Every finding on record at Morgan Park Healthcare

Based on interview and record review, the facility failed to ensure that two residents (R1 and R2) with history of illicit drug use, without individual community pass privileges, gain access to illicit drugs. This failure affected 2 of 3 residents reviewed for supervision and accidents. This failure resulted in R1 testing positive for Cocaine and Cannabinoid and R2 found unresponsive and treated with Narcan.Findings include:R1's medical diagnoses include but are not limited to human immunodeficiency virus, schizophrenia, anxiety, bipolar, essential hypertension, major depressive disorder. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R1's cognition was intact.On [DATE] at 9:21am V9 (Licensed Practical Nurse/LPN) stated that she responded to a code being called and when she arrived, she observed staff performing CPR (Cardiopulmonary Resuscitation) on R1. V9 stated that R1 was given one dose of Narcan by the facility's staff and then a second does by the paramedics. V9 stated that R1 did not respond to the 1st dose of Narcan, but R1 did respond to the 2nd dose of Narcan given by the paramedics. V9 stated that drug use in the facility is an issue. V9 stated that she is unsure who is giving the drugs to the residents. V9 stated that R1 has a history of drug use.On [DATE] at 11:03am V23 (LPN) stated that she found R1 lying on the couch on the 1st floor unresponsive. V23 stated that staff performed CPR on R1 until paramedics arrived and took over.On [DATE] at 10:55am V18 (Medical Doctor) stated that the cocaine and marijuana that R1 used could have caused R1's cardiac arrest. V18 stated that cocaine is toxic to the heart and causes constriction of blood vessels. V18 stated that he has been told that the residents that are using drugs at the facility obtain the drugs from outside of the facility. V18 stated that R1 should not have had access to drugs because R1 did not go outside into the community.R1's progress note dated [DATE] documents in part, Resident noted with altered mental status and decreased responsiveness to verbal and tactile stimuli compared to baseline. NP (Nurse Practitioner) was notified of the resident's change in condition. Per recommendation, 911 was activated. The resident was transferred to the hospital.R1's progress note dated [DATE] documents in part, Writer contacted hospital, admitting diagnosis cardiac arrest.R1's hospital note dated [DATE] documents in part, Assessment: Out-of hospital Cardiac Arrest with ROSC (Return of Spontaneous Circulation). Etiology unclear Suspect drug overdose.R1's hospital urine drug screen dated [DATE] documents in part, Urine Drug Screen (Abnormal). UR (urine) Cocaine Metabolite: Detected. UR Cannabinoid: Detected.R1's care plan dated [DATE] documents in part, Resident has a history of substance abuse and has potential for complications such as recurrence of substance use, postacute withdrawal symptoms, mood and/or behavior disturbance: Alcohol, Narcotics. Will exhibit acceptable behavior as evidenced by: No use of addictive substances unless prescribed by MD (Medical Doctor).R2's medical diagnoses include but are not limited to insomnia, opioid use, psychoactive substance abuse, alcohol abuse, schizoaffective disorder bipolar type, suicidal ideations.R2's MDS dated [DATE] has a BIMS score of 15 indicating R2's cognition is intact.Review of R2's records shows that R2 had community pass discontinued on [DATE]. No new community pass orders were observed in R2's records.R2's progress note dated [DATE] documents in part, Called to resident room observed resident on floor laying on his back. Noted non verbally responsive, Narcan x2 sternal rubs, ice to body continue to attempt to arouse. Call to NP (Nurse Practitioner) with orders to send to hospital for evaluation. R2's hospital records dated [DATE] documents in part, History of Present Illness (HPI): Pt (patient) stated he snorted too much heroin today. Narcan given and sx (symptoms) completely resoled. Discharge Plan: chief Complaint: Overdose.On [DATE] at 3:50pm R2 stated that on the day of his overdose in July, R2 found a bag of drugs on the ground in the smoking area. R2 stated that he does not know what kind of drugs were in the bag, but he did the drugs anyway and overdosed. R2 stated that he was woken up from the drug overdose with Narcan and water. R2 stated that he has found drugs inside the facility multiple times. On [DATE] at 11:47am V12 (LPN) stated that she was R2's nurse the day that R2 overdosed on drugs. V12 stated that R2 returned to the nursing unit R2 was talking very loud and making unusual hand gestures. V12 stated that R2 does not have those behaviors when R2 is sober. V12 stated that she asked R2 what was wrong with him and R2 responded stating that R2 had taken some drugs and was high. V12 stated that R2 then walked to his room. V12 stated that when she made it to R2's room, R2 was lying on the floor and was unresponsive. V12 stated that after administering 2 doses of Narcan, performing sternal rubs and rubbing R2 with ice, R2 began to respond. V12 stated that she then sent R2 to the hospital for an evaluation. V12 stated that each resident at the facility has their own Narcan order. V12 stated that extra Narcan has been provided and placed on the medication cart because they have a lot of residents to overdose on drugs.On [DATE] at 2:20pm V1 (Administrator) stated that residents should not have access to drugs without leaving the facility on a community pass. Facility's pamphlet titled Residents' Rights dated 11/18 documents in part, As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges according to state and federal laws. Your rights to safety: Your facility must be safe, clean, comfortable and homelike.Facility's policy titled Safety and Supervision of Residents reviewed 11/2025 documents in part, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation: Facility-Oriented Approach to Safety. 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Resident-Oriented Approach to Safety:1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. System Approach to Safety: 2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on interview and record review the facility failed to exercise reasonable care to protect a resident's personal property ensuring that the resident's property was kept in a safe location. This failure affected one of three residents (R1) reviewed for protection of personal property.Findings include:R1's medical diagnoses include but are not limited to human immunodeficiency virus, schizophrenia, anxiety, bipolar, essential hypertension, major depressive disorder. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R1's cognition was intact.R1's progress note dated 06/30/26 documents in part, Resident noted with altered mental status and decreased responsiveness to verbal and tactile stimuli compared to baseline. NP (Nurse Practitioner) was notified of the resident's change in condition. Per recommendation, 911 was activated. The resident was transferred to the hospital.On 08/24/26 at 3:04pm V7 (Certified Alcohol and Drug Abuse Counselor/CADAC) stated that she took possession of R1's phone after R1 went into cardiac arrest. V7 stated that she tried to give R1's phone to the paramedics but the paramedics would not take the phone. V7 stated that she then returned the phone to R1's bedroom. V7 stated that after she returned the phone to R1's bedroom, another resident took the phone and held on to it until R1's father picked up the phone. V7 stated that she is unsure if she should have given the phone to another staff member to lock it up until family picked it up. On 08/25/26 at 12:38pm R4 stated that she retrieved R1's phone from R1's bedroom R4 stated that she entered R1's bedroom with V7 (CADAC) and noticed that R1's belongings had been tampered with. R4 stated that she took R1's phone and informed V7 that she would hold on to it until R1's family comes to retrieve the phone. R4 stated that she also informed the CNAs (Certified Nursing Assistants) on the unit that she was in possession of R1's phone. R4 stated that V7 came a few days ago and stated that R1's father was on site to retrieve R1's phone. R4 stated that at that time, she gave R1's phone to V7. On 08/25/26 at 1:27pm V2 (Director of Nursing/DON) stated that it is not okay for a resident to be in possession of another resident's property without permission from that resident. V2 stated that R1's phone should have been locked up and safe guarded until R1's family picked up the phone.Facility's policy titled Belongings (discharged ) dated 04/26 documents in part, Policy: The facility protects the personal effect of a resident who has been transferred or discharged from the facility.Facility's policy titled Residents' Rights dated 11/18 documents in part, Your personal property rights. You facility must try to keep your property from being lost or stolen.

Based on observation, interview, and record review the facility failed to ensure that a resident (R6) who depends on staff's assistance for their ADL (Activities of Daily Living) care received incontinence care. This failure affected one residents R6 out of six residents reviewed for ADL care. Findings include:R6's face sheet shows that R6 has a diagnosis of lack of coordination, weakness, hemiplegia, and hemiparesis following cerebral infarction affecting non dominant side.R6's Brief Interview for Mental Status (BIMS) dated 6/12/26 with a score of 13 which indicates that R6 is cognitively intact. R6's Minimum Data Set (MDS) dated [DATE] shows that R6 is dependent for Activities of Daily Living (ADL) care, toileting, and personal hygiene.On 7/13/26 at 12:40 pm, surveyor toured the facility's 2 North unit, and a strong pungent odor consistent with urine and feces was detected upon leaving the elevator and entering R6's room from the hallway. Surveyor observed R6 from the doorway lying in bed gesturing for the surveyor to enter R6's room. R6 was asked if her continence brief needed to be changed, R6 nodded her head up and down signaling yes however, R6 was not able to say how long R6 had been for staff to provide her with incontinence care. On 7/13/26 at 12:45 pm, Surveyor requested V11 (Certified Nursing Assistant, CNA) to perform an incontinence check with R6. R6 was observed lying in bed with a large amount of soft brown stool present on the front of R6's, incontinence brief, abdomen extending through R6's perineal area, back and bed linens. A strong urine odor was present, and the bed linens was saturated in urine. The odor was sufficiently strong that it was detectable from the hallway outside the residents room. V11 stated that her shift started at 7:00 am and 12:45 pm was the first time she provided incontinence care to R6 for the day. On 7/15/26 at 10:13 am, V3 (Assistant Director of Nursing, ADON) stated that the nursing staff should be rounding on residents every two hours, prn (as needed) and after each meal by the Certified Nursing Assistants (CNA's) to ensure that the residents are taking care of properly and adequately. V3 stated if a resident is soiled in urine and feces that can cause the resident to acquire bedsores, pressure ulcers, excoriations, and the facility to have an odor of urine and feces. The facility's undated document titled Activities of daily Living (ADLS) document, in part: Purpose: To preserve ADL function, promote independence and increase self-esteem and dignity.

Based on interview and record review, the facility failed to ensure physician-ordered physical therapy, occupational therapy and speech therapy screening upon admission was completed for one resident (R2). This failure affected one of six residents reviewed for specialized rehabilitative services. Findings include:R2's face sheet shows that R2 has a diagnosis of dysphagia, nontraumatic subarachnoid hemorrhage from anterior communicating artery, obstructive hydrocephalus and cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery. R2 was admitted to the facility on [DATE] and discharged from the facility on 6/24/26.R2's electronic medical record chart does not show a Brief Interview for Mental Status (BIMS) during R2's stay at the facility. R2's Physician Order Sheet (POS) dated 6/16/26 shows orders for PT (physical therapy), OT (occupational therapy), ST (speech therapy) screen on admit, readmit, and/or as needed. May eval (evaluate) and tx (treat) if applicable. R2's care plan dated 6/17/26 documents in part: Dysphagia: Interventions: Speech therapy as ordered to eval (evaluate) and treat as indicated. R2's hospital record dated 6/16/26 documents, in part: Assessment: Discharge needs based on today's assessment: Therapy needs at discharge: Intensive daily therapy . therapy five or more times per week.On 7/13/26 at 12:04 pm, V6 (Certified Occupational Therapy Assistant, COTA, Therapy Manager) stated that she is the therapy manager for the facility. V6 explained that the therapy department PT (Physical therapy), OT (occupational therapy), SLP/ST (speech language pathologist) did not evaluate R2 when R2 resided at the facility. V6 then explained that she is not sure why R2 was not seen by the therapy department and that the therapy department may have been backed up with evaluating residents. V6 then explained that all residents are screened for therapy services upon admission to the facility and that residents who are admitted with dysphagia, a gastrostomy tube (Gtube), and an oral diet should be evaluated by the speech therapist upon admission due to the risk of aspiration. V6 also explained that she coordinates the new admission resident screenings and relay them to PT, OT, SLP/ST to perform a screening and evaluation on the resident upon their admission to the facility. V6 stated, I don't recall why she was not seen. I swear I don't know how I missed her (referring to R2). V6 stated if a resident who has orders to be seen by PT, OT and SLP/ST upon admission is not seen the resident can decline and the facility can be in trouble.On 7/14/26 at 11:36 am, V19 (Dietitian) explained that she was informed that R2 was not tolerating her diet and that R2 would only have G tube feeding orders. V19 also stated she will usually review the residents speech therapy notes however she did not recall R2 having any ST/SLP notes. On 7/15/26 at 10:40 am, V20 (Speech Language Pathologist, SLP/ST) stated that she recalls R2's name on the communication board in therapy room. V20 explained that the communication board is written by V6 (Therapy Manager, Certified Occupational Therapy Assistant, COTA) as a means of communication and is utilized in the therapy department to notify therapy staff regarding incoming residents, new admissions, and evaluations request for residents. V20 then explained that she recalls R2's name written on the board to perform a screening and swallow evaluation. V20 then explained once she attempted to access R2's medical chart in her electronic medical record at the facility she was not able to pull up R2's name in the facility's computer on June 23, 2026, and she then asked the floor nurse regarding R2's status and was informed that R2 had discharged from the facility. V20 stated that she is at the facility two days a week usually on Tuesdays and Thursdays however the days can vary. V20 then explained that she was not sure how long R2 was at the facility prior to V20 attempting to evaluate R2. V20 also explained that she is not made aware of how long new admissions are at the facility prior to the days that V20 is scheduled care for residents at the facility. V20 explained that whenever she is scheduled at the facility is when V20 will check the communication board and evaluate residents who require SLP/ST services. The facility's policy dated 2025 and titled Resident/Patient admission to Rehab Program documents in part: Purpose: To design a formal standardized process and criteria for residents/patient admission into the rehabilitation program. Policy: In accordance with OBRA (Omnibus Budget Reconciliation Act) state Guidelines, resident/patient will have access to rehabilitation services based on appropriate clinical need, outcome of the assessment and the ability of the rehabilitation department to provide the needed services and interventions. Resident/patients will not be discriminated against based on their diagnosis, age, gender, sexual orientation, payer source, financial, physical, status or cognitive status. Procedure: 1. The therapist will screen resident/patients by reviewing the medical record and admission information to predetermine the resident/patience the need for rehabilitation services. Hospital records of therapy services and doctors recommendations are helpful to review. 2. This therapist will screen all new admits, readmitted resident/patients, referrals, and resident/patients annually, according to the screening policy. 3. Any evaluation is indicated, discontinue the screen and request evaluation orders. It is not to perform any evaluation without doctor's orders. 4. Perform the evaluation and request clarification treatment orders, when indicated, based on resident/patients clinical needs. Ensure that the medical director clarification orders are documented in the resident/patients chart . 6. If any evaluation is not appropriate, complete the screen as indicated . 11. Specialized therapist (PT, OT, ST) shall be included in the preadmission process in order to ensure timely assessments are performed and services offered. It is the responsibility of the therapist to contact the hospital or other provider regarding specialized therapy services to be initiated upon admission to the facility. The facility's undated policy titled Specialized Rehabilitative Services Policy documents, in part: Definition: Specialized rehabilitative services include but are not limited to physical therapy, speech/language and audiology, pathology, respiratory therapy patient off therapy. Such services are utilized to restore, maintain, or improve the residence optimal level of functioning, self-care, independence, and quality of life. Purpose: to ensure appropriate rehabilitative services are available to the residents and outline the responsibilities of therapy providers as well facility staff. Policy: it is the policy of this facility to provide specialized and supportive rehabilitative services either directly or through arrangements with services provider. Services shall be provided in accordance with the assessment results, the written comprehend plan of care in accordance with physicians orders. Standards: 1. The coordinator is responsible to oversee the provision of therapy services for physical, occupational and speech/audiology to arrange for contract services when facility employed staff are not available . 3. Rehabilitative services shall be provided to all residents whose physician has determined a new and the resident or their legal representative consents to the service. 4. A qualified therapist evaluates the resident and develop a plan of care includes the amount, frequency and duration therapy as ordered by the physician. 5. Therapists are responsible to communicate in writing to the nursing department recommendations for restorative programs which reinforce skills wired door therapy.

