 5mg and Atorvastatin 20mg. R2 took one dose of 5mg Oxybutynin the evening of May 18th. This medication error triggered urinary retention with R2, and he had to be catheterized in the hospital. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Cerebral infarction, unspecified, Hemiplegia and Hemiparesis following unspecified Cerebrovascular disease affecting left dominant side, Essential (Primary) Hypertension, Unspecified lack of expected normal physiological development in childhood, Cerebral Infarction due to unspecified occlusion or stenosis of right middle cerebral artery, Muscle Weakness (Generalized). On 06/14/2023 at 10:32am V3 (Director of Nursing/DON) stated, When R2 discharged from the facility on 05/18/2023, it was an agency nurse who did the discharge education with R2. V4 (agency nurse) is the one who did the medication teaching upon R2's discharge. V4 is the one who packed R2's medications and sent it home with R2 on the day of discharge. From my understanding, R2 was sent home with 2 wrong medications, and was taking the wrong medication at home. R2 was sent home with medication for urinary retention, and R2 did not have anything wrong with his bladder. We had no knowledge that R2 went home with the wrong medication. The facility had no knowledge that this medication error transpired upon discharge from the facility. The facility was notified by R2's physician of this medication error 2 to 3 weeks after R2's discharge from the facility. R2 was sent home with Oxybutynin and Atorvastatin by error. Oxybutynin is for an overactive bladder, and if taken when not needed, can cause urinary retention. The medication, Oxybutynin, causes the bladder to relax, and when taken by error, it can cause urinary retention. When a resident is discharged from the facility, the nurse does the medication reconciliation with the doctor prior to discharge. Then the nurse goes over the medication with the resident, and the nurse sends the resident's medication home with the resident. R2 was sent home with 2 incorrect medications, and from what was reported to us by R2's physician, the medication caused R2 to have urinary retention, and R2 had to go to the hospital, where R2 was catheterized. Since the error occurred upon R2's discharge, I have done in-service, as well as I implemented a new patient discharge form. The form assists the nurse with educating the resident/care giver about discharge medication and follow up appointments. The resident/care giver must sign the form on the bottom, indicating understanding. On 06/14/2023 at 12:01pm V6 (Licensed Practical Nurse) stated, I have done a discharge with a resident in the facility. When a resident is discharged , the nurse will do a medication reconciliation with the physician. Once the medication reconciliation is done, the nurse will do a medication education with the resident and/or the family. During a discharge, the nurse will educate the resident/family on the medication name and what the mediation is for and what time the medication should be taken. After the medication education is complete, the nurse will pack the medication into a bag and the medication is sent home with the resident. Narcotics are not sent home with the resident. Upon discharge, the nurse has to review the reconciled medication list and compare it to the medication bingo cards on hand to make sure that the correct medication is being sent home with the resident who is discharging from the facility. I go over the appointments that the resident needs to follow up on once the resident is discharged . I answer all the resident's and family questions, and make sure that the instructions and the medications are understood. I make sure that the resident and family understands how and when the medication is supposed to be taken. On 06/15/2023 at 1:55pm V9 (Physician/Medical Director) stated, R2 was given the wrong medication in error. The correct medication was sent to the pharmacy for R2. The wrong medication was given to R2 in bingo cards at the time R2 was being discharged from the facility. Medication bingo cards for a different patient were sent home with R2, that is the error that occurred. R2 was sent home with Oxybutynin, which were for another resident at the facility. Oxybutynin can cause urinary retention and constipation; all types of anticholinergic symptoms can occur, and this medication was not intended for this patient. R2 was in the hospital emergency room and had to be catheterized with a foley catheter. R2 has prostate enlargement and that can already slow down urine output, and on top of that R2 received Oxybutynin. With R2 having an enlarged prostate and receiving Oxybutynin, this medication blocked urine output and he was not supposed to receive this medication it was given to him in error. R2 was never supposed to be on this medication. On 06/14/2023 at 1:54pm, V1 (Administrator) informed surveyor that V4 (agency nurse) was out of the country, therefore, not available for an interview. R2's Progress Note (dated 05/18/2023) documents, Resident alert and oriented x4, discharged home with meds around 10:30am. Patient teaching completed with clear understanding. Stable upon discharge. DON made aware. Review of R2's Medication Administration Record (dated 05/01/2023 to 05/18/2023) documents that R2 was receiving Atorvastatin Calcium Oral Tablet 80mg 1 tablet at bedtime. The medication administration record indicated that Oxybutynin 5mg was not being administered to R2 while R2 resided at the facility. Medications-Leave of Absence, Discharge Policy (undated) states: Drugs which have been dispensed for individual resident use and are labeled in accordance with State and Federal law may be furnished to a resident upon his or her discharge provided that: The charge nurse is responsible for documenting medications provided upon discharge in the resident's medical record. Prevention of Medication Error In-service (dated 06/09/2023) states: Review and verify each medication for correct patient, correct medication, correct dosage, correct route, and correct time against the transfer orders, or medication listed on the transfer documents.