Based on observations, interviews and record review, the facility failed to provide a safe, clean, comfortable, homelike environment by ensuring that the toilets in residents' rooms were functioning for four residents (R4, R11, R21 & R24) and ensuring that one resident's (R4) dresser drawer was not broken with exposed nails. These failures have affected four residents from the sample of 4 residents reviewed for homelike environment.Findings include:R4's admission Record documents R4's diagnoses including opioid dependence, anxiety disorder, major depressive disorder, adverse effect of other opioids, elevated white blood cell count, and pneumonia. R4's admission date to the facility is documented as 1/22/26.R4's Minimum Data Set (MDS) section C showed a BIMS (Brief Interview for Mental Status) score, dated 5/19/26, of 15. R4 is cognitively intact.On 6/8/2026 at 12:22 PM, R4's room was observed with the bedside dresser top drawer broken, and nails are exposed. The toilet appears clogged with a brown substance floating and water overflowing to the floor. Two urinals were noted in the room hanging on the bedside rails, one with a three-fourths amount of yellow liquid that appears to be urine. R4 stated that the toilet has been clogged for a week now and he has to walk a long way to use the public toilet; that's why he uses the urinal for convenience. R4 stated that dresser top drawer was broken and nails exposed since his admission to the facility. On 6/8/2026 at 12:40 PM, R21's room was observed with three urinals noted on the floor. R21 stated that the toilet has been clogged and that he reported it to maintenance many times. R21 stated that he uses a urinal because the toilet is clogged. R1 stated that he needs to walk a long way to use the public toilet. R21 stated that he has a frequency of urination; that's why he uses urinals for convenience. R21 stated that he empties urinals by himself in the public toilet.R21's admission Record documents R21's diagnoses including acute kidney failure, anemia, chronic kidney disease, hypertension, hyperlipidemia, myocardial infraction and inguinal hernia.R21's Minimum Data Set (MDS) section C showed a BIMS (Brief Interview for Mental Status) score, dated 4/13/26, of 15. R21 is cognitively intact.On 6/8/2026 at 12:50 PM, R14's room was observed with two urinals on the floor. R14 stated that the toilet has been clogged for a few days now and he uses the public toilet at the end of the hallway.R14's admission Record documents R14's diagnoses including weight loss, alcohol use, atherosclerotic heart disease, complete loss of teeth, frequency of micturition, nicotine dependence, insomnia, psychoactive substance abuse, unsteadiness on feet.R14's Minimum Data Set (MDS) section C showed a BIMS (Brief Interview for Mental Status) score, dated 4/21/26, of 14. R14 is cognitively intact.On 6/8/2026 at 12:50 PM, R24's room was observed with two urinals on the floor. R24 stated that he doesn't remember when the toilet was clogged; he uses the public toilet at the end of the hallway.R24's admission Record documents R24's diagnoses including hemiplegia and hemiparesis, unsteadiness on feet, atherosclerotic heart disease, insomnia, cerebral infraction, chronic obstructive pulmonary disease, gastro esophageal reflux disease, absence of left and right leg above knee, anxiety disorder, anemia, constipation.R24's Minimum Data Set (MDS) section C showed a BIMS (Brief Interview for Mental Status) score, dated 3/19/26, of 14. R24 is cognitively intact.On 6/9/2026 at 10:10 AM, the surveyor made an observation of R4's room with V11 (Maintenance Director) and noted a urinal with three-fourths urine was in the side rails of R4's bed. Three urinals were noted on the floor next to R21's bed, with one urinal half filled with urine. The toilet in R4's room is clogged and covered with a plastic sheet. V11 stated that R4's dresser upper drawer is broken and nails are exposed. V11 stated that it is unsafe for the residents. V11 stated he doesn't do routine rounds and only does repairs by the work order book. V11 stated that R4's room toilet is clogged. V11 stated that residents will report any maintenance issues to the nurse, and they will write it in the work order book. The toilet needed to be rodded.On 6/9/2026 at 10:25 AM, the surveyor made an observation of R4's room with V24 (Licensed Practical Nurse). V24 stated that she noted 3 urinals on the floor of R21's bedside, with one urinal half filled with urine. V24 also stated that she noted a urinal with three-fourths filled with urine in R4's side rails and one empty urinal on the floor. V24 stated that the toilet appears to be clogged; she doesn't know since when it's clogged. V24 stated that R4's dresser top drawer is broken, and nails are visible; it's not safe for the residents. V24 also stated that residents report maintenance complaints to nurses, and they write them in the work order book and report them to the maintenance department.The facility maintenance log was reviewed from May to June 2026. On 6/3/26, an entry of concern is noted that R4's/R21's room toilet is stopped up, and Yes is marked that the area is serviced. On 5/15/26, an entry of concern is noted that R4/R21's toilet is clogged, and Yes is marked that the area is serviced. No further entries of concern are noted for R4/R21's clogged toilet as observed by this surveyor on 6/8/26. No entries are documented for R11/R24's clogged toilet or for R4's broken dresser with nails exposed.The facility document, undated, titled Attachment J: Statement of Resident Rights, noted in part: The resident has a right to a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior.The facility document, dated 10/2024, titled Policy and Procedure: Safe, Clean, Comfortable and Homelike Environment, noted in part: The facility will provide a safe, clean, comfortable and homelike environment to the residents while taking into consideration a person-centered care, where residents' independence is promoted. Purpose: To ensure that the facility remains a pleasant place to live. Procedure: The facility will be kept clean and well-maintained through regular cleaning schedules, a preventive maintenance program, and the repair or enhancement of existing structures, systems, and fixtures.The facility document, dated 7/24, titled Job Description of Maintenance Director, noted in part: Assure the proper maintenance and running condition of all electricity and plumbing in the entire facility including c. the resident's room. Perform all repairs that do not fall under the purview of housekeeping.

Based on interviews and record review, the facility failed to ensure that: a Fall Risk Assessment was completed for one resident (R12) who sustained a fall in the facility that resulted in a fracture; failed to ensure that an Incident Report was completed for two residents (R12 and R9) post falls; and failed to ensure that Fall Interventions were updated on the Care Plan for (R8, R9 and R12). These failures have affected three of four residents reviewed for falls.Findings include:R12 is [AGE] year old with diagnosis including but not limited to: traumatic arthropathy of right hip, bilateral primary osteoarthritis of knee, anxiety disorder, hypoxemia and essential hypertension. R12's BIMS (Brief Interview of Mental Status) score is 14, which indicates cognitively intact.On 6/8/26 at 11:15 am, R12 stated the following, I broke my ankle here (in facility) on 4/18/26 from a fall. When I fell, I (R12) was in the restroom trying to get up from the toilet. My CNA (Certified Nurse Assistant/ V19)) was busy, so I tried to transfer from the toilet to the wheelchair by myself. I did not want to bother her (V19). When I (R12) started to transfer, I slid to the floor. The next morning, my ankle was swollen, and I was sent to the hospital.On 6/9/26 at 3:12 pm V19 CNA (Certified Nurse Assistant) stated the following, I was assigned to (R12) the day that she fell trying to transfer from the toilet. I (V19) was helping another resident at the time and had told (R12) that I would be back to help her once she was done using the restroom. She was waiting on the toilet, and I had told her that I would be right back. After five to ten minutes, I heard (R12) yelling out my name and went to her bathroom. When I got there, she (R12) was on the floor, and her leg was caught in her chair near the leg rest. It appeared that (R12) twisted her leg trying to transfer before she fell. I notified the nurse.Facility document titled State Report (Facility Reported Incident) dated 4/21/26 documents the following, on 4/20/26 (corrected date of 4/18/26 confirmed by V2/ADON, Assistant Director of Nursing) R12 reported left foot pain. Upon assessment, R12's foot and ankle were noted to be swollen. The Physician was notified and gave orders for a STAT (immediate) x-ray of the left foot and ankle. X-ray results revealed a fracture to the left lateral malleolus. R12 was transported to the local hospital and returned with cast to the left ankle. Facility document titled Witness Statement and dated 4/18/26 documents the following signed statement from V19 (CNA), As I entered the resident's bathroom (R12) upon hearing her (R12) call me, I noticed her foot caught in her chair and reported it to the nurse.R12's Section GG- Functional Abilities assessment dated [DATE] documents, R12 uses a wheelchair; R12 requires maximal assistance with toilet transfers.R12's Hospital Patient Report dated 4/19/26 documents, Left ankle x-ray reveals acute nondisplaced fracture of the lateral malleolus. R12's Care Plan dated 4/13/26 documents, R12 is at risk for falls related to limited mobility due to Cardiopulmonary insufficiency. R12's Fall Care Plan documents no new fall intervention was added after R12's 4/18/26 fall occurrence.R12's EMR (Electronic Medical Record) excludes any Fall Risk Assessment after R12's 4/18/26 fall occurrence. R12's EMR excludes a Fall Incident Report regarding R12's 4/18/26 fall occurrence. R9 is [AGE] year old with diagnosis including but not limited to: gout, malignant neoplasm of prostate, aphasia, hemiplegia and hemiparesis following cerebral infarction.R9's BIMS (Brief Interview of Mental Status) score is zero, which indicates severe cognitive impairment. On 6/8/26 at 12:50 pm, V13 (LPN/ Licensed Practical Nurse) stated, R9 has been discharged . He had fallen out of bed on 3/16/26 and somehow hit the back of his head. He was assessed and sent to the hospital where he received sutures. I'm not sure how he fell out of the bed, but his bed was in the lowest position. I can't remember if there were floor mats by his bed. I'm not sure if he had fallen in the past. After each fall we (nurses) complete incident report, fall assessment and update care plan. The purpose of the incident report and the fall assessment is to capture what occurred and assess the possible cause. I believe the fall nurse (V18) is the person that updates the care plan interventions.Facility document titled State Report (Facility Reported Incident) dated 3/17/26 documents the following: On 3/14/26, R9 was observed on the floor next to his bed. R9 was immediately assessed and noted with an open area to the back of the head. Area cleansed and a pressure dressing was applied. R9's Medical Doctor and family were made aware and an order to transport to the local hospital was received. R9 returned with staples to the back of his head.R9's Fall Risk Review completed by V13 LPN on 3/16/26 documents: R9 has balance issues; R9 uses an assistive device.R9's EMR excludes a Fall Incident Report for R9's 3/14/26 fall occurrence. R9's Fall Care Plan dated 1/29/26 documents no new fall intervention was added after R9's 3/14/26 fall occurrence.Facility Census Report dated 6/8/26 excludes R9 as an active resident of the facility. R8 is [AGE] year old with diagnosis including but not limited to: repeated falls, unsteadiness on feet, other lack of coordination, and muscle weakness.R8's BIMS (Brief Interview of Mental Status) score is blank, which indicates that R8 is rarely/never understood. Facility document titled State Report (Facility Reported Incident) dated 11/20/25 for the initial reportable sent to the State agency documents the following: On 11/19/25, R8 was observed on the floor next to his bed. The staff nurse immediately assessed the resident and he was noted to have an open area to the forehead. R8's family and physician were made aware. New orders were received to transport R8 to the hospital. R8 returned with sutures to the forehead. Facility document titled State Report (Facility Reported Incident) dated 11/26/25 for the final reportable sent to the State agency documents the following: The residents' care plan and assessments were updated accordingly.R8's Fall Care Plan dated (initial date) 1/15/25 documents no updated fall interventions after R8's 11/19/25 fall occurrence to 11/26/25, as the final State Report indicates.R8's Fall Incident Report dated 11/19/25 and reported by V32 (LPN) documents the following: Nurse (V32) was alerted by a noise from R8's room and immediately went to observe R8. R8 observed to by laying on left side near the front of his bed. R8 unable to give a description; R8 sustained a laceration to the face; R8's bed was in the lowest position; R8's call light was within reach. R8's Fall Risk Review dated 11/19/25 documents: R9 had at least one fall within the past three months.Facility Census Report dated 6/8/26 excludes R8 as an active resident of the facility. On 6/9/26 at 12:34 pm V2 (ADON/ Assistant Director of Nursing) stated the following, I'm not sure what happened with (R12's) fall. She did sustain a fracture, and it was reported to IDPH (Illinois Department of Public Health). Incident reports and post-fall assessments are done after each fall to investigate the fall, to assess the well-being of the resident and prevent future falls. I'm honestly not sure if the assigned nurse or the fall nurse is responsible for the fall assessment. The incident report should be done by the assigned nurse. Incident reports are completed in the risk management system (electronic charting system). I can't locate an Incident report or fall assessment for (R12's) fall on 4/18/26. I only have the report sent to IDPH about the incident. The fall occurred on 4/18/26, but the incident was reported to IDPH on 4/21/26 after (R12) was hospitalized and we were made aware of the fracture. On 6/9/26 at 1:19 pm V18 (Fall/ Restorative nurse) stated the following, After a resident falls, I complete an incident report in risk management to find out the root cause of the fall. I investigate the fall by getting statements from the staff and the resident regarding the fall and I update the care plan with interventions to prevent a possible fall again. (R12) stated that she tried transferring herself because she did not want to bother her CNA. (R8 and R9) were both observed right before their falls by the assigned nurses. Their (R8 and R9) beds were in the lowest position and they hadn't fallen from the bed in the past. I don't do a fall assessment after the fall. I think the assigned nurse does that, but I'm not sure. It is important to document fall incidents in our system so that we can track the falls and again, prevent the falls from happening again.Facility policy titled Fall Prevention Program dated 2/28/26 documents: The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized necessary; A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident; Accident/Incident Reports involving falls will be reviewed by the Director of Nursing and the IDT (Interdisciplinary Team) to ensure appropriate care and services were provided and determine possible safety interventions.

Based on observations, interviews and record review, the facility failed to ensure that prescribed medication was administered to four residents (R7, R10, R11 and R12) within an hour of the scheduled time, and the facility failed to ensure that an IV (Intravenous) medication hanging at R10's bedside was labeled with the date and time it was administered. These failures affected four residents (R7, R10, R11 and R12) reviewed for nursing care in a total sample of twelve residents. Findings include:On [DATE] at 12:00 pm, V22 (LPN/ Licensed Practical Nurse) was standing near the medication cart on the 2nd floor (2 South) viewing the EMAR (Electronic Medication Administration Record).At that time, the 9 AM medication was flagged (red color coded) for four residents (R7, R10, R11 and R12).On [DATE] at 12:00 pm, V22 (LPN) stated the following, The medication turns red in the system when they are an hour or more late. Their medication (R7, R10, R11 and R12) isn't late, I just haven't signed them out yet.On [DATE] at 12:15 pm, R7 stated that she had not had her morning (9 am) medication yet.R7's BIMS (Brief Interview for Mental Status) score indicates a score of 15, which indicates cognitively intact.R7's 9 AM Medication list includes the following: Acidophilus/ Pectin 100 MG (Milligram), Docusate sodium 100 MG, Methadone HCL (Hydrochloride)10 MG and Quetiapine fumarate 150 MG.R7 is [AGE] year old with diagnosis including but not limited to: Essential hypertension, bipolar disorder, opioid abuse, neuralgia and neuritis. On [DATE] at 12:23 pm, R12 stated that he had not had his morning medication yet.R12's BIMS (Brief Interview for Mental Status) score indicates a score of 15, which indicates cognitively intact.R12's 9 AM Medication list includes the following: Gabapentin 400 MG oral capsule, Polyethylene Glycol 3350 powder 17 GM (gram) by mouth, Sennosides- docusate sodium 8.6- 50 MG oral tablet.R12 is [AGE] year old with diagnosis including but not limited to: Schizophrenia, acquired absence of right toes, acquired absence of left leg below knee, gangrene and pain in unspecified joint. On [DATE] at 12:30 pm, R11 stated the following, I'm still waiting on my morning medication.R11's BIMS (Brief Interview for Mental Status) score indicates a score of 10, which indicates moderate cognitive impairment.R11's 9 AM Medication list includes the following: Enoxaparin Sodium solution 40 MG/ 0.4 ML (milliliter) subcutaneous injection, Flomax 0.4 MG oral tab, Keppra 500 MG oral tab, Lactobacillus oral capsule, Nifedipine Extended Release- 60 MG oral tab, Suboxone sublingual film 4-1 MG, Sennosides- docusate sodium 8.6- 50 MG oral tab, and PEG 3350- Potassium CHL- Sodium bicarbonate- Sodium chloride- sodium sulfate 10 ML by mouth.R11 is [AGE] year old with diagnosis including but not limited to: Chronic obstructive pulmonary disease, epilepsy, other toxic encephalopathy, neuralgia and neuritis. On [DATE] at 12:57 pm, Surveyor noted an empty 50 ml- IV (milliliters-intravenous) bag hanging on an IV pole next to R10's bed.The IV bag was not labeled with a hang time (time of administration), or initials by the nurse that administered the IV fluid.On [DATE] at 12:58 pm, R10 stated the following, I have not received any medication yet today. I'm supposed to have my morning medication early, but I always get it late. It's lunch time already. That's why I'm still in bed, because I have not had my morning medication and I feel sluggish. I know that I will feel better after getting my medication.On [DATE] at 1:00 pm, V22 entered R10's room to administer her scheduled 9 am medication.At that time, V22 (LPN) stated the following, I think the overnight nurse gave R10 the IV medication this morning before she left. She worked 11p- 7a, but she sometimes gives R10 the 9 am medication early. I'm not sure. The IV bag should be labeled with a date and the initials of the nurse that gave it just so that the following nurse will know the time that it is administered. The medication should be signed out in the MAR as well to make sure that the medication is not given twice. I may have overlooked their medication (R7, R10, R11 and R12) this morning because my computer battery died.R10's BIMS (Brief Interview for Mental Status) score indicates a score of 15, which indicates cognitively intact.R10's 9 AM Medication list include the following: Bisacodyl 5 MG, Buprenorphine HCL- Naloxone HCL sublingual film 8-2 MG, Clonidine HCL 0.1 MG, Folic acid 1 MG, Miralax powder 15 GM, Penicillin G sodium injection solution 5 million units IV (intravenously) and Phenazopyridine HCL 200 MG, Pregabalin 50 MG, Pyridoxine HCL 50 MG, Senna tablet, Thiamine HCL 100 MG and Multivitamin.R10 is [AGE] year old with diagnosis including but not limited to: Type 2 Diabetes mellitus, hypokalemia, urinary tract infection and Methicillin resistant staphylococcus aureus infection, and polyneuropathy. On [DATE] at 3:36 pm, V2 (DON/ Director of Nursing) stated the following, Medication is usually scheduled for daily (9 am), twice a day (9 am and 5 pm), or at bedtime (9 pm). 10:00 am would be the latest time to give a mediation scheduled for 9:00 am. Medication should be signed out immediately after they are given. If the medication is not signed out, no one can determine when it was given. If it is not signed out, it wasn't given. If medication is scheduled for 9 am, it should be given one hour before and one hour after the scheduled time (between 8 am and 10 am). R10's IV medication should have been labeled by the nurse that gave it. We cannot say when the last dose of the medication was given if it is not labeled or signed out in the system. If a medication turns red on the MAR (Medication Administration Record) it is late.Facility policy titled Medication Administration and dated 1/2026 documents, Medication should be administered within one hour of the prescribed times or according to liberalized medication pass; the individual administering the medication shall initial the resident's Medication Administration Record on the appropriate line and date for that specific day after administering the medication.Facility policy titled Intravenous Therapy and dated 1/2026 documents, each solution bag should be labeled with contents, date and time when hung and expiration period of any medication.

Based on interview and record review the facility failed to update the care plan for one (R1) of 6 (R1, R3, R4, R5, R6, R7) residents reviewed for falls.Findings Include:R1 was admitted to the facility on [DATE] with diagnosis not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and With Stage 5 Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, End Stage Renal Disease, Dependence on Renal Dialysis, Dementia, Epilepsy, Acute Pain, Presence of Automatic (Implantable) Cardiac Defibrillator, Seizures, Alzheimer's Disease and Diabetic Retinopathy with Macular Edema. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 07 indicating severe cognitive impact.R1's Initial reportable dated 03/23/26 document in part: R1 was observed on the floor next to the bed. R1 was assessed and noted an open area to the back of the head. R1 was transported to the hospital and returned with staples to the back of the head.R1's final reportable dated 03/27/26 document in part: R1 attempted to reposition himself in bed and subsequently fell from the side of the bed onto the floor. Staff assessed R1 and noted a laceration to the back of his head, an order was obtained to transfer R1 to the hospital for further evaluation. R1 returned to the facility with sutures to the back of his head. Upon R1's return to the facility, interventions were implemented including a low bed and floor mats. R1's care plan was updated to reflect the same changes.R1's care plan document in part: Focus: Resident is at risk for falls R/T (related/to) cardiorespiratory conditions and comorbidities Revision on: 12/09/25. Interventions: Be sure call light is within reach and encourage the resident to use it for assistance as needed. Staff to respond promptly to all requests for assistance. Date Initiated: 12/08/25. Anticipate and meet individual needs of the resident. Date Initiated: 12/08/25. Focus: R1 has impaired cognitive function/dementia or impaired thought processes r/t Dementia.On 04/18/26 at 12:50 PM per telephone interview V11 (Licensed Practical Nurse) stated I came off lunch and was doing rounds when I observed R1 on the floor next to his bed. I assessed R1 and observed bleeding from the back of his head. The doctor ordered to send R1 out to the hospital. R1 came back with 4 staples to his head. The fall interventions R1 had in place: R1 had a helmet for seizures, bed low to the floor and I am not sure if R1 had mats on the floor. R1 was a high fall risk and a total care x 1 assist.On 04/18/26 at 01:03 PM Per telephone interview V14 (Certified Nurse Assistant) stated On 03/22/26 I was checking on R1 like every 5 - 10 minutes because he likes to get up. R1 was a total assist, alert and oriented x1 and was confused. At 9 pm I was across from R1's room charting. V11 (Licensed Practical Nurse) did rounds again and that is when R1 fell and hurt himself. R1 did not have a floor mat but was in a low bed and the call light was in reach clipped to his pillow. R1 would not use the call light.On 04/18/26 at 09:49 AM V6 (Licensed Practical Nurse) stated R1 has had falls in the past and he is a fall risk. R1 had a hematoma and some staples to the back of his head.On 04/18/26 at 09:52 AM V7 (Licensed Practical Nurse) stated R1 was a fall risk and was monitored in the dining room, bed lowest position and no skid socks.On 04/18/26 at 01:18 PM Per telephone interview V16 (Director of Nursing) stated R1 had a fall in the facility. There is an interdisciplinary approach, and I am not the fall nurse. V11 (Licensed Practical Nurse) called me and said that she (V11) was doing rounds and found R1 on the floor. R1 had an open area to the back of his head and was sent to the hospital. R1 came back from the hospital with staples. We did a review of the medications that he was taking, root cause analysis. The initial intervention when the fall first happened was to send R1 to the hospital. The new interventions were floor matt and the low bed. I am not sure why the care plan was not updated.On 04/19/26 at 01:00 PM Per telephone interview V15 (Restorative Nurse) stated I don't remember R1's exact fall but I remember he was a resident. I am responsible for entering the fall interventions and it should be entered within 24 hours. If it is not entered in the care plan I must not have updated the care plan properly.Policy:Titled Policy and Procedure Care Plan revised 01/24 document in part: All residents will have comprehensive assessments, and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. Purpose: To promote continuity of care and communication among staff, increase resident safety and safeguard against adverse events. Procedure: 4. Members of the interdisciplinary team participate at care conferences. b. The interdisciplinary team develops a comprehensive, individualized care plan based on interdisciplinary team assessments and comprehensive assessment of the resident prior to the care conference. 5. Care plans are reviewed and discussed individually. a. Concerns, problems, needs, and/or strengths are listed based on residents' individual needs. Physicians' orders and personal care and nursing needs are also listed based upon comprehensive assessments. c. Goals are resident oriented, specific problem-oriented goals relative to medical and nursing diagnosis, realistic, measurable, and directed towards increased functional levels. 7. Care conferences for review and revision of resident's care plan are scheduled at a conducive time for residents and their families. a. Skilled and intermediate residents every 90 days and PRN (as needed). b. When a significant change occurs in a resident's condition, the MDS coordinator or designee is notified by a member of the interdisciplinary team. The care plan is then reviewed and updated. 8. The MDS coordinator or designee has responsibility for each resident's care plan. a. The MDS coordinator or designee is responsible for coordinating each resident's care plan and for ensuring that the appropriate information is available to all staff and is transmitted at time of discharge or transfer. b. The interdisciplinary team is responsible for the implementation of resident care management. 9. All interdisciplinary team departments are responsible for charting that reflects the care plan concerns, problems, needs and /or strengths, approaches, progress of lack of progress with possible reasons for and any new problems. 10. The MDS coordinator or designee is responsible for in-service training for all departments and shifts to ensure understanding of the care plan process and each person's responsibility and participation in the care plan.

Based on interview and record review, the facility failed to monitor, supervise, and intervene for seven residents (R1, R3, R7, R19, R20, R21, R22) with known substance use disorders. This failure resulted in the residents engaging in activities suspected of drug use and overdose. R1, R7, R19, and R21 were found unresponsive in the facility. R3 was found unresponsive in the facility and expired with suspicion of drug overdose. The facility also failed to provide supervision and monitoring for residents. As a result of these failures, R4 fell on the floor on [DATE], while located inside the facility and sustained a left femur fracture. The facility also failed to update a fall care plan and follow assessments to prevent 1 out of three residents (R6) from falling. These residents were reviewed for accidents and supervision in a sample of 22.This was identified as an Immediate Jeopardy began on [DATE]. On [DATE] at 2:35 PM, V1 (Administrator) was notified of the immediate jeopardy.The facility presented an abatement removal plan on [DATE], at 5:01 PM. The plan was not approved. The facility submitted a revised abatement plan on [DATE], at 4:32 PM, [DATE], at 4:16 PM, and [DATE], at 5:25 PM. None of these plans were approved. The facility submitted a revised abatement plan on [DATE], at 4:48 PM. This plan was approved on [DATE].On [DATE], the surveyor confirmed by reviewing the staff in-service list included in the approved abatement Plan, substance abuse prevention competency forms, resident council meeting minutes held on [DATE], residents' care plans regarding substance abuse history, physician order sets, progress notes since [DATE], substance abuse disorder assessments for R1, R19, R20 and R21, observations of a staff member searching belongings upon visitor/resident/staff entering the facility. Also, interviewing R20, R21 and another resident with a history of substance abuse, certified nursing assistant, licensed practical nurse, housekeeper, and social service director, the immediacy was removed on [DATE]. However, the non-compliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-services training. Findings include: R3's face sheet documents R3 is a [AGE] year-old individual admitted to the facility on [DATE] and discharged on [DATE] (death). R3 has diagnoses not limited to opioid dependence, uncomplicated, anxiety disorder, unspecified, obstructive sleep apnea, and major depressive disorder, recurrent, unspecified. R3's progress note dated [DATE], at 2:21 PM, documents during rounding, resident observed unresponsive to verbal and tactile stimuli. No respirations or palpable pulse noted. CPR (cardiopulmonary resuscitation) initiated. Code blue and 911 were called. All resuscitation efforts were unsuccessful. Time of death announced at 10:00 AM. Resident was picked up and transported to funeral home. R3's death certificate dated [DATE], documents in part that an autopsy was not performed. On [DATE], at 4:03 PM, R11 was observed in her room, ambulatory, and in no apparent distress. R11 stated that it will be two years in April since she has been residing in this facility. R3's obituary was on R11's bedside dresser. R11 stated we got along really good, he was like my big brother, unfortunately he OD (overdosed) and died. They found him while passing out breakfast. By the time the CNA (certified nursing assistant) found R3, he already had liquid coming out of his nose. The morning CNA was V30 (Certified Nursing Assistant), and she had her hands full passing out the trays. R11 said she heard V30 say who is that on the floor? R11 ran to check, and it was R3, lying flat on his back. His eyes were already black, he (R3) was ice cold, and was stiff. R11 stated R3's room was across from R11's room. Usually, R3 would play music in the morning and was ready by breakfast time. R11 stated when R3 expired, people started telling the truth that R3 had been doing drugs. R11 stated that R3 was not the first resident that has overdosed and died in this place. There were at least five residents. R11 stated another buddy of ours said he was with him (R3), and they did some (illicit drug) at 1:00 AM that night. R11 stated that she will keep the name confidential. R11 stated that it is easy to bring in drugs because staff do not check purses or do searches. R11 stated I (R11) am in school for CNA and denied that she uses any illegal substances. R11 stated that the last OD that she recalls is R21 and it happened about two months ago. R11 stated that during the night shift I (R11) did not see anyone because R11 does not get medications. R11 stated that she thinks the 11:00 PM – 7:00 AM staff didn't check on R3. R11 stated that the 7:00 AM- 3:00 PM staff did not do rounds that morning because it was not until breakfast time that R3 was discovered. R11 stated that R11 remembers that day because no one came to R11's room to announce themselves and say I will be your CNA or nurse. R11's face sheet documents R11 is a [AGE] year-old individual admitted to the facility on [DATE]. R11's MDS/Minimum Data Set, dated [DATE] documents that R11 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R11 has intact cognitive response. On [DATE], at 12:45 PM V25 (Licensed Practical Nurse) stated that V25 has seen that substance before. Two months ago, V25 was informed that R20 was walking out from another resident's room and it (the same size of baggie with the white loose powdered substance) was dropped on the floor. The housekeeper grabbed it and brought it to V25. It was the same white, dusty, substance that appeared to be cocaine. V25 stated that R20 has tested positive for cocaine. V25 stated that he has addressed this with R20 and R20 confessed to doing cocaine. R20 had just got their pass (outside privilege pass) back from testing positive for cocaine. R20 was upset due to losing their pass again. I (V25) notified whoever was the social worker on the 3rd floor that day. I was the nurse on duty for R20. V25 could not recall the exact date but it was two months ago. V25 admitted that he did not document this incident. V25 stated that he should have documented it because it is important to keep a history on this information. On [DATE], at 1:01 PM, V25 (Licensed Practical Nurse) stated regarding R21, there was a recent incident that happened last week on Thursday. V25 stated R21 was passed out and there were five or six of those baggies inside a bigger bag, like a sandwich clear bag in R21's room. V25 said that the baggies were inside the narcotic box. When V39 (certified alcohol and substance abuse counselor) got to work in the morning, V25 gave V39 the substances. V25 stated that V39 did not tell V25 that Narcan was administered to R21. V25 stated that in the past they did drug screens, but he is not sure about now. If the drug screens were positive, the residents were placed on pass restriction. V25 stated I (V25) heard social services say that residents who are repetitive offenders are going to set up outpatient rehab. V25 stated that there is absolutely a substance abuse issue going on in the facility. On [DATE], at 1:38 PM, R21 stated that she does not know how the substance in the bag got to R21's room. R21 stated she said she picked it up. I (R21) don't remember her name; it was a nurse. She was kind of short, your height. She asked me what that is. R21 responded that no one asked R21 to do a drug test and just placed R21 on a pass restriction. R21 stated that she had just gotten her pass back and she thinks that someone set her up. R21 stated when I (R21) first got here, I was using heroin, but now I am on methadone. We used to go out but now they give it here. It has been about 5-6 months since the last time I overdosed. R21 stated that the staff administered Narcan. I (R21) stayed in the hospital for three days, and it's been so long, I don't know who I got it from. R21 stated I (R21) have no idea how they come. People get drugs in jail, everywhere. R21 stated that she has not attended a group class for a while now because they haven't had them consistently in the last five months. R21's face sheet documents R21 is a [AGE] year-old individual admitted to the facility on [DATE], with diagnoses not limited to: abuse of other non-psychoactive substances, other psychoactive substance abuse, uncomplicated, opioid abuse, in remission. R21's MDS/Minimum Data Set, dated [DATE], documents that R21 has a BIMS/Brief Interview for Mental Status score of 14/15, indicating that R21 has intact cognitive response. R21's social service note dated [DATE], at 3:07 PM, documents in part, resident presented to Counselor/Social Services office to discuss recent incident involving contraband. R21's social service note dated [DATE], at 3:18 PM, documents in part, resident (R21) admitted to substance use and possession of contraband. This is a repeat incident that occurred again today. Counselor and nursing staff met with the resident for counseling, conducted a room search, and confiscated all contraband. The resident was educated on the importance of maintaining sobriety. Community access remains restricted. Due to repeated incidents, the resident will be prompted to admit to an inpatient detox/substance abuse program soon. On [DATE], at 1:58 PM, R20 stated that she cannot remember when R20 tested positive for cocaine but R20 stated that is not her drug of choice. R20 stated that this happened a while ago. R20 stated that she is currently on a 30-minute community pass. R20 stated that she goes out to smoke cigarettes by the parking lot or to the bus stop. R20 denied that she has overdosed or passed out in the facility. R20 denied that staff have had to administer Narcan to R20. R20 stated that was R21, she was the one, they had to hit her up with the Narcan. It happens with her all the d*** time. R20 stated that the illegal drugs are sold on the second floor by a resident and R20 won't say the name. R20 stated that they sell crack cocaine and heroin. R20 stated that there is a resident that sells that and another that sells marijuana. The crack cocaine is $10.00 dollars and the packaging varies; they might have a clear bag or might have a design on it. The heroin bag costs $10.00 dollars too. R20 stated that the staff are supposed to check the bags, but they do not. R20 stated that R20 does not know where R3 got illicit drug from but R3 always was with R22. R20's face sheet documents R20 is a [AGE] year-old individual admitted to the facility on [DATE] with diagnoses not limited to: opioid abuse. R20's MDS/Minimum Data Set, dated [DATE], documents that R20 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R20 has intact cognitive response. R20's social service note dated [DATE], at 2:35 PM, documents in part resident admitted to substance use and possession of contraband. On [DATE] at 2:20 PM, V26 (Certified Nursing Assistant) stated that she has not found illicit substances in residents' rooms herself but V26 was told where they came from. V26 saw the substance in a clear cup when the nurses were discussing it by the nurse's station. V26 stated that the night shift nurse found the substance on R22's bed. V26 stated I (V26) came to work for the 11:00 PM-7:00 AM shift because I work all shifts. The substance was a white, loose, powdered substance in a small clear bag, about one inch by one inch in size. This happened on Saturday night going into the Sunday shift. V26 stated that the nurses said it was heroin, and they ended up having to report it to the nurse supervisor. V26 stated that she heard R3 overdosed but V26 was not here the day R3 expired. V26 stated that she heard R19 overdosed but cannot remember the exact date but V26 thinks it was about a month ago. V26 stated I (V26) noticed R19 wasn't there one day and the next time I saw her, R19 said she (R19) had gotten a hold of a bad drug. V26 stated that she has heard R20 sells drugs and another resident. R22's health status/progress note dated [DATE], at 11:00 PM documents in part, upon coming to the unit and making rounds, it was noticed in resident's (R22) room on his side table a small baggy with a white powdery substance. Resident denies that it is his and doesn't know where it came from. The substance was confiscated. Per protocol, 911 was called. On [DATE], at 2:32 PM, R19 was sitting on her wheelchair in her room, in no apparent distress. R19 stated that she does have a history of substance abuse. R19 admitted that she had taken something while in the facility. R19 stated that her choice is cocaine. R19 stated I (R19) bought it from a friend about a couple of weeks ago. R19 stated that she overdosed because they gave her Narcan. R19 stated that she cannot recall who the nurse was because there are so many nurses. R19 stated that she bought the cocaine from here and it cost $5.00. R19's face sheet documents R19 is a [AGE] year-old individual admitted to the facility on [DATE], with diagnoses not limited to: opioid abuse, uncomplicated, opioid use, and unspecified with withdrawal. R19's MDS/Minimum Data Set, dated [DATE], documents that R19 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R19 has intact cognitive response. On [DATE], at 10:06 AM, R22 stated that he had known R3 for four to five months because they were roommates initially before R22 transferred to this room. That day, I (R22) got up about 8:30 AM to brush my teeth. A code blue was called, and I rushed into his room. R3 was laid out. R22 stated that R3 did not have a roommate when R3 passed. R3 stated that R3 wanted R22 to move back to R3's room. R22 stated that he was with R3 the other night, but not the night that R3 died. R22 stated that he last saw R3 the night before around 8:30 PM. R22 stated R3 must have passed between 4:00 AM to 8:00 AM. R22 stated usually R3 will be cleaning his room at 7:00 AM, every morning. R22 admitted that R3 was using heroin which was R3's preferred drug of choice. R22 stated that R3 was getting heroin from inside the facility. R3 stated that the guy that sold it is now gone. R22 preferred not to say the name of the seller. R22 stated he (R3) did have some on him that night and it was a clear small bag with white powder. R22 stated he probably snorted it. R22 stated that the heroin costs $10.00 and some bags have designs. R22 denied that R3 used cocaine and stated R3 wouldn't use cocaine. R22 stated that R3 maybe relapsed about a month before he died because maybe he ran into the wrong person. If someone is restricted, someone can go out for you, it is easy. If you pay someone $5.00 or $10.00, they will go get it. R22 denied witnessing anyone overdosing. R22 stated the third floor was overdosing and dying around that time, like October through [DATE]. R22 stated that R3 and R22 would use the drug and would share one baggie or have one each. R22 stated she (R21) is probably on restriction now. I don't mess with her. R21 did overdose but I don't know when. When asked who was in R3's room that morning, R22 stated that R11 was in there because R11 ran over there first and tried to resuscitate him, and as well as the staff that were there. R22 stated that the last time and R3 and R22 used illicit drugs together was the day before R3 expired. R22's face sheet documents R22 is a [AGE] year-old individual admitted to the facility on [DATE], with diagnoses not limited to: abuse of other non-psychoactive substances. R22's MDS/Minimum Data Set, dated [DATE], documents that R22 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R22 has intact cognitive response. R22's care plan documents in part the resident have a history of substance abuse/chemical dependency related to abuse of psycho-active substances. R22's care plan documents in part the resident has experienced the death and therefore, the loss of his close friend. Date Initiated: [DATE]. On [DATE], at 3:25 PM, V29 (Licensed Practical Nurse) stated I (V29) was running late that morning, I don't remember what time it was, but my shift starts at 7:00 AM. V29 stated that the CNA (certified nursing assistant) found R3. V29 came to get me and I then called the code. V29 stated that the night shift nurse was gone already and had given report to the other nurse that was working on the other side. At this time, I (V29) do not recall who the other nurse was. V29 stated I (V29) didn't get a chance to do rounds; I had literally walked in when this happened. It looked like he had been laying down for quite a while. He was cold and rigid already. V29 stated that R3's eyes were open and completely black. V29 stated residents are supposed to be monitored every 30 minutes, either the nurse or CNA, when I (V29) am there. I can't speak for someone else. V29 stated that R3's health status before his death, as far as last time V29 saw him, was not declining and was still regular (baseline). V29 stated that R3 was alert and oriented. V29 heard that he had drug-seeking behaviors. One time he was in the hospital after he was given Narcan. V29 stated I don't recall when this exactly happened, I was a new nurse in late August, early September. When that happened, I was in the first three weeks of my employment. V29 stated the morning when R3 was found unresponsive, staff moved R3 to bed. R3 had little bit of foam from his mouth. On [DATE], at 11:38 AM, V30 (Certified Nursing Assistant) stated, she was the assigned CNA for R3 the day that she found R3 unresponsive. That day I (V30) was late, at 8:00 AM. V30 stated when I (V30) arrived at the unit, staff started passing trays for breakfast. Breakfast can be between 8:00 AM through 9:00 AM. When I (V30) took his tray in his room, I saw him lying on the floor. He (R3) was closer to the window in the room. He looked deceased . His eyes were kind of dark and open. V30 stated that she ran quickly and got the nurse. V30 stated yes, I've heard about the drug abuse issue in the facility, and I am not sure what is going on with it. On [DATE], at 12:18 PM, V41 (Licensed Practical Nurse) stated R3 was not prescribed any medications for the night shift (11:00 PM-7:00 AM). V41 stated I (V41) usually come at 11:00 PM. R3 was up walking and talking at the nurse's station for some ice. V41 stated that around 4:00 AM or 5:00 AM was the last time V41 saw R3. R3 was in bed and alive. V41 stated that is the time I (V41) usually start my medication pass. V41 stated that R3 was not a check and change patient because R3 was able to go to the restroom on his own. V41 stated that general signs of overdosing could be foaming out of the mouth, nodding, unable to arouse to stimuli, basically unresponsive. V41 stated that some interventions would include administering Narcan and checking vital signs. Narcan cannot be given hours later because of the possibility of organ death and death. On [DATE], at 4:01 PM, V42 (Certified Nursing Assistant) stated, V42 was not working the day that R3 expired. V42 stated that she came back to work one day or two days after R3 died. I think I (V42) last saw R3 three or two days before he passed. I only work on Wednesday and Friday. He would come out of his room around 1:00 AM-2:00 AM and sweep his room out, listen to music, make himself something to eat, and go back to sleep. V42 stated you wouldn't see him (R3) without (R22). I would come in at 11:00 PM, and they would stay up until about 1:00 AM-2:00 AM. On [DATE] at 12:42 PM, V39 (Certified alcohol and substance abuse counselor) stated, V39 has been working for the facility for three months. V39 stated, I (V39) did take R21's pass recently because contraband was found in her room. On February 18th, 2026, V25 (Licensed Practical Nurse) found it on R21's dresser and gave it to me. R21 did not tell me (V39) where she got it from. She denied having contraband. R21 just had gotten her community pass (30-minute pass) the day before. V39 stated that R21's pass was restricted on [DATE]. V39 stated I (V39) don't have any in-house drug screens for R21. I (V39) wasn't there when they collected the contraband, I was just getting to work. (V25) gave it to me. He told me he found it the night prior and there was no drug test conducted. If the nurses suspect, whoever suspects, they should drug test that person. V39 stated that the facility's policy is that if there is suspicion of substance abuse, the residents will get drug screened if they accept. If it is positive, their pass is restricted. If they still have contraband, we call the police. A lot of the time the police don't come – I think it's the neighborhood we are in. I'm (V39) not sure why they do not come. We conduct room searches, ask them where they get the drugs from, get them into a program if they are not already in a substance abuse program, take their pass away, if they have guardian or POA (power of attorney) they are notified, document in their files, do an incident report in the computer program under risk management, contact ADON (assistant director of nursing) and DON (director of nursing), notify administration, edit the care plan, and do a substance abuse assessment. I (V39) guess I didn't complete a substance abuse assessment for R21 on [DATE]. V39 stated that there is no substance abuse assessment done on [DATE]. V39 stated I (V39) think they have the right like everyone else to be free from overdosing. V39 stated that the risk of overdosing is death. On [DATE] at 1:31 PM, V32 (Housekeeping) stated last year around October through [DATE], there were a lot of overdoses. V32 stated that he could not recall the exact names, but this was on the third floor. On [DATE], at 1:10 PM, V38 (Licensed Practical Nurse) stated of course, the residents are doing drugs. We had a few people overdose in here and somebody must be bringing it to them. We still have people that are not on pass restrictions, and we don't know who they are cool with. I (V38) am not sure what they are doing for the residents to overdose. V38 stated yes some of the people (residents) relapse in this building. On [DATE], at 1:06 PM, R44 (R3's Physician) stated if R3 was noted with a bag of white, loose, powdered substance R44 would have suspected R3 of overdosing. R44 stated I (R44) reviewed all my notes, and he (R3) was stable with his chronic conditions. R44 stated if there was foam coming out of his nose or mouth that would be an indicator of an overdose. R3's care plan documents in part substance use. Resident has tested positive for opioids. Resident stated relapse has occurred. Date Initiated: [DATE]. Revision on: [DATE]. No interventions in the substance use care plan regarding monitoring R3 noted. 2. R7 was a [AGE] year-old resident with diagnoses that include but are not limited to unspecified injury at unspecified level of cervical spinal cord, opioid dependence, neurogenic bowel, spinal stenosis, cervical region, reflex neuropathic bladder, central cord syndrome at C2 and C5 level of cervical spinal cord. R7 has a BIMS (Brief Interview for mental status) score of 15 indicating intact cognition. On [DATE], at 12:40 PM, V25 (Licensed Practical Nurse) stated R7 had just arrived at the facility like an hour and a half earlier. I did my initial assessment on R7. R7 asked me if I could visit my family. I said yes. R7 informed me that R7's son is coming to visit. Approximately half hour later someone stopped at the nursing station saying they were here to see R7. I escorted them to R7's room and left out of the room so they could visit. I was at the nursing station and approximately ten minutes later the visitor left the room. Approximately 30 to 45 minutes later the CNA (Certified Nursing Assistant) found R7 unresponsive with an unknown bagged substance on R7's chest. I went to assess R7 and called a rapid response. R7's vital signs were normal however R7's respirations were slowed and R7 was unresponsive. I saw the substance (one bag) on R7's chest. I called 911 then administered two to three doses of Narcan (naloxone). I read in R7's history that he had just come from a rehab facility for overdose a couple days before. I used my nursing judgement and administered Narcan. I did sternal rubs and applied a cold compression to R7. Upon pulling R7's sheets back, I observed an additional six to eight bags of the substance. The bags were about a quarter of a quarter, square and clear. The substance inside the bags was white dust, loose powder. V25 stated it must have been a couple minutes after R7 had used the drug before it was caught. V25 stated the incident happened on the 3:00 PM-11:00 PM shift. V25 stated In my opinion, the substance appeared to be cocaine. R7 did not wake up before leaving the facility. R7 was unresponsive when R7 left the building with 911. R7 returned from the hospital a couple hours later. I asked R7 who the visitor was. R7 would not tell me who it was but R7 said it was not R7's son. R7 was apologetic as to what happened. Residents should not be using controlled substances in the facility. On [DATE], at 12:10 PM, V31 (Medical Health Technician) stated, I have been a social worker in the facility for one year. I have only encountered R7 once. I want to say it was the 21st of December. I was not in the building when the incident happened. I read about the incident with R7 in a general report that is generated on residents' behaviors, refusals, etc. that have occurred within the current day and day prior. The report said R7 was found to be unresponsive. R7 was given Narcan. R7 was sent out to the hospital and was sent back to the facility. I spoke to R7 about what happened. R7 was hesitant to state what happened. R7 said he had it in his system and it has been in his system. R7 never identified what it was. V31 stated from their understanding it was a possible substance abuse. R7 had substances in their system. V31 stated I went to counsel R7 about substance abuse and maintaining sobriety. I initiated the substance abuse protocol which means I will restrict a community pass for 30 days, document what happened, my encounter with the resident, update the care plan for substance abuse and refer to the resident to the inhouse substance abuse program. On [DATE], at 4:30 PM, V2 (Director of Nursing) stated within the first hours of being in the building R7 had to be sent out to the hospital for drug usage/overdose. R7 had a visitor and was found with an unknown powdery substance that we assumed was street drugs. On [DATE], at 4:56 PM, V1 (Administrator) stated, I recall hearing R7 had an illegal substance on them. I don't know what drug it was. The residents should not have illegal drugs in the facility. The residents should not be using illegal drugs in the facility. R7's nursing progress note dated [DATE], at 12:23 AM, reads in part: The resident (R7) arrived at the facility ambulance service via 2 paramedics in stable condition. The writer was notified by the CNA (Certified Nursing Assistant) that the resident (R7) was observed unresponsive in bed. Writer entered the room to assess the resident. Resident is unresponsive, findings of unknown substance on chest. Writer administered Narcan 3 times before emergency response arrived. Resident was transferred to community hospital to follow up for admitting diagnosis. R7 hospital record for hospital admission, dated [DATE], reads in part: Laboratory Tests, dated [DATE], note Urine Opiates Screen – Positive A, Urine Fentanyl Screen – Positive A, Urine Benzodiazepines Screen – Positive A. Labs: Drug screen positive for fentanyl, heroin, and benzos (benzodiazepines). The impression is polysubstance abuse and hypotension (low blood pressure). R7 Social Service Note, [DATE], at 4:57 PM reads in part: Writer received a report that resident (R7) admitted to substance use. R1's current face sheet documents R1's medical conditions to include but are not limited to other secondary parkinsonism, chronic obstructive pulmonary disease, unspecified, transient cerebral ischemic attack, unspecified, cerebral infarction, unspecified. MDS (Minimum Data Set) section C dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) as 2/15 indicating R1 has severe cognitive abilities. On [DATE], at 1:13 PM, R1 was observed in the dining room sitting on his wheelchair next to a table. R1 answered simple questions by shaking his head yes or no. R1 was unable to communicate clearly. R1's nursing progress notes dated [DATE], 8:36 AM document: Upon doing rounds, writer noted R1 lying in bed, with the rise and fall of his chest. R1 had nasal flaring. R1 not responding to verbal or painful stimuli. V24 (LPN) called a rapid response and administered 4mg Narcan intranasally. R1 was not responding to 2nd dose of Narcan 4mg administered intranasally. R1 opened eyes, grunting noted. VS (Vital signs) as followed by 123/70 (Blood Pressure), (Pulse) 78, (respirations) 13, (Oxygen saturation) o2 94, BS (Blood Sugar) 159. Supplemental o2 administered 4L (liters) via nasal cannula. Fire department arrived to transport R1 to hospital. R1's Hospital records dated [DATE], document R1 was seen at the hospital for Opiate overdose and UTI (Urinary Tract infection). Hospital physician progress notes dated [DATE], document R1 was brought to the ED (Emergency Department) after being found unresponsive at the facility. Per ED, R1 received Naloxone (Narcan) with clinical improvement and is now awake, oriented and hemodynamically stable. Interpretation: Despite a negative USD (Urine Drug Screen), the naloxone response plus history of opioid misuse suggests recent opioid exposure (possible short-acting opioid) not captured by screen, concentration below cut off, timing and collection, or non-standard analog. On [DATE], at 10:55AM, V28 (Nurse Practitioner-NP) via phone stated she does not remember if she received a call from a nurse notifying her R1 was administered Narcan after being found unresponsive. V28 stated she has given Narcan to residents in the facility on multiple occasions. There is a huge population of residents at the facility with illicit drug use history. V28 stated Narcan is given to a resident if nurses suspect opioid/illicit drug use. If a resident is nonresponsive and illicit drug use is suspected, the nurse administers Narcan to the resident. If the resident has opioid/illicit drug in the system, the resident will start to come around and start responding. On [DATE], at 12:18PM, V24 (Licensed Practical Nurse-LPN) stated via phone that she worked at the facility for a very short time and does not remember R1 or calling code for R1. V24 stated she did not give Narcan to any resident including R1 when she worked at the facility. On [DATE], at 12:35 PM, V25(Licensed Practical Nurse) stated he did not administer Narcan to R1 on [DATE]. V25 said he responded to rapid response call for R1who was found unresponsive. V25 went to help V24 (Licensed Practical Nurse). V25 stated he was signed into his work computer on R1's floor and V24 must have charted under his name. V25 stated he was in the middle of administering medications, and he did not have to log off