Based on observations, interviews and record reviews, the facility failed to provide the necessary treatment and services to promote healing and prevent infection from developing for 2 (R1 and R2) of 3 residents reviewed for wounds. These failures resulted in a clinical wound status change for R2's sacral wound in which facility staff noted the wound with drainage and a foul odor. The emergency room records document in part that R2's sacral wound with pus drainage and the likely source of [CONDITION(S)]. Findings include: R1's face sheet documents in part admitted [DATE]. It does not document in part any diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor reviewed R1's progress notes from admission. V20's (Nurse) progress notes dated 06/07/2022 1:42 PM and 1:50 PM document in part: R1 admitted to the facility with stage 3 pressure ulcer on sacrum. First provider progress note was from V9 (Nurse Practitioner). V9's progress note dated 06/08/2022 11:50 AM, does not document in part regarding R1's sacral pressure ulcer or wound treatment orders. First physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No progress note mentioning R1's sacral wound until V10's (Nurse) progress note dated 06/20/2022 3:43 AM. It documents in part: R1's wound with no drainage and area was pink and healing. Surveyor reviewed R1's progress notes closer to time of discharge. V6's (Nurse) progress note dated 07/07/2022 at 7:17 AM documents in part: Sacrum wound cleansed noted with necrotic tissue white base, foul odor. Endorsed to the next shift nurse to notified [V12] when [V12] comes today or refer to wound doctor. V10's progress noted dated 07/09/2022 3:54 AM documents in part: Drsg (dressing) changed as ordered to necrotic sacral wound; lg (large) amt (amount) of foul smelling watery brown drainage observed; Will endorse to AM nurse to make MD (Physician) or NP (Nurse Practitioner) aware. V11's (Nurse) progress note dated 07/10/2022 2:09 AM documents in part: small amount of drainage noted with foul odor to R1's sacral wound. V19's (Nurse) progress noted dated 07/11/2022 4:39 AM documents in part: . dressing changed as ordered to necrotic sacral wound, with nonstop large amount of foul smelling watering brown drainage noted. Endorsed to AM nurse to Follow up with MD. Progress note dated 07/11/2022 12:19 PM documents in part: R1 sent to the hospital for non-responsiveness and low oxygen saturation. Reviewed R1's progress notes from V6's progress note on 07/07/2022 at 7:17 AM thru R1's discharge notes to the hospital. Progress notes do not document in part that facility notified NP or MD of R1's sacral wound status change. On 08/23/2022 at 2:56 PM, V6 stated [V6] was not sure if R1's MD was notified. Attempted telephone interview with V10 on 08/24/2022 at 8:49 AM; however, unsuccessful. During a telephone interview with V11 on 08/24/2022 at 8:51 AM, V11 stated could not recall if R1's MD was notified. During a telephone interview with V19 on 08/24/2022 at 12:59 PM, V19 stated can only recall what V19 wrote in the progress note. Does not know if the nurse notified the MD. Surveyor reviewed R1's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date 06/08/2022 7:00 PM. V20 created the order for V12. POS does not document in part any additional treatment orders put in place when R1's sacral wound had a clinical status change. Surveyor reviewed R1's June TAR (Treatment Administration Records). No charting for [MEDICATION(S)] dressing to sacrum on 06/08/2022 and 06/11/2022. No progress notes that document that dressing was changed/applied on said dates. Surveyor reviewed R1's comprehensive care plan. It does not contain a care plan for R3's sacral pressure ulcer. On 08/23/2022 at 11:08 AM, V2 (Director of Nursing) stated the facility currently does not have a dedicated Wound Physician or Wound Nurse on staff. V2 stated the floor nurses are responsible for carrying out the wound assessments and treatments. V2 stated there was no Wound Physician since V2 started on 04/11/2022. V2 stated in the meantime, V5 (Physician) has been overseeing the residents' wounds. However, during a telephone interview with V5 on 08/24/2022 at 9:00 AM, V5 stated [V5] only oversees [V5's] residents' wounds. V5 stated [V5] does not oversee other providers' patients' wounds or all of facility's wounds. V5 does not have specific training or certification in wound care and does not have the title of Wound Physician. On 08/23/2022 at 2:56 PM, V6 stated during admission, the nurses are to measure the wound and describe how it looks such as whether it is clean or with a discharge or odor. V6 stated the nurse will inform the doctor, get treatment orders and carry out the orders. On 08/23/2022 at 3:33 PM, V1 (Chief Operating Officer) agreed that wounds need to be measured during wound assessments. During a telephone interview with V9 on 