Based on observation, interview, and record review the facility failed to follow their policy to protect two residents (R13, R14) from abuse in a sample of 22 residents reviewed for abuse. This failure resulted in psychosocial harm to R13 and R14.Findings include:R13 is a [AGE] year-old resident with diagnoses that include but are not limited to asthma, iron deficiency anemia, osteoarthritis. R13 has a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition.R14 is a [AGE] year-old resident with diagnoses that include but are not limited to asthma, chronic obstructive pulmonary disease, osteoarthritis, anemia, morbid (severe) obesity. R14 has a BIMS score of 15 indicating intact cognition.R16 is a [AGE] year-old resident with diagnoses that include but are not limited to heart failure, atherosclerotic heart disease of native coronary artery, anemia, osteoarthritis, type 2 diabetes mellitus, cocaine abuse with intoxication. R16 has a BIMS score of 15 indicating intact cognition.On 2/24/26 at 2:48 PM, R13 stated that R13 and R13's mother (R14) resides in the same room. R13 stated that R13 does not feel safe because someone (R16) is being verbally abusive and using foul language towards R13. R13 stated that R16 has called R13 a b**l sucker, and a d**k sucker. R13 stated this happened about two months ago and there were no staff around. R13 stated I never disrespected R16. I've always been cordial, and R16 continues to spread rumors about me and R14. R13 stated that R16 sits in the hallway and says we (R13, R14) stink. R16's room is next door to ours and our rooms share a restroom. R16 does not want R13 and R14 to use the restroom that they share. R13 and R14 have a bedside commode in their room that they use. Writer observed a bedside commode with urine in it inside of R13 and R14's room. R13 stated that they feel the CNAs (Certified Nursing Assistants) and nurses are part of it because R16 has been here for a long time and R16 is favored. R13 stated that R13 and R14 ignore it and try to keep the peace. On 2/24/26 at 3:34 PM, R13 stated that the bullying situation is frustrating and makes them (R13, R14) feel angry. Sometimes I feel that if I say something it will get worse. At this point I feel like I should say something because it is getting out of hand. R13 stated that R16 has made fun of R13 and R14 for using the restroom's toilet and said they stink. R13 stated so they (R13, R14) prefer to use the bedside commode, so they don't have to be ridiculed. If we try to use the bathroom, R16 will walk in. It is like their (R16's) territory. I am stressed out and have anxiety because R16 doesn't stop. R14 stated that R14 does not feel safe but R14 is staying in the facility because R14's son is a resident in the facility and R14 wants to stay near him. On 2/24/26 at 3:50 PM, R16 stated they have been in the facility for two years. When questioned if there are any issues between R16 and R13 and R14, R16 stated not that I know of, I barely even see them, we use the bathroom, and I don't have any problems. If they have a problem with me, I don't know about it. R16 denied any verbal altercations. R16 stated that R16 just regularly sits in the hallway and drinks her coffee. R16 stated I used to be really tight with them but one day, R14 said I heard you said something about R13 sucking d**k. I told R14 I never said anything about y'all. I don't say anything to them. R16 stated that R13 still speaks to R16 and says hi and bye and R16's feelings were hurt for a minute. R16 stated that nobody knows them (R13, R14), they keep to themselves. R16 denied ever saying anything about R13 and R14. R16 denied having any altercations with anyone else. R16 said I came to the facility for toe amputation and open-heart surgery. R16 stated there were no staff when R14 came up to R16 and only a couple of other residents. R16 denied telling anyone not to use the restroom. R16 stated that R13 and R14 have one of those porta potties. Writer observed the restroom and noted purple mats and decorations (frames) in the restroom. R16 stated that they decorated the restroom to make it like home.On 2/24/26 at 4:03 PM, R11 stated it will be two years in April since they have been residing in this facility. R11 stated as soon as R16 is mad at you, they (R16) will be ignorant and disrespectful. I never witnessed them (R13, R14, R16) having an argument or disagreement. But I've heard they (R13, R14 and R16) have had differences especially because of the bathroom. I heard R16 said that R13 and R14 left the bathroom dirty, and R16 told them to clean up after themselves. R11 stated that R16 picks at people and if R16 doesn't like you they try to get you off of the floor. R16 thinks they run this floor. R11 stated that a lot of nurses and CNAs (Certified Nursing Assistants) get along well with R16. R16 knows about one of my diagnoses. How does R16 know about it, if not from staff. R16 knows who to pick on and who not to pick on. We've had our argument, and I told R16 to leave me alone and I'll stay out of their way. I don't like R16s spirit. R11 denied having any issues with R13 and R14.On 2/24/26 at 4:33 PM, V17 (Assistant Director of Nursing) and V18 (Assistant Administrator) were notified that R13 and R14 made allegations of verbal abuse and bullying to IDPH (Illinois Department of Public Health) surveyors. V17 and V18 stated they were going to follow up accordingly. On 2/26/26 at 1:15 PM, V25 (Licensed Practical Nurse) stated I have had abuse training. We have in-services about every three months and if an incident occurs. The Abuse Coordinator is the Administrator. Types of abuse include verbal, physical, and financial. If I witnessed abuse, I would report immediately. Verbal bullying, calling names is abuse. On 2/26/26 at 12:10 PM, V31 (Medical Health Technician) stated I have been a social worker in the facility for one year. I have had abuse in-services. Maybe every two weeks we have one. Types of abuse include physical, mental, emotional, financial, and verbal. The Administrator is the Abuse Coordinator. I would immediately report abuse to the Abuse Coordinator.On 2/26/26 at 3:50 PM, V23 (Social Service Director) stated I have been with the facility for six to seven months. I oversee the other social workers. They notify me of any concerns with the residents. Any abuse witnessed, suspected, or heard about, I would report to the Abuse Coordinator, the Administrator. On 2/27/26 at 9:52 AM, V35 (Wound Care Coordinator) stated I would report abuse to the administrator who is the abuse Coordinator. Verbal bullying is abuse.On 2/27/26 at 10:51 AM, V36 (Certified Nursing Assistant) stated they are familiar with R16 and stated R16 respects V36 and V36 respects R16. V36 denied witnessing any bullying or abuse by any residents. V36 stated that R16 is cordial with other residents. V36 stated the Abuse Coordinator is the Administrator and types of abuse are verbal, physical, financial, mental, and sexual. V36 stated that the last time V36 received abuse training was a couple of months ago. On 2/27/26 at 10:55 AM, V37 (Registered Nurse) stated V37 has worked for the facility for three months. V37 stated R16's demeanor can be described as outgoing and outspoken. V37 stated R13 and R14 are both quiet and will come out of their room if they need anything. V37 stated there has not been any incidents or concerns brought up to V37 regarding R13, R14, and R16. V37 stated there has not been any disagreements or incidents regarding their shared restroom brought up to V37. V37 denied witnessing or hearing about any bullying or abuse going on between R13, R14, and R16. V37 stated the Administrator is the Abuse Coordinator and V37 stated bullying is a type of abuse because it could be psychological or intimidating. V37 stated bullying is something they would report immediately including all forms of abuse.R13 Social Service Note, 02/24/2026 19:03, reads in part: Writer received a report that Resident alleged peers made an inappropriate statement towards her. Resident verbalized emotional distress related to the alleged inappropriate comment.R16 progress notes; 07/16/2025, 05/02/2025, 04/19/2025, 02/11/2025 document multiple episodes of verbal altercations, verbal aggression toward peers and facility staff members. Provoking and derogatory name calling.R16 is care planned for verbal aggression; the resident (R16) has a history of manipulative, aggressive, inappropriate, attention-seeking behavior. The history includes: conflicts/altercation with others, threatening behavior, verbal or physical aggression towards peers. Manipulative behaviors; the resident (R16) displays manipulative behavior which is disruptive, insensitive and/or disrespectful to staff and peers. This behavior is related to: anger and depression, symptoms/problems are manifested by: threatening or acting in a verbally and/or physically aggressive manner.Initial Reportable Event, incident date 2/24/2026, involving R13, R14, R16 reads in part: Resident reported inappropriate behavior from co-peer.Facility Policy and Procedure Abuse Prevention Program, 1/24, reads in part: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish.

Based on observations, interviews, and records review, the facility failed to follow their employee handbook policy related to employee cell phone use. This failure has the potential to affect 115 residents residing in the unit.Findings include: On 02/25/2026 at 9:24AM, surveyor exits R4's room and is located on the second-floor north unit nurses' station. Surveyor sees a black phone and hears an audible ringing sound coming from the phone located on a desk at the nurses' station. Surveyor observes V14 (Central Supply Manager/Transportation) standing directly next to the nurses' station phone and is observed talking on her personal cell phone while ignoring the audible rings coming from the nurses' station phone. Surveyor also observes V15 (Restorative CNA/Certified Nursing Assistant) sitting in a chair at the second-floor north nurses' station with his head looking down and personal cell phone in his hand and texting. V15 also observed ignoring the audible rings coming from the nurses' station phone and never looks up from texting on his phone. Once V14 and V15 observes surveyor, V15 stops texting and puts his phone away while V14 puts her cell phone in her pocket and answers the phone at the nurses' station. V14 states she did not hear the nurses' station phone ringing at first because she was talking on her own personal cell phone. V15 states he did not hear the nurses' station phone ringing because he was texting. V15 states it is everyone's responsibility to answer the phone at the nurses' station. V15 states the phone calls are usually for the nurses', so he never answers the phone at the nurses' station anyway. Facility Census dated 02/24/2026 documents that there are a total of 57 residents residing on the second-floor north unit of the facility. Facility document undated, titled Employee Handbook documents in part, Personal Electronic Devices- Cell phone usage while on duty is prohibited. Examples of such devices includes mobile telephones, laptops, tablets hand-held email or texting devices. You may however use such devices, in designated areas, while on break. If you have an emergency situation that must be immediately tended to, please inform your Supervisor. Employees who use personal electronic devices while on duty may be subject to disciplinary action, up to and including termination. Personal cell phones must be left with your personal belongings while in the facility. Consultants and managers must have their cell phones on quiet/vibrate mode and should not talk on their phones in resident care areas. On 02/24/2026 at 1:02 PM-1:10PM, V6 (Certified Nursing Assistant -CNA) was observed sitting in the hallway on 3N with her personal cell phone in her hands scrolling on her phone. V6 stated she is not supposed to be on her personal phone when monitoring hallway for resident safety. If she is on the phone, she might not monitor residents properly which can lead to residents not receiving the care they need. Residents can sustain injuries; residents can get into confrontations. V6 stated staff using personal phones while in the units is not part of her job description. V6 stated she is assigned 20 residents and 3N houses 58 residents' total. On 02/25/2026 at 12:58PM, V2(Director of Nursing-DON) stated Certified Nursing Assistants (CNAs) or nurses are not supposed to use their cell phones on the units. Cell phones are only allowed in the break room when staff are on break. Cell phone use in the units is distracting, can cause HIPAA (Health Insurance Portability and Accountability Act) violations and is unprofessional. If the CNAs and nurses are on their cell phones, they cannot provide proper care to residents. Accidents and injuries can happen to the residents.

Based on observation, interview, and record review the facility failed to ensure proper indwelling catheter care for two residents (R7, R9) of 22 residents reviewed.Findings include: R9 is a [AGE] year-old individual whose current face sheet documents medical diagnosis to include but not limited to: cardiac arrhythmia, unspecified, gastro-esophageal reflux disease with esophagitis, without bleeding, retention of urine, unspecified, other obstructive and reflux uropathy, disorder of the autonomic nervous system, unspecified. R9's Minimum Data Set (MDS) Section C - Cognitive Patterns dated 02/16/2026 documents R9's Brief Interview for Mental Status 14/15, indicating R9 has intact cognitive abilities. Section GG - functional abilities documents R9 requires supervision or touching assistance with eating and oral hygiene, is dependent on staff for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene. On 02/24/2026 at 12:46PM, R9 was observed laying in bed eating lunch, was alert, oriented to person, place, time and situation. R1 was observed with an indwelling urinary catheter. The catheter bag was observed on the floor. R9 stated he cannot see what is placed on the floor and does not know if the urinary bag is on the floor. On 02/24/2026 at 12:48PM, V3(Licensed Practical Nurse-LPN) and surveyor observed R9 lying in bed. R9's urinary catheter was observed to be approximately halfway full. The urinary bag was placed directly on the floor. V3 stated urinary catheter bags are not supposed to be placed on the floor, it should be hooked on the bed frame below the bladder. It is an infection control issue. The floor is dirty. Germs can get into the catheter causing R1 to develop urinary tract infections (UTI). CNAs (certified Nursing Assistants) are supposed to hook it up to the bed frame off the floor. Nurses are supposed to check and make sure the urinary catheter bag is hooked on the bed frame below the kidneys. On 02/27/2026 at 10:48AM V35(Licensed Practical Nurse - LPN) Urinary catheter should be cleaned every day with normal saline then hooked on the bed frame above the kidneys. It cannot be placed on the floor, because it can cause friction and pulling which can cause resident harm. The catheter should never be placed on the floor, which is dirty. It can pick up germs that can cause residents to develop urinary tract infections. It is an infection control issue. On 02/25/2026 at 12:58PM, V2 (Director of Nursing-DON) V2 stated urinary catheters should not be placed on the floor. It should be hung on the side of the bed away from the floor and below the kidneys to prevent back flow and germs from the floor from entering the catheter. Placing the urinary bag on the floor can cause a resident to develop a urinary tract infection. R9's Physician Order Sheet (POS) documents: Catheter: May change urinary drainage bag every 24 hours as needed when unable to observe urine. 2/27/26 at 9:52 AM, V35 (Wound Care Coordinator) stated signs of infection include redness, swelling, puss/sediment to the area, discharge. The catheter area is cleaned daily, and the catheter is changed on order, typically 30 days for infection control or upon doctor's request. We assess the site and clean with normal saline. The catheter bag is placed below the kidneys so the urine can flow downwards with natural gravity on the side of the bed. The urine should not flow backwards so not to risk a UTI (urinary tract infection). The bag should not be on the floor for infection control. R7 catheter care order reads in part: change foley cath (catheter) as needed for blockage, leaking or malfunctioning. R7 is care planned for risk for infection or complications related to catheter use due to neurogenic bladder. R7 Health Status/Progress Note, 01/19/2026 05:45, reads in part: Upon making rounds resident (R7) noted lethargic and slow to respond. Resident noted warm to touch. Vitals taken and were noted at 107/72, 130, 14, 80% on R/A (room air), 103.0. Supplemental 02 (oxygen) administered at 3L/Min (liters/minute) via nasal cannula, 02 increased to 90%. Tylenol administered for temperature. Head of bed maintained elevated. No pain or discomfort noted. On call clinician for MD (medical doctor) phoned, awaiting return call. 911 was called to transport resident to hospital. R7 Nursing Progress Note, 01/19/2026 13:07, reads in part: called and received admitting from hospital diagnosis of hypoxia and sepsis. R7 hospital record for hospital admission 1/19/2026 reads in part: Patient (R7) has indwelling Foley catheter and was reported on non-draining for unknown periods of time with change of urine color to dark brown. Upon arrival to ER (emergency room), temperature was 100.8, HR (heart rate) 122. Activities at onset: other (clogged Foley catheter). Urine appearance: turbid A, Urine leukocyte esterase: Large A, Urine bacteria: many A. Diagnosis: AMS (altered mental status). Hypoxia on BIPAP (Bilevel Positive Airway Pressure), possible postictal, sepsis, hypotension, UTI (urinary tract infection). Ordered change of the Foley catheter which was clogged, and inserted a new Foley catheter which is freely draining. Color of urine is dark brown. Urinalysis: turbid, heavy proteinuria, large leukocyte esterase, many bacteria.

Based on interview and record review, the facility failed to follow its policy and revise a care plan to ensure that the resident's care plan addressed each fall and interventions were changed with each fall for one (R4) out of three residents reviewed for care plans following a fall. Findings include: On 02/25/2026 at 1:36PM, V13 (Restorative Nurse) states she is responsible for inputting fall preventative interventions in the resident's care plan. V13 states residents' care plans should be updated to reflect each fall and the fall care plan interventions should also be updated with different interventions. V13 states if a resident falls multiple times, the fall interventions should not remain the same because this indicates that those interventions are not working to prevent the resident from falling. V13 states this puts the residents at a greater risk of falling when interventions are not changed. V13 deploys R4's care plan dated 11/09/2025 and states she did not update fall interventions for R4 after he fell on [DATE]. V13 states it is important to update the care plan to ensure that residents have the fall prevention intervention and equipment that they need. V13 states the definition of updating the care plan is to add new fall precaution interventions. R4's care plan dated 10/15/2025 was reviewed and documents: R4 is at risk for falls r/t Confusion, Gait/balance problems, Incontinence. Interventions include: Anticipate and meet R4's needs, Date Initiated: 10/04/2023, Assist with proper positioning while in bed, Date Initiated: 06/25/2024, Be sure R4's call light is within reach and encourage R4 to use it for assistance as needed. R4 needs prompt response to all requests for assistance, Date Initiated: 10/04/2023, Bed bolsters to assist with identifying bed perimeter, Date Initiated: 04/08/2024, Educate R4/family/caregivers about safety reminders and what to do if a fall occurs, Date Initiated: 10/04/2023, Ensure that R4 is wearing appropriate footwear when ambulating or mobilizing in w/c, Date Initiated: 10/04/2023, Follow facility fall protocol. Date Initiated: 10/04/2023, Frequent monitoring, Date Initiated: 04/08/2024, Keep commonly used items in reach, Date Initiated: 06/25/2024, Keep resident's immediate environment clutter free, Date Initiated: 06/25/2024, Maintain bed in low position when resident is in bed, Date Initiated: 04/08/2024, Monitor medication side effects and report to MD PRN, Date Initiated: 06/25/2024, R4 has dycem in his wheelchair to prevent sliding, Date Initiated 10/04/2023, R4 provided with a floor mat, Date Initiated: 10/04/2023, R4 will wear hipsters to prevent injury from falls.R4 is at risk for falls R/T History of Falls. Interventions include: Floor mat on side of the bed, Date Initiated: 06/25/2024, frequent Checks, Date Initiated: 04/08/2024, Low bed Date Initiated: 04/08/2024.Record review of R4's care plan dated 11/09/2025 shows that there is no updated care plan to reflect new interventions implemented after R4 fell on [DATE].Facility policy dated 01/2024 titled Care Plan documents in part When a significant change occurs in a resident's condition, the MDS coordinator or designee is notified by a member of the interdisciplinary team. The care plan is then reviewed and updated.

Based on interview and record review, the facility failed to treat a resident's personal belongings with respect and ensure the resident has access to their personal belongings. This failure affects one (R4) resident out of three residents reviewed for resident rights. Findings include: On 02/25/2026 at 9:11AM, surveyor located inside of R4's room and observes a black television/TV measuring approximately 32 inches diagonally. The TV was attached to a portable TV stand, TV observed on and in working condition. On 02/25/2026 at 9:12AM, V11 (CNA) states the TV located inside of R4's room was recently purchased by R4's family because R4's previous TV was broken in the facility. V11 states she heard that a nurse (identified as V12/RN) broke R4's previous TV by bumping it with R4's bathroom door. V11 states R4's family purchased R4's previous TV as well.On 02/26/2026 at 8:27AM, V12 (Licensed Practical Nurse/LPN) states she was located inside of R4's room with three CNAs, who were assisting her with transferring R4 via a mechanical lift. V12 states she cannot remember the names of the CNAs. V12 states R4's TV was sitting on the bedside table and it fell to the floor during transferring R4. V12 states R4's TV did not fall on the floor but, fell on a bag of dirty clothes and one of the CNAs picked it up and placed it back on the bedside table in the same position. V12 states she never looked at R4's TV after it fell and did not know that it was broken. V12 states she went on vacation for one month and when she returned, she heard hearsay that she was the person who broke R4's TV. V12 states she heard that one of the nurses informed V34 (R4's family member) that V12 broke R4's TV. V12 states this hearsay is not true and she did not break R4's TV. V12 states she never addressed the hearsay because she did not want to get into any confrontations.On 02/27/2026 at 10:25AM, V1 (Administrator) states she was also contacted about 2-3 months ago by V34 (R4's family member) regarding R4's broken TV. V1 states R4's previous TV was a TV that R4 had for five years, and the TV just went out and stopped working. V1 states to her knowledge, the facility has replaced R4's TV because the facility replaces residents' TVs all the time. V1 states she is not sure if she has an invoice for R4's TV replacement but she spoke with V22 (Maintenance Director) and informed him to replace R4's TV. V1 states she never went inside of R4's room to verify if R4's TV was broken. On 02/27/2026 at 11:09AM, V22 (Maintenance Director) states several months ago, R4's TV was broken in the facility. V22 states he is not sure how R4's previous TV broke. V22 states R4's family bought R4 another TV. V22 states he is the person who put R4's TV on the TV stand inside of R4's room.Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2018 documents in part, You may keep and use your own property.

Based on observation, interview and record review the facility failed to provide a safe, functional, clean and comfortable environment. This failure affects all residents residing in the facility.Findings include:On 2/20/2026 at 11:15am surveyor observed a picture with a bath blanket covering it on the 3rd floor at the end of the North Hall. The glass in the picture frame had been broken out at the top and in the middle but there was broken glass shards at the bottom of the picture frame. On 2/20/2026 at 11:21am V9 (Housekeeper) stated the picture frame is broken with glass shards and if someone bumps into the picture frame it could be dangerous.On 2/20/2026 at 11:22am V26 (Certified Nursing Assistant) stated it's a broken picture frame with glass shards protruding from the bottom of the frame and it is a hazard to residents and can be used as a weapon.On 2/20/2026 at 11:28am surveyor observed, on the second floor, the wall, in the shower room, behind the toilet with a brown substance splattered on the wall and a yellowish gray and black debris on the bottom of the toilet and floor.On 2/20/2026 at 11:30am V16 (Housekeeper) stated the brown substance looks like feces on the wall and the yellowish gray substances looks like urine and the bathroom should be cleaned twice a day and this mess should have been cleaned up.On 2/20/2026 at 2:08pm V25 (Maintenance Director) stated he was made aware that there was a picture frame on 3 North about 5 minutes after the surveyor saw it and that the frame had been taken down. V25 stated that it was not documented in the work order binder.On 2/21/2026 at 8:48am V28 (Housekeeping Director) stated yes, the entire toilet and the wall behind it should be cleaned daily and as needed and the purpose is to disinfect the bathroom and allow it to appear homelike. No, I was not aware that there was a broken picture frame with glass shards still in the frame on 3 North. V28 stated he will make sure those two items (bathroom cleaned and picture frame removed) are taken care of. Preventative Maintenance Program with a reviewed date of 11/2023 documents, in part, all facility areas are kept clean and in safe condition.Undated Performance Evaluation Housekeeping Assistant documents, in part, Main duties: G. remove dirt, dust, grease, film etc. from surfaces using proper cleaning /disinfecting solutions.

Based on observation, interview and record review the facility failed to follow sanitation and food handling practices while preparing resident meals. Failed to record temperatures of food before serving residents. Failed to maintain temperatures of food before serving food to residents. This failure affected 20 residents reviewed for food safety.Findings include:On 02/20/26 at 12:00pm observed V21 (Dietary Aide) and V22 (Cook) preparing meal trays and meals for resident dining. V21 and V22 were observed with full facial beards with no beard coverings.On 02/20/26 at 12:03pm V15 (Dietary Manager) stated that V21 (Dietary Aide) and V22 (Cook) should both have beard coverings on while preparing resident meals. V15 stated that hair can fall in the resident's food and that not covering their beards is unsanitary.On 02/20/26 at 12:05pm V22 (Cook) stated that he didn't know that the facility had hair nets for beards. V22 stated that he should have a hair net over his beard so that hair doesn't fall in the food.On 02/20/26 at 12:08pm V21 (Dietary Aide) observed with ungloved hands, lick his hand and pick up menu ticket and place it on the resident meal tray. Observed V21 prepare multiple trays which V15 (Dietary Manager) counted as 20 trays before V21 sanitized his hands and placed gloves on.On 02/20/26 at 12:08pm V21 (Dietary Aide) stated that he should not have licked his fingers and continued to prepare the meal trays. V21 stated that licking his fingers is unsanitary.On 02/20/26 at 12:14pm V21 (Dietary Aide) observed with gloved hands, place mask over V21's face, adjusting mask at ear and nose placement. V21 then observed to continue preparing meal trays without removing gloves and sanitizing hands.On 02/20/26 at 12:14pm V15 (Dietary Manager) stated that V21 (Dietary Aide) should have sanitized his hands and replaced his gloves before continuing the tray line.On 02/20/26 at 12:27pm surveyor observed delivery of the 3 south meal carts delivered to the 3 south dining room. V15 (Dietary Manager) pulled random tray from meal cart. V15 checked temperature of food on the meal tray. Ham on the meal tray tempted at 87.8 degrees Fahrenheit. V15 stated that the ham should be at least 110 degrees Fahrenheit. V15 stated serving food at the right temperature makes it safe for residents to eat and makes it palatable.On 02/20/26 at 12:34pm surveyor requested to view temperature log of temperature checks before lunch was served. V22 (Cook) stated that he checked the temperatures before he served the lunch to residents, but he did not write them down anywhere. V22 stated that he is unable to provide me with a temperature log.On 02/20/26 at 12:34pm V15 (Dietary Manager) stated that V22 (Cook) should have taken the food temperatures before serving the food to the residents. V15 stated that the food temperatures should be taken to make sure that food is safe to serve to the residents. V15 stated that food temperature checks should be kept on a log.Facility policy titled Employee Health and Personal Hygiene) revised 09/17/23 documents in part, Policy: Food service employees shall maintain good personal hygiene and be free from communicable illnesses and infections while working in the facility. Procedure:. Hair restraints will be worn at all times. Beards should be well-trimmed and covered with an appropriate hair restraint. Personnel that are serving food on trays or for activities must wear gloves while handling ready to eat food but do not have to hairnets.Facility's policy titled General Preparation and Cooking Practices revised 09/18/23 documents in part, Policy: The facility will follow sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness. Procedure: Hands are washed thoroughly before touching food or equipment. Hairnets or caps and beard guards are used in the preparation of food. Foods that have become unsafe must be discarded. The following situations may render foods to be unsafe. when it is contaminated by hands or bodily fluids. When it has exceeded the time and temperature requirement. Hot food prepped for serving will maintain a minimum temperature of greater than or equal to 135F (degrees Fahrenheit) when on the table and prior to being served to the residents. If the food is below 135F, the staff must reheat the food to 165F to assure time and temperature control. Internal temperatures for cooking meals must meet: 145 degrees for fish, veal, lamb, pork, and other red meats.Facility's policy titled Tray Service dated 10/25/23 documents in part, Policy: Employees will use measures to ensure the sanitation and safety of food provision on the tray line, transportation of meals, and tray delivery. Procedure:. 3. Temperatures are taken prior to service to ensure hot foods and cold foods are maintained at the appropriate temperatures. Temperatures will also be recorded 30 minutes into the meal service to ensure temperatures are maintained. 4. If items are not at the correct temperatures, action will be taken so that temperatures are restored to the correct temperatures. 5. Temperatures are recorded on the Tray Line Temperature Log and kept on file for 1 year. 8. Food will be delivered to the residents in a sanitary way to prevent food-borne illness. Protocol: 11. All food that is transported from the kitchen to other areas for service will be handled in a safe manner, covered to prevent contamination, and in closed food carts. Hot foods will be at least 120-135 degrees, and cold food will be at 40-45 degrees at the time of service for palatability.Facility's job description titled Dietary Aide documents in part, Summary: The Dietary Aide is responsible for aiding all food functions as directed/instructed and in accordance with established food policies and procedures. Essential Duties and Responsibilities: Ensure that the department is maintained in a clean and safe manner by assuring that necessary equipment and supplies are maintained. Dietary Aide must also ensure the facility's standards on Infection Control Precautions are being followed when performing daily tasks.Facility's job description titled Cook documents in part, Summary: The [NAME] is responsible for food preparation in accordance with current applicable federal, state, and local standard, guideline and regulation with our established policies and procedures, and as may be directed by the Dietitian and/or Director of Food Services, to assure that quality food service is provided at all times. Essential Duties and Responsibilities:. Ensure that all food service procedures are followed in accordance with established policies.

Based on observation, interview, and record review the facility failed to maintain an effective pest control that eliminated roaches and mice in the facility. This failure has the potential to affect all 213 residents in the facility. Findings include: On 2/13/2026 at 10:30 AM, R18 stated bugs she identified as roaches are seen in the hallways and seldom in her room; no roaches in her food but have seen roaches in the dining room crawling on trays left over from lunch or dinner; mice seen in the hall running from one room to the next; and seen roaches in the shower room. On 2/13/2026 at 10:49 am, V21 (Certified Nurse Assistant-(CNA) stated she saw roaches on unit 2 North's hallway floors this week and have not seen any roaches in resident's food. On 2/13/2026 at 11:08 AM, R19 stated bugs in his room are roaches and are coming from the resident's room next door. On 2/13/2026 at 11:15 AM, R9 stated they saw bugs described as roaches crawling on his table and has seen mice in their room since he was admitted 8 months ago and no roaches in food. On 2/13/2026 at 10:01 am, Surveyor and V11 (Maintenance Assistant) observed the facility dumpster area with two dumpsters that had four open lids and trash surrounding the dumpster area. V11 stated that he believes that the dumpster lids should be closed and that the housekeeping department is responsible for the dumpster area. V12 stated, I don't deal with that (referring to the dumpster area). V11 then explained if the dumpster lids are left open and trash is left around the dumpster area pest such as roaches and mice can come into the facility. On 2/13/2026 at 10:07 am, Surveyor and V12 (Housekeeping Supervisor) observed the facility dumpster area with two dumpsters that had four open lids and trash surrounding the dumpster area. V12 stated that the dumpster area should be cleaned more than daily. V12 then explained if the dumpster area is left with trash and lids open it is not good and can attract cats, varmints and rodents to the facility On 2/13/26 at 10:13 am, V10 (Certified Nursing Assistant, CNA) stated that she has witnessed roaches all throughout the third-floor unit including residents rooms at the facility. V10 also stated that about a month ago she has witnessed a resident kill a mouse and bring the dead mouse to the nursing station to the unit nurse. On 2/13/26 at 10:16 am, R6 stated that she observed roaches in her room and mice in the nourishment room underneath the sink. R6 stated that she reports the sightings of roaches and mice to the facility staff, and nothing is being done because she continues to see them. At 10:19 am, Surveyor and R6 observed mouse/rodent droppings located underneath the sink cabinet area within the nourishment room on the third floor. The observed droppings were located on the floor surface beneath the plumbing area and appeared to be consistent with rodent feces. On 2/13/26 at 10:22 am, Surveyor observed R7 in bed asleep with dead roaches next to R7's nightstand in R7's room. On 2/13/26 at 10:25 am, R8, R12 and R13 all stated that they see roaches in their room crawling throughout the baseboards usually at nighttime. R8, 12, and R13 all stated that about one month ago there was a mouse on a glue trap in R8, R12 and R13's room. R8 stated that he reported the mouse on the glue trap however nothing was done. R8 further explained that the mouse laid on the glue trap making a squeaking noise so R8 put the mouse on the glue trap in a trash bag and took the mouse to the third-floor nurses station and staff then disposed of the mouse. R12 and R13 all stated they witnessed the event. On 2/13/26 at 10:30 am, R9 stated that he sees mice coming through the baseboard in his room every night. R9 stated that V8 (Maintenance Director) sprayed foam around the baseboards in R9's room however he still sees the mice every night. R9 also stated that he sees roaches in his room every day. R9 states that he continues to request staff to place glue traps for his room however nothing has been done. On 2/13/26 at 10:33 am, Surveyor observed three small roaches in the third-floor shower room behind the linen cart across from the shower stall area. On 2/13/26 at 10:40 am, R10 and R11 both stated that about one week ago R10 and R11 observed a dead mouse in their room. R11 stated that he placed the dead mouse in a plastic bag and took it to the housekeeping staff and requested a glue trap for R11's room however the housekeeping staff stated they did not have a glue trap and tossed the mouse into the garbage. On 2/13/26 at 10:48 am, V13 (Licensed Practical Nurse, LPN) denied ever seeing mice or roaches at the facility. At 10:55 am, Surveyor and V13 went into the third-floor shower room and observed three roaches behind the linen cart across from the shower stall area. V13 stated, This is the first time I seen roaches here. O 2/13/26 at 10:56 am, V14 (CNA) stated that she sees roaches every day in all the residents rooms. When V14 was asked the facility's protocol for when there is a sighting of a pest and V14 stated, I just step on it (referring to the roaches) and kill them. On 2/13/26 at 11:20 am, V1 (Administrator) denied any knowledge of mice in the facility. V1 stated that she was not aware of residents with concerns for mice in the facility. V1 then stated that she is aware of residents with concerns for roaches in the facility and that the pest control company treats the facility twice a month. When V1 was asked if there has been request for the pest control company to treat the facility more frequently, V1 stated that at this time the pest control company only visits the facility twice a month. The facility's policy dated 5/14 and titled Waste Management documents, in part: Purpose: to prevent the spread of infection: Standards: 4. Trash containers will be emptied when full but at the end of each shift. Plastic liners shall be tied and placed in outside dumpster and the dumpster lid kept closed. 5. Maintenance and Housekeeping personnel shall assure (ensure) the dumpster area is kept clean and all trash bags are inside the dumpster, and dumpster lids closed. The facility's policy dated 11/24 and titled Pest Control Policy documents, in part: Purpose: To prevent or control insects and rodents from spreading disease. Standards: 1. The Environmental Service Director will be responsible for coordinating the facility pest control program . 3. The pest control program will be conducted on a regular and as needed basis . 5. Employees are instructed to promptly report all observations of pests to their department heads 10. The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents. 16. Outside dumpsters shall be of sufficient size so that the lid can be tightly closed. The container shall be stored on a smooth surface of non-absorbent material. 17. The dumpster shall be kept clean and maintained in good repair.

Based on observation, interview and record review the facility failed to provide a safe, functional, clean and comfortable environment. This failure affects all 213 residents residing in the facility.Finding includes: On 2/13/2026 at 9:43am surveyor observed the base boards missing by room [ROOM NUMBER] and on the right side of the hallway on the first floor between rooms 111 & 113. Surveyor also observed missing floor panels in the center of the hallway floor. On 2/13/2026 at 9:59am surveyor observed the baseboard by medical equipment room missing with a hole in the wall, stained ceiling panels are not secured due to the holding rails being warped in the 1st floor dining room and missing parts of squares in the floor on the elevator (Elevator 3). At 10:10am on the second-floor surveyor observed the wall, in the shower room, behind the toilet with a brown substance splattered on the wall and the bottom of the toilet and floor with grayish black debri across from the nurse's station. On 2/13/2026 at 10:55am surveyor reviewed the work order binder and none of these issues were found in the binder. On 2/13/2026 at 1:46pm surveyor observed the tile is broken in front of the elevator on the third floor. On 2/14/2026 at 1:50pm via email V8 (Maintenance Director) said, No, the baseboard should not be peeling or pulled from the wall and the walls should not have holes in them in resident rooms and that these issues does not provide a homelike environment for the residents. On 2/14/2026 at 2:07pm via email V1 (Administrator) said, No they (residents) shouldn't have residence walls with holes in them, and no they shouldn't have stained ceiling tiles even though they are replaced often but with so many leaks, and over flows we get water marks, but no, they shouldn't have them. V21 verified observation of both shower rooms on the second floor containing dirty floors, brown splatter on the shower's toilet wall, tub filled with water and debris, and missing drywall along the base of the floor behind the toilet. On 2/13/2026 at 10:49 AM, V21 (Certified Nurse's Assistant-(CNA) stated V21 stated housekeeping cleans good and housekeeping/floor techs respond quickly to staff cleaning requests. V21 verified observation of both shower rooms on the second floor contained dirty floors, brown splatter on the shower's toilet wall, tub filled with water and debris, and missing drywall along the base of the floor behind the toilet. Maintenance is responsible for repairs around the facility. On 2/13/2026 at 11:01 AM, V20 (Housekeeper) he (V20) cleans residents' rooms and floor techs are responsible for cleaning the shower room, bathroom, hallway, dining room, elevator and taking out garbage. V20 stated the purpose of cleaning and sanitizing the facility is the health of residents. Policy titled Preventative Maintenance Program with a reviewed date of 1/2026 documents, in part, 5. All facility areas are kept clean and in safe condition. 14. Ceiling tiles are free from watermarks or spots and 15. Wall coverings are intact and free of tears or loose seams. Job Description titled with an updated date of 7/2024 documents, in part, the primary purpose of this position is to maintain the orderly functioning of all equipment in the facility, 4. Assure the proper maintenance and running condition of all electricity and plumbing in the entire facility including (but not limited to) c. the resident's room and perform all repairs that do not fall under the purview of housekeeping.

Based on observation, interviews and record review, the facility failed to ensure that the dumpster was closed and free from trash. These failures have the potential to affect all 213 residents residing at the facility.Findings include: On 2/13/2026 at 10:01 am, Surveyor and V11 (Maintenance Assistant) observed the facility dumpster area with foul odor, two dumpsters that had four open lids, scattered debris and trash surrounding the perimeter on the ground around the dumpster area. V11 stated that he believes that the dumpster lids should be closed and that the housekeeping department is responsible for the dumpster area. V12 stated, I don't deal with that (referring to the dumpster area). V11 then explained if the dumpster lids are left open and trash is left around the dumpster area pest such as roaches and mice can come into the facility. On 2/13/2026 at 10:07 am, Surveyor and V12 (Housekeeping Supervisor) ) observed the facility dumpster area with foul odor, two dumpsters that had four open lids, scattered debris and trash surrounding the perimeter on the ground around the dumpster area. V12 stated that the dumpster area should be cleaned more than daily. V12 then explained if the dumpster area is left with trash and lids open it is not good and can attract cats, varmints and rodents to the facility The facility's policy dated 5/14 and titled Waste Management documents, in part: Purpose: to prevent the spread of infection: Standards: 4. Trash containers will be emptied when full but at the end of each shift. Plastic liners shall be tied and placed in outside dumpster and the dumpster lid kept closed. 5. Maintenance and Housekeeping personnel shall assure (ensure) the dumpster area is kept clean and all trash bags are inside the dumpster, and dumpster lids closed.

Based on observation, interview, and record review the facility failed to maintain clean kitchen and food storage room floors and walls, compromising safe and sanitary dietary conditions. This failure has the potential to affect 213 residents residing in the facility. On 2/13/2026 at 11:29, V22 (Dietary Manager) stated the dietary aides and cooks are responsible for cleaning the floors in their assigned stations; she (V22) is in the process of revising job descriptions; has not received complaints of bugs in food; has not observed bugs in the kitchen; and there is not a staffing issue in the kitchen. V22 stated the purpose of clean and sanitation in the kitchen practice good cleaning practices for the health of the residents. V22 verified the kitchen contained dirty floors with trash on the floors and debris along the walls throughout the kitchen. V22 verified mice and insect glue traps in the storage room under storage racks. On 2/13/2026 at 12:54 pm, V27 (Dietary Aide) stated all dietary staff are responsible for keeping the kitchen clean and sanitary; she (V27) mopped the kitchen after breakfast this morning; she has seen roaches in the kitchen on the counter by the sink; exterminator treats the kitchen twice a week; and the purpose of keeping the kitchen clean is to prevent the residents from getting sick. V27 verified the kitchen floor contained dirt, trash, and debris throughout the kitchen.Facility's Policy titled Residents' Rights undated documents, in part, in section (i) Safe Environment: The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely.Facility's Food Service Supervisor Job Description undated documents a Job Summary: The Food Service Supervisor is responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting, and physical management of the dietary department's employees and equipment in a way that the dietary services of the facility shall be maintained I accordance with established policies. The Food Service Supervisor is directly responsible to the administrator. Main duties include. #5. Supervise the receiving and storage of food and kitchen supplies and maintain the storage room in a neat and orderly manner. #7. Inspect and supervise food preparation and service to ensure that infection control and the highest standards in all aspects of the dietary department are followed. Facility's Dietary Aide Job Description undated documents a Job Summary: The Dietary Aide is responsible for aiding all food functions as directed/instructed and in accordance with established food policies and procedures. Essential Duties and Responsibilities include- Ensure that the department is maintained in a clean & safe manner by assuring that necessary equipment & supplies are maintained. Dietary Aide must also ensure the facility's standards on Infection Control Precautions are being followed when performing daily tasks . Sweeping and mopping floors in the kitchen/dish room as instructed by supervisor. Facility's Food and Sanitation Policy dated 4/2017, in part The following sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness.

Based on observation, interviews, and record reviews, the facility failed to ensure a resident was transferred as per assessment, care plan, and proper procedure/use of equipment (Hoyer lift) for 1 (R1) out of 3 residents reviewed for the right of every resident to be safe and free of accidents. These failures affected 1 resident (R1) resulting in R1 sustaining a fractured left leg and undergoing surgery on the left leg (left leg nailing procedure) with three (3) separate incisions with staples. Findings include: R1 is [AGE] years old initially admitted in the facility on 02/14/2024. R1 diagnosis includes Alzheimer's Disease, anxiety disorder, left below the knee amputation, and more recent sustained fracture of lower end of left femur. R1 has an intact cognition with a score of 12 on her Brief Interview of Mental Status (BIMS) dated 02/10/2025. On 03/18/2025 at 12:01 PM, R1 was seen on her bed in her room. R1 able to express thoughts well within topic during conversation. R1 stated she had a fracture on her left leg. R1 took off the sheet that covers her left leg with below the knee amputation. R1 has three incisions on her left leg. R1 stated that when she came back from dialysis, the staff that help her lost her balance. R1 said, I guess, I am too heavy for her. R1 stated that the staff that helped her did not use a gait belt. And both the staff and her (R1) hit the floor. R1 stated that she was sitting on a dialysis chair (Geri chair) when she was transferred to the bed and fell . R1 stated that it takes two (2) people to transfer her. But when she fell it was only us (her and the staff) because the staff cannot find anybody. R1 said, Sometimes they use equipment (Hoyer lift) if it is available. But sometimes it just disappears. It is from another unit. R1 stated that she knows that she needs Hoyer lift or at least two (2) people when she transfers. R1 stated that she weighs two hundred forty-three pounds (243 LBS.). R1 said, I think it's safer if I use the lift. It is safer if two people help me that is how I see it. R1 stated that somedays they have don't have CNAs (Certified Nursing Assistants). And there are times they only have one (1) CNA, but they do not come inside her room. When asked why only one (1) staff helped her. R1 said, I really don't know why she was the only one who helped me. On 03/18/2025 at 12:22 PM, V4 (Licensed Practical Nurse) stated that she was informed by V5 (Certified Nursing Assistant) that R1 slide to the fall mat. And that V5 was transferring R1 from chair to bed. V4 stated that V5 was by herself when she transferred R1. V4 stated that R1 needs Hoyer lift because the facility does not use lifting of resident by staff. V4 said, There is no lifting of residents by staff policy in facility. V4 stated that she did not remember if she asked V5 why she was not using a Hoyer lift. And stated that it may be that someone else was using the Hoyer lift that time. On 03/18/2025 at 12:39 PM, V5 (Certified Nursing Assistant) stated that she was the staff that transferred R1 when she fell . V5 stated that it was nighttime and time for R1 to go back to bed, V5 stated that she went to look for the Hoyer lift and it was not working at that time. She looked for another staff to help her transfer R1 but was not able to find anyone. V5 stated that she transferred R1 by herself. V5 said, I was gonna pivot her (R1) to slide her over to the bed because I cannot lift her. And you are not supposed to lift her. I did it myself. I tried to slide her, and she ended up sliding from the chair and slide on the mat. V5 stated that all of facility's Hoyer lifts were not working or not charged. V5 said, I know that I should have made safety the first priority and will not transfer her again by myself. On 03/19/2025 at 10:24 AM, V6 (Restorative Manager / Fall Prevention Coordinator / Licensed Practical Nurse) stated that R1 is a total assist and needs to be transfered with the Hoyer Lift in and out of her wheelchair or dialysis chair (Geri chair). V6 said, R1 is an amputee, and her transfer ability is not strong, and it is not safe to transfer when not using Hoyer lift. V6 confirmed that under MDS (Minimum Data Set) assessment sit to stand was not done during assessment because of R1's medical conditions and safety concerns. V6 stated that facility has a Safe Lifting Policy as part of nursing staff education. And the same policy needs to be signed before starting to work with residents or new hires. V6 said, Staff needs to follow the policy. On 03/19/2025 at 11:47 AM, with V2 (Director of Nursing) and V7 (Nurse Consultant). V7 stated that probably R1 needs to be with mechanical lift during transfers. V2 stated that she did not do the investigation. And that she does not know anything about it. V2 stated that during that time she was the Assistant Director of Nursing (ADON). R1's MDS (Minimum Data Set) assessment dated [DATE] on functional abilities sit to stand: the ability to come to a standing position from siting in a chair, wheelchair, or on the side of the bed. Assessed as 88 that means not attempted due to medical condition or safety concerns. R1's Care Plan for activities of daily living (ADL) and mobility dated 02/15/2024 is to transfer with mechanical lift (Hoyer) with two (2) persons. R1's notes documents history of falls on 08/30/2024, V8 (Registered Nurse) clinical notes reads that R1 slide out of her bed while CNA (Certified Nursing Assistant) providing care. On 12/14/2024 V8's (Registered Nurse) note reads that R1 fell in the dining room. On 03/19/2025 at 01:09 PM, with V9 (Certified Nurse Assistant) the facility was found to have only one (1) mechanical (Hoyer) lift available to use on the floor. V9 cannot locate the second mechanical lift. Per V9 the facility has only two (2) mechanical lifts for all the residents. V9 stated that she is assigned to nine (9) residents and two (2) of the residents needs a lift. V9 said, the 2nd floor alone has around eighty (80) to ninety (90) residents. V9 was asked if with only one (1) lift available would that be enough for residents to use? V9 replied, That would be a problem. At 01:50 PM, V6 (Restorative Manager / Fall Prevention Coordinator / Licensed Practical Nurse) stated an estimated thirty (30) residents need a Hoyer lift for transfer. Per facility's census dated 03/18/2025, facility has three hundred (300) available beds. Two hundred eleven (211) are occupied by residents. R1's X-Ray result dated 2/11/2025 reads: Fracture on the left leg. (Acute, mildly comminuted nondisplaced distal femoral fracture). R1's hospital record dated 02/11/2025 documents as follows: Description: R1 status post left below knee amputation fell while being helped from a wheelchair bringing down facility staff too. R1 sustained left femur (leg) fracture. Admitting diagnosis, mechanical fall at the nursing home resulting in left femoral fracture. Under pain assessment, R1 screams and yells in pain upon therapist application to left lower extremities. Procedure or surgery done due to left femur fracture: Intermedullary nailing left distal femur fracture (femoral nailing). Safe Lifting Policy for all employees in nursing department reads: The Safe Lifting Policy exists to ensure a safe working environment for resident handlers. The policy is to be reviewed and signed by all staff that performs or may perform resident handling. The safety committee will review this policy annually with changes made accordingly. Under process and procedure: Total Lift Transfers needs Hoyer type of lift with 2 or more caregivers. Fall Prevention Policy dated 02/18/2014, reads: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Transfer conveyances shall be used to transfer residents in accordance with the plan of care. Per R1's care plan she needs Hoyer lift with two (2) persons assisting with the transfer. Centers for Disease Control and Prevention on Safe Lifting and Movement of Nursing Home Resident dated February 2006 reads: Safe resident lifting programs that incorporate mechanical lifting equipment can protect workers from injury, reduce workers' compensation costs, and improve the quality of care delivered to residents.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that indwelling urinary catheters/urine drainage bags are monitored, and failed to document when indwelling urinary catheters are inserted and/or urine drainage bags are changed for three of three residents (R2, R3, R4) reviewed for catheters. These failures resulted in R2 sustaining (10/14/24) abdominal pain and UTI (Urinary Tract Infection). R3 and R4 sustained Purple Urine Bag Syndrome which is a rare phenomenon where the urine drainage bag turns purple due to a chemical reaction between bacteria in the urine and the plastic of the bag often associated with UTI's in patients using long-term catheters. Findings include: On 11/22/24, IDPH (Illinois Department of Public Health) received allegations regarding the facility's lack of catheter care resulting in R2's UTI. 1. R2 was admitted to the facility on [DATE] and discharged on [DATE]. R2's diagnoses include flaccid neuropathic bladder. R2's care plan states (8/9/24) resident has indwelling catheter related to diagnosis of flaccid neuropathic bladder. Intervention: Change indwelling catheter and urinary drainage bag as needed per MD (Medical Doctor) orders. Monitor for signs/symptoms of pain/discomfort. (10/23/24) Resident is on antibiotic for urine infection. R2's POS (Physician Order Sheets) include (6/26/24) Change urinary catheter as needed if displaced, clogged, or there is no urinary output. Change urinary drainage bag with each catheter change as needed. (7/2/24) Catheter size 18 FR (French) indication obstructive uropathy. R2's progress notes include (10/14/24) resident discharged to hospital. Reason for transfer: Abdominal Pain. (10/22/24) admitted from hospital. Primary Admitting Diagnoses: UTI, Abdominal Pain. On 12/4/24 at 10:41am, V2 (DON/Director of Nursing) presented R2's (September-November 2024) MARS (Medication Administration Records) and stated He (R2) didn't have no TARS. [Treatment orders should be transcribed on the TAR, not the MAR]. R2's (September & October 2024) MARS include Change urinary catheter as needed if displaced, clogged, or there is no urinary output. Change urinary drainage bag with each catheter change as needed for catheter care however the required catheter size is excluded, and nothing is documented on either MAR. In addition, R2's (November 2024) MAR excludes any catheter care. On 12/4/24 at 2:26pm, surveyor inquired where indwelling urinary catheter orders are supposed to be transcribed and V2 stated Some of the orders go to the MAR and some of them go to the TAR. Surveyor inquired what the MAR is used for V2 responded That is the medication administration. Surveyor inquired if catheters belong on the MAR and V2 replied They can go on the MAR because the template allows it to go on the MAR. [The MAR is for prescribed medication]. Surveyor inquired how often urine drainage bags should be changed V2 stated Drainage bags are changed um, I know that one of the orders is every 30 days, and PRN (as needed) if there is any leakage, color changes of the bag like sediment or any obstruction and it's not draining properly. Surveyor inquired when R2's indwelling urinary catheter was placed V2 responded Let me look it up, I think he had it for a while they said. V2 reviewed R2's EMR (Electronic Medical Records) and stated I think he came here with the catheter; I would have to go through all of his records. I know that he went out maybe like October and it was changed then because he had a UTI. Surveyor inquired if the size or type of catheter is on R2's MAR V2 responded He had a suprapubic catheter but I'm not seeing a size or the site on there. Surveyor inquired when R2's urinary drainage bag was changed (prior to developing the UTI) V2 replied I can't even see when the bag was changed. (R2 was admitted in March 2024 - 7 months prior). Surveyor inquired if R2's (November 2024) MAR includes catheter care V2 stated No, I seen that it was missing when I pulled it. Yeah, it's not there. Surveyor inquired why R2 was transferred to the hospital on 10/14/24 V2 responded He had abdominal pain. Surveyor inquired why R2 was admitted to the hospital and V2 replied He had a UTI. 2. R3's diagnoses include neuromuscular dysfunction of bladder. R3's (11/29/23) care plan states resident has an indwelling urinary catheter related to neuromuscular dysfunction of the bladder. Interventions: Change catheter and urinary drainage bag as needed per Medical Doctors orders. R3's POS includes (2/12/24) May change urinary drainage bag as needed (schedule as PRN). (6/26/24) Foley catheter 18Fr diagnosis neuromuscular dysfunction of bladder. May change urinary catheter if displaced, clogged, or no urinary output as needed. R3's (November-December 2024) MARS include the following: Change urinary catheter as needed [the required catheter size (18Fr) is excluded]. May change urinary drainage bag as needed however nothing is documented. R3's (9/9/24) BIMS determined a score of 15 (cognition intact). On 12/2/24 at 2:00pm, Surveyor inquired if R3 acquired a UTI at the facility R3 stated No however R3's urinary catheter bag and tubing appeared purple (discolored), and sediment was noted in the tubing. The contents in the catheter bag were barely visible due to dark discoloration. Surveyor inquired when R3's catheter was placed and R3 responded That was April. Surveyor inquired when R3's catheter bag was last changed R3 replied I don't even know. On 12/4/24 at 2:26pm, Surveyor inquired what color indwelling urinary catheter tubing and/or bags are supposed to be and V2 (Director of Nursing) stated The tubing should be clear, the bag should be clear as well unless there's urine in it and it should have no sediment in it or anything. On 12/4/24 at 2:51pm, surveyor inquired when R3's indwelling urinary catheter was placed V2 stated I'm not sure when the catheter was placed, I see the order at the beginning of the year January 4. Surveyor inquired when R3's urine drainage bag was changed V2 responded I don't see where it's changed at, I just see the order for PRN. On 12/4/24 at 3:05pm, V2 inspected R3's indwelling urinary catheter (as requested). Surveyor inquired what color is R3's urine drainage bag? V2 stated Purple. R3 responded Nobody came in here and changed it. Surveyor inquired about the contents in R3's catheter tubing V2 replied I see a little sediment. R3 responded They (staff) should have changed this a long time ago. V2 exited R3's room and affirmed That needs changed bad. 3. R4's diagnoses include hydronephrosis with ureteral stricture. R4's (9/10/24) care plan states resident has a suprapubic catheter. Interventions: monitor and report to Medical Doctor signs/symptoms of UTI. R4's (7/2/24) POS includes suprapubic catheter 20Fr for obstructive uropathy. May change urinary drainage bag as needed for prevention when unable to observe urine contents in the urinary drainage bag/tubing or as ordered by the physician (schedule as PRN). [Change suprapubic catheter if occluded is excluded]. On 12/2/24 at 3:20pm, V2 (DON) presented R4's (November 2024) MAR. Surveyor inquired about R4's requested (November 2024) TAR V2 stated He (R4) don't have a TAR, just the MAR. R4's (November- December 2024) MARS exclude change suprapubic catheter (20Fr) and nothing is documented for urinary drainage bag change. On 12/2/24 at 1:40pm, surveyor inquired when indwelling urinary catheters are changed at the facility V6 (LPN/Licensed Practical Nurse) stated About every week. I know it's due on the night shift. Surveyor inquired when R4's catheter bag was last changed and V6 accessed R4's EMR (Electronic Medical Records) and stated, It's not coming up on the TAR but there's an order for it. V6 and surveyor subsequently inspected R4, his urinary catheter bag and tubing appeared purple (discolored) and thick sediment was noted in the tubing. The contents in the bag were barely visible due to dark discoloration. On 12/4/24 at 2:58pm, surveyor inquired when R4's indwelling urinary catheter was placed V2 stated I don't have a date for him either. Surveyor inquired when R4's urine drainage bag was changed V2 responded It's nothing documented. Surveyor inquired what a purple discoloration of the urinary drainage bag is indicative of V2 replied It could be hydration, like the tea looking color or some sediments that set in for a while. On 12/4/24 at 3:10pm, (2 days after the initial inspection) V2 inspected R4's catheter (as requested). Surveyor inquired what color is R4's urine drainage bag V2 stated It's purple. Surveyor inquired about the contents in R4's catheter tubing V2 responded It's sediment in the tubing. It's um, white milky sediment. The (10/31/18) catheter care policy includes Policy: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Urinary catheter and tubing will be removed and reinserted when any of the following are observed: inability to observe urine contents in the urinary drainage bag or tubing.

Based on observation, interview, and record review, the facility failed to follow the doctor's wound care order and keep a wound clean and dry for one resident (R442) and failed to follow policies for proper handling of garbage for 7 residents reviewed in a sample of 35. This failure caused harm to R442, who was admitted with a diagnosed surgical wound and hospital discharge orders for IV (Intravenous therapy) antibiotics for skin and soft tissue infection. R442's wounds were not cleaned, and wounds' dressings changed as ordered, causing the resident's wound dressing and wound to appear uncleaned increasing the risk of further infection/delaying the healing progress. Findings include: 1. On 10/01/2024, 12:38 PM R442 states that his needs are not being met. He says he has a lot of pain to his left leg. R442 states that he had surgery to his left leg, and he that the leg has about 71 staples. R442 states that he takes pain medication, and it does help. R442 states that they are not doing the wound care and he states that he has been in the facility over a week, and it's been 3 or 4 days since the dressing has been changed. R442 states that he asked the wound care nurse about the dressing being changed and he states that wound care told him that they would be back next Monday. One large dressing covering R442's left lower leg (back) noted with what appears like large amounts of dark brown color drainage (fluid that comes out of a wound). Another large dressing covering R442's left lower leg (shin area) noted with what appears like large amounts of dark brown color drainage. No labels with date or time of dressing change are on the dressings. R442's current face sheet document R442 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: disruption of external operation (surgical) wound. R442's current physician order sheet (POS) documents in part: Left Lower Leg Fasciotomy Sites (Medial and Lateral Calf) Clean with normal saline pat dry apply Xeroform cover with a dry dressing. One time a day every Mon, Wed, Fri related to disruption of external operation (surgical) wound, order start date 09/27/2024. R442's current physician order sheet documents in part: ceFAZolin in Sodium Chloride Intravenous Solution 2-0.9 GM/100ML-% (Cefazolin Sodium in Sodium Chloride) Use 2 gram intravenously every 8 hours for skin and soft tissue infection for 8 Days, order start date 09/26/2024. On 10/02/2024, 10:11 AM R442 is lying on his bed. One large dressing covering R442's left lower leg (back) noted with what appears like large amounts of dark brown color drainage (fluid that comes out of a wound). Another large dressing covering R442's left lower leg (shin area) noted with what appears like large amounts of dark brown color drainage. No labels with date or time of dressing change are on the dressings. R442 states that his wound dressings have not been changed and his wounds have not been cleaned. R442 states that he mostly has pain in the nighttime. On 10/03/2024, 9:50 AM, one large dressing was covering R442's left lower leg (back) noted with what appears like large amounts of dark brown color drainage (fluid that comes out of a wound). Another large dressing was covering R442's left lower leg (shin area) noted with what appears like large amounts of dark brown color drainage. No labels with date or time of dressing change are on the dressings. R442 states that the dressing has not been changed at all since last week. R442 states that the dressing has been hanging off. R442's left upper inner leg noted with multiple staples, dry dressing hanging off. On 10/03/2024, 10:36 AM, V16 (Wound Care/Licensed Practical Nurse) states that she has worked for the facility for almost a month. She has been the wound care nurse for a week. V16 states that the wound care team is aware that there are residents that are in the facility that need an initial skin assessment done. V16 states that the importance for the resident to have a complete skin assessment by wound care team is to prevent skin breakdown and to check if the resident doesn't have any wounds coming from the hospital or from home. V16 states that she has not performed any wound care for R442. V16 states that if wound care is not done as ordered, the wound can be exposed to further infection and the wound can get worse. V16 states that an infected wound can appear with mucus, color, bleeding, odor, and is hot to touch. V16 states that the resident can experience fevers, chills, pain, and possibly signs of sepsis. V16 states that it is important to follow wound care orders to prevent further harm or infection. On 10/03/2024, 11:05 AM V17 (Wound Care Coordinator/Licensed Practical Nurse) states that this her 4th day working as the wound care coordinator. V17 states that she has previous wound care experience. V17 states that she has not seen R442. V17 states she would like to go and confirm she hasn't seen R442 yet. On 10/03/2024,11:16 AM V17 states that she can confirm that she has not seen R442 and is not familiar with his orders. V17 states that she was provided the wound care list yesterday, since the report is due on Friday. V17 states that she also did not have access to the computer the past 3 days, and she will review everyone on the list and see them. V17 states that if the wound care treatment is not done, a wound can get infected. V17 states that the signs of infection are swelling, pain, redness, warmth, elevated temperature, and odor. V17 states that they do not have to have all these signs to be infected. V17 states they are just indicators. V17 states that residents that were supposed to be seen yesterday for wound care, were not seen. On 10/03/2024, 12:03 PM V16 and V17 explained to R442 what they were there to do his wound care. V17 assessed R442 for pain. R442 states that his pain level is a 7 on a 0 to 10 pain scale. V17 called R442's nurse to administer his pain medication. R442 agreed for V17 to start wound care. One large dressing covering R442's left lower leg (back) noted with what appears like large amounts of dark brown color drainage (fluid that comes out of a wound). Another large dressing covering R442's left lower leg (shin area) noted with what appears like large amounts of dark brown color drainage. V17 states that he felt numbness to his shin area. R442 felt some areas of his left lower leg. Observed V17 removing one dressing at a time, slowly due to being very stuck to the wounds. V17 using normal saline to wet areas and slowly removing dressings. V17 was asked to describe what she sees and V17 states that without knowing what it is, she said it can be collagen, eschar, dead skin, or dried blood. V17 asked R442 if he had a skin graft done and R442 responded no, and he said it was just covered. R442 states that when he got to the facility, they looked at it and it did not look like this. R442 states that when he saw it when he first got to the facility, it looked like a fresh wound, and it didn't look black like how it looks now. R442 asked V17 why the wounds looked black and V16 states it looks like old blood. V17 states that it feels like it is a dressing, and it could be blood and the drainage mixed. V17 informed surveyor that this removal of dressing can take some time and V17 states that she wants to make sure that she takes her time removing the dressings. Surveyor got closer to the wounds, and they smelled malodorous. V17 states that the dressings appear saturated with drainage. As surveyor was walking out, V17 states that surveyor can look at the wound bed for the wound on the shin area, V17 states that the top of the wound noted with eschar, wound bed is dark pink granulated skin. V17 states that the dressing looked like black to dark burgundy possibly because of dried blood. V17 states that the dressings are long overdue to be changed. Reviewed R442's care plan, assessments. No skin assessment or wound care assessments noted. No wound care progress notes noted. R442's Minimum Data Set (MDS), dated [DATE], documents R442 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R442 is cognitively intact. R442's Minimum Data Set (MDS), section M dated 9/26/2024, documents in part R442 has a surgical wound. R442's treatment administration record (TAR) for September 2024, shows documentation that wound care treatment was signed off as administered. Discrepancies noted with R442's treatment administration record (TAR) for October 2024. It documents that V16 signed for wound care treatment on 10/02/2024. When interviewed V16, she states that she denies seeing R442 and providing him with any wound care treatment. R442's Nurse Practitioner Narrative/Physician Assistant note dated 9/30/2024 5:37 PM documents in part the resident (R442) was treated in the hospital for lower extremity revascularization with acute limb ischemia f/p (follow post) LLE (left lower extremity) thromboembolectomy and compartment fasciotomies. ASSESSMENT/PLAN: SURGICAL WOUND LEFT LEG -Wound care to see -keep area clean and dry -fall precautions -PT/OT (physical therapy/occupational therapy) consult -Cefazolin IV Q8h -Amoxicillin 875-125 mg Q8h On 10/04/2024, V1(Administrator) via email noted that R442 does not have any completed skin assessments done. Facility document dated 11/2023, titled Wound Policy documents in part: To promote healing of existing pressure and non-pressure ulcers . Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee . The goals of wound treatment are to: a. Keep the ulcer bed moist and the surrounding skin dry, b. Protect the ulcer from contamination, and c. Promote healing. 45111 2. On 10/01/2024 at 12:10pm, V38 (Housekeeping) was observed dragging on the floor of the second-floor North unit hallway a large clear plastic bag, which was not tied or secured. Observed in the bag was soiled incontinence wear and garbage. V38 stated the garbage bag was too heavy for her, therefore she dragged it around the unit collecting garbage from residents' room and then put it in the dirty utility room. V38 stated she was moving too fast and should not have filled the garbage so much to a point where she could not carry it. V38 stated it is unsanitary to drag garbage on the unit because that is cross contamination and can spread germs in the unit. On 10/03/2024, at 3:41pm, V24 (Housekeeping Director) stated housekeepers are supposed to carry garbage upright and not drag it in the hallway because garbage and can spread bacteria and lead to infection control issues and residents can get sick. V24 said V38 (Housekeeping) should not have loaded garbage up so heavy that she could not carry it or lift it. V24 stated the garbage V38 was dragging in the hallway of the second floor North unit consisted of used incontinence wear and garbage from residents rooms and should not be dragged across the hall way. It should have been put it in the housekeeping cart which has a compartment for garbage, then the garbage cart emptied in the soiled utility room to prevent cross contamination in the units which could cause germs to spread which can make residents sick. Facility Policy titled Housekeeping Guidelines, no date, documents: Waste handling and disposal will be in accordance with local and state regulations.

Based on record review and interview the facility failed to implement care plan interventions, failed to conduct a physical assessment, failed to obtain vital signs, failed to contact the Physician/Nurse Practitioner, failed to ensure that a Nurse was on the unit when EMS (Emergency Medical Services) arrived, failed to follow Physician orders, and/or failed to provide timely care to three of three residents (R2, R3, R4) reviewed for change in condition. These failures resulted in: R2 sustaining abdominal pain secondary to small bowel obstruction and death caused by septic shock with multi organ failure likely from ischemic bowel. In addition, R3 sustained excruciating pain due to pulmonary embolism. Findings include: 1. On 9/19/24, IDPH (Illinois Department of Public Health) received allegations that the facility failed to send a resident to the hospital (for emergency care) in a timely manner. R2's diagnoses include but not limited to schizoaffective disorder, dementia, rhabdomyolysis, CKD (Chronic Kidney Disease), hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left side. R2's (10/2/23) functional assessment affirms supervision or touching assistance is required for eating and partial moderate assistance is required for toileting. R2's care plan includes (6/2/21) Resident is at risk for renal insufficiency related to history of CKD and rhabdomyolysis. Intervention: monitor and report any signs of vomiting, muscle discomfort, fever, and generalized weakness. Monitor and report changes in mental status. R2's (2/16/23) POS (Physician Order Sheets) include anti-psychotic medication use: observe closely for significant side effects, sedation, loss of appetite, and constipation. Enter the number of times side effect noted (requires progress note of physician notification for each occurrence). R2's (10/2/23) progress notes state 12:29pm, Chief complaint: review of depression symptoms. Patient reports mood is Ok. She appears confused but can answer simple questions. Claims to feel sad because her son passed away a week ago. No notes seen about her son's recent passing. Appetite is less because of feeling sad. 9:12pm, Writer made aware that family member (V5) in residents' room has phoned 911 for resident complaining of not feeling well. Unit supervisor made aware; PCP (Primary Care Physician) paged to make aware. Appropriate paperwork given to EMT's (Emergency Medical Technicians) patient transferred via gurney x2 [vital signs and physical assessment are excluded]. On 9/26/24 at 1:02pm, surveyor requested R2's (10/2/23) SBAR (Situation Background Assessment Recommendation) and/or change in condition report (which include vital signs at time of transfer) however neither were received during this survey. On 9/26/24 at 2:15pm, surveyor inquired from V5 (Family) about R2's (10/2/23) change in condition. V5 stated, I (V5) went up there (facility) and my mother (R2) looked like her normal self, but she (R2) wasn't asking for food, and she usually likes to eat. She (R2) said that she was nauseated and hadn't eaten in a while, so I (V5) told the Nurse, and the Nurse seemed a little lax about it. My brother (V6) went up there around 9:00 at night and said she (R2) still didn't eat so I (V5) told him (V6) to call 911. When the EMT's got there they said ain't nobody up on the floor to give them any paperwork. When I (V5) got to the hospital, I found out she (R2) hadn't pooped for 2 weeks, and the doctor told me she threw up her bowels in the CT (Computed Tomography) scan. She (R2) had a bowel obstruction that led to sepsis. The nursing home was supposed to be recording her bowel movements and her eating. If they (facility staff) knew that there was a problem ahead of time, why did the family have to get her (R2) out of there (facility). Nurses are supposed to know the signs that something is wrong and be monitoring your input and output. It's basically a case of neglect. She passed away October 4th, 2023. On 9/26/24 at 2:21pm, surveyor requested R2's September/October (2023) input and output (including bowel movements) documentation however neither were received during this survey. On 9/30/24 at 10:12am, surveyor inquired about R2's (10/2/23) change in condition, V8 (LPN/Licensed Practical Nurse) stated I (V8) was not taking care of her (R2) that day. I was called downstairs by the CNA (Certified Nursing Assistant) to take care of some paperwork for her (R2). The Nurse was out on a lunch break to my understanding. The family was at the bedside and called 911 to have her (R2) sent out to the hospital. I printed out the face sheet and the orders, those are the necessary documents when you send somebody out [SBAR and/or change in condition report were excluded]. Surveyor inquired if V8 assessed R2 prior to transfer, V8 responded No, she was already on the gurney to be transferred when I came down. Surveyor inquired if V8 obtained R2's vital signs prior to transfer, V8 replied No, she was already on the gurney for transfer. Surveyor inquired who covers the unit while the Nurse goes on break, V8 stated The other Nurses are supposed to be made aware when you go on break so they can cover for you. Surveyor inquired if there was a Nurse manager on duty that day, V8 responded I don't recall. Surveyor inquired how many (evening shift) Nurses are assigned to each floor, V8 replied There's 2 on each unit. Surveyor inquired if any Nurses were present on R2's unit during change in condition and/or transfer, V8 stated Not on that unit when I arrived, no. R2's (10/2/23) history & physical states resident presented to the ED (Emergency Department) with abdominal pain and vomiting. Report obtained from EMS states that patient was on a non- nursing floor at her nursing home with no providers on the floor when she was found vomiting profusely complaining of left lower quadrant abdominal pain. CT (Computed Tomography) scan was obtained with signs of bowel obstruction. While in CT scan patient had an episode of emesis which was presumed to be aspirated because afterwards, she became slightly more hypoxic. General surgery evaluated the patient and placed an NG (Nasogastric) tube with brownish output. After placement of NG tube patient's clinical status deteriorated becoming increasingly hypoxic and tachycardic and as the patient has a contraindication to BiPAP with the persistent vomiting a decision was made to intubate for this hypoxia. Notable labs include elevated creatinine from baseline, elevated lactate 6.5 and slight leukocytosis 13.7. While in the ER, blood pressures were difficult to obtain with the most readily available pressure reading of 140/auscultation with subsequent decline to 80/auscultation. She was started on Levophed (vasoconstrictor used to treat life-threatening low blood pressure) at that time and quickly escalated to max dose. R2's (10/3/23) surgery consult states patient presented from nursing home with 2 weeks of abdominal pain and poor oral intake. Patient reports she had 2 weeks of abdominal pain, and no bowel movements though continues to pass gas. CT abdomen and pelvis finding concerning for small bowel obstruction. R2's (10/3/23) history of present illness states resident presented to ER from nursing home due to abdominal pain with vomiting. Per notes, for two weeks. Patient was revealed to have a small bowel obstruction with an NG tube placed. However, patient's condition worsened and required intubation due to hypoxia which the patient started to vomit fecal material. Patient was started on IV Zosyn (Antibiotic) and Doxycycline (Antibiotic) for aspiration pneumonia. R2's (10/4/23) discharge summary states despite full life-sustaining measures patient gradually became PEA (Pulseless Electrical Activity) and time of death pronounced at 11:00am. Cause of death septic shock with multi organ failure likely from ischemic bowel. On 9/30/24 at 12:43pm, surveyor inquired about the expectation of Nurse's when residents experience a change in condition V7 (Medical Director) stated The Nurse should be at minimum getting vital signs, reviewing any obvious history of the patient and calling the physician. Surveyor inquired if a resident has not had a bowel movement for 2 weeks what's the potential harm, V7 responded The potential for harm is it can lead to fecal impaction, horrible pain, decreased appetite, or a bowel obstruction. Surveyor inquired if a resident vomits feces what's the potential harm, V7 replied I think there's a lot of potential for harm, they can have pneumonia or upper GI (Gastrointestinal) pain, but I think the biggest thing would be aspiration pneumonia. 2. R3's diagnoses include COPD (Chronic Obstructive Pulmonary Disease). R3's (6/14/24) care plan states resident has the potential for impaired gas exchange related to COPD. Intervention: monitor and report signs/symptoms of respiratory distress unrelieved with treatment to medical doctor. Monitor resident for shortness of breath and implement interventions as ordered if needed. R3's POS includes (6/14/24) oxycodone 5mg every 4 hours as needed for moderate pain and (7/1/24) stat left rib x-ray. R3's progress notes include (7/1/24) 12:30pm, resident complained of pain in chest upon inhalation causing him to have a hard time breathing deeply. Information relayed to Nurse Practitioner who gave order for a chest x-ray of the left rib. Order noted and carried out. Writer scheduled x-ray with (provider) who was unable to provide an ETA (Estimated Time of Arrival). 8:30pm, [8 hours later] resident complained of pain to exterior left side of chest wall. Resident informed nursing staff on AM shift, orders received for stat CXR (Chest X-ray). While resident was awaiting arrival for CXR to be complete, resident proceeded to call 911 using his personal phone. Resident CXR was not completed as ordered. Pain 5/10, resident receives oxycodone 5mg (milligrams) per orders. (7/2/24) Resident admitted to ICU (Intensive Care Unit) diagnosis pulmonary embolism. R3's (9/20/24) BIMS determined a score of 15 (cognition intact). On 9/25/24 at 3:36pm, surveyor inquired about R3's (7/1/24) change in condition. R3 stated That's when I had the blood clot. I had to call and go to the hospital; the pain was too bad for me to breathe and move around. Surveyor inquired what the staff implemented when they were made aware of R3's change in condition R3 responded The 2nd shift called someone, and they supposed to be sending someone to do some x-ray, but they never showed up. When it came to the 3rd shift, I was in excruciating pain. I had asked them (staff) to call the doctor, but they kept saying what the other shift did, so I had to call 911 myself. The doctor said I had a blood clot. On 9/30/24 at 10:45am, surveyor inquired about R3's (7/1/24) change in condition, V10 (LPN) stated He (R3) was complaining about chest pain that day, only when he breathed in deep, he said he had a sharp pain. So, I (V10) listened to his (R3) heart sounds, lung sounds everything sounded clear, and his oxygen saturation was fine. I called the doctor and let her (doctor) know that he was in pain, she (doctor) ordered a stat chest x-ray. I called to schedule the x-ray and charted that he (x-ray provider) was unable to provide an ETA. Surveyor inquired if V10 contacted the doctor to report that the x-ray provider was unable to provide an ETA for R3's x-ray (which was ordered stat), V10 responded No. On 9/30/24 at 12:48, surveyor inquired if a procedure is ordered stat what's the expected turnaround time, V7 (Medical Director) stated I would say like 2 hours for someone to draw blood or get an x-ray because we need to call somebody to come and do that. Surveyor inquired if an x-ray is ordered stat and the provider is unable to do it stat what should be done, V7 responded I would recommend the patient go to the hospital to get more immediate care. Surveyor inquired if a resident has chest pain upon inspiration and difficulty breathing what's the potential cause, V7 replied Two potential causes could be a heart attack or could be a pulmonary embolism. Surveyor inquired if a pulmonary embolism is not treated timely what's the potential harm, V7 stated death. 3. R4's diagnoses include obesity, hemiplegia affecting right dominant side, constipation, and cognitive communication deficit. R4's (6/28/23) care plan states resident has a diagnosis of constipation. Interventions: Monitor/document/report to medical doctor signs and symptoms of complications related to constipation. R4's (7/21/24) POS includes stat KUB (Kidney Ureter Bladder). R4's (7/21/24) progress notes state 10:00am, resident observed projectile vomiting x2. Bowel sounds normal in all 4 quadrants. No distention noted. When asked if resident was nauseous or in pain, she shook her head no. Writer relayed this information to NP (Nurse Practitioner) who gave the order to get a stat KUB. (X-ray provider) phoned to schedule stat KUB and gave an estimated time of arrival 4-6 hours. 10:25pm, Writer relayed results of resident's KUB to NP. R4's (7/21/24) abdomen x-ray results affirm it was electronically signed at 8:03pm [x-ray performed time is excluded]. R4's (7/12/24) BIMS affirms resident is rarely/never understood. On 9/24/24 at 2:39pm, surveyor spoke to R4 however received no verbal response. On 9/30/24 at 10:28am, V10 (LPN) stated Whenever there's any change in condition you will do an SBAR. Surveyor inquired when R4's (7/21/24) KUB was obtained, V10 stated I scheduled a stat KUB, and they (x-ray provider) gave an ETA of 4 to 6 hours. Surveyor inquired about stat turnaround time, V10 responded I believe it's between 2 to 4 hours. Surveyor inquired if V10 contacted the Nurse Practitioner to report that the x-ray providers ETA was going to be 4 to 6 hours (therefore not stat), V10 replied No, I should have called the doctor. Surveyor inquired when R4's (7/21/24) KUB was obtained, V10 stated I'm not sure but it says I relayed the results at 10:25pm [roughly 12 hours after orders were received]. I'm not exactly sure what time they (x-ray provider) came. The change in resident's condition policy (reviewed 11/2023) states Nursing will notify the resident's physician or nurse practitioner when: there is significant change in the resident's physical, mental or emotional status. It is deemed necessary or appropriate in the best interest of the resident. Communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate documents.

Based on interviews and record reviews, the facility failed to follow the recommendation of the dietitian and obtain a doctor's order for one-to-one feeding assistance for one resident (R4); failed to provide one-to-one feeding assistance; failed to elevate the head of the bed to an upright position for eating; and failed to care plan for one-to-one feeding assistance. These failures resulted in R4 being given food for lunch without one-to-one feeding assistance; R4 choked on the food and subsequently expired on [DATE]. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] at 1:55 pm when V27 (R4's Family Member, Healthcare Power of Attorney, HCPOA) entered R4's room to see R4 unresponsive, with chewed up food with saliva hanging out of R4's mouth with R4's head of the bed in a low position with no staff present in R4's room. On [DATE] at 1:10 pm, V1 (Administrator) and V2 (Director of Nursing, DON) were notified of the Immediate Jeopardy. The survey team confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R4's Admission Record documents, in part, diagnoses of multiple sclerosis, protein-calorie malnutrition, dysphagia (oral phase), anorexia, schizoaffective disorder, cognitive communication deficit, and hypertension. In R4's Death Certificate, V45 (Medical Examiner) documents, in part, that R4's cause of death is choking in the facility on [DATE] at 2:00 pm. R4's autopsy results were used to complete R4's manner of death which is an accident. R4's injury (accident) occurred on [DATE] at 1:55 pm in the facility, and the description of how R4's accident occurred is listed as food lodged in airway. On [DATE] at 11:40 am, V27 (R4's Family Member, HCPOA) stated I (V27) got to the floor on [DATE] before 2 pm. I got off the elevator and saw 4 to 5 people at the front desk (nurse