08/24/2022 at 8:32 AM, V9 stated facility did not inform V9 that R1 had a sacral wound. V9 stated [V9] reviewed all the provider's progress notes and does not see documentation on a sacral wound. V9 stated for a stage 3 pressure wound, there should have been treatments in place. When surveyor asked V9 about [MEDICATION(S)], V9 stated That's just a protection. No medication. It's just a dressing. During a telephone interview with V5 on 08/24/2022 at 9:00 AM, V5 stated [V5] was not the main provider for R1. V5 stated colleague V12 was the main provider for R1. V5 stated [V5] was not treating R1's sacral wound. Attempted telephone interview with V12 on 08/24/2022 9:24 AM. V12 stated won't be back in the office until September and declines to answer questions regarding R1. During a follow-up interview with V5 on 08/24/2022 at 10:01 AM, V5 stated will answer surveyor's questions based on R1's chart. At 10:06 AM, V5 stated R1's provider notes do not include wound care orders. At 10:13 AM, V5 stated [V5] does not see wound assessment notes in the electronic medical records. Surveyor read R1's POS for sacral wound. V5 stated cannot answer whether [MEDICATION(S)] order was medicated or not or whether it was appropriate. V5 stated there is no generalized treatment plan for a stage 3 pressure ulcer. V5 stated the treatment depends on the integrity of the wound and the wound bed. V5 stated there are many wound characteristics that play a factor in the treatment plan and the stage of the wound is not enough to have a generalized answer for the proper treatment. V5 stated a proper wound assessment wound have the date of the assessment, the known appearance or start date of the wound, the location of the wound, the size of the wound, the peri wound characteristics, the color of the wound and if there's odor or presence of any drainage. Surveyor read facility's nursing notes from 06/20/2022, 07/07/2022 and 07/09/2022. V5 stated I would say clinical status of the wound had changed. Surveyor requested R1's focused wound assessments from V1 and V2. Did not receive the documents at the completion of the survey. Surveyor reviewed R1's faxed hospital records to IDPH (Illinois Department of Public Health. Page 3 documents in part a large sacral wound. Page 5 and 6 documents in part V8's (emergency room Physician) Attending Attestation Statement created 07/11/2022 12:03 PM. It documents in part: [R1] has a sacral decub with pus draining, which is likely the source of [CONDITION(S)]. We discussed that fully treating the infection may require debridement that could be painful or even surgeries, depending on how deep it is. While they want to mostly focus on comfort at this point and we have given IV (Intravenous) [MEDICATION(S)] for pain, they did decide to start IV antibiotics while they discuss and come to terms with this. This was under the understanding that the antibiotics alone would likely not cure [R1] and the plan to not purse any invasive treatment. Facility's policy titled Skin and Wound Care Policy effective 07/08/2021 documents in part: All residents and patients will receive appropriate care to decrease the risk of skin breakdown. Dependent patients/residents will be assessed during care for any changes in skin condition including redness (non-blanching [CONDITION(S)]) and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider and the wound care coordinator. Care plans should be documented when interventions are put into place and when interventions are updated. Facility's policy titled Care Plan Policy effective 07/01/2018 documents in part: Policy It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Every resident will have Interdisciplinary Care Plan, with the Interim Interdisciplinary Care Plan initiated within 48 hours of admission. Procedure The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care. It is our purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care. R2 R2 is a resident of the facility. On 08/23/2022 at 12:12 PM, surveyor conducted interview and assessment of R2. R2 is oriented to person, place, time and situation. R2 stated admitted to the facility with wound on right buttocks from a bedpan injury at the hospital. R2 stated staff applying an ointment to the site. R2 stated staff have not applied a dressing to it. At 12:18 PM, V3 (Certified Nurse Aide) assisted R2 turn onto left side to face the bathroom. R2 with a small wound to right buttocks. Wound is dry and open to air. No dressing to site. V3 stated staff is putting A&D ointment to site. No other treatments. R2's POS documents in part active order created 08/22/2022 11:54 AM: Wound care (right buttocks). Frequency: Daily. Clean wound with saline, dry, apply Medi honey, cover with [MEDICATION(S)] change daily and PRN [as needed] if soiled. Surveyor reviewed R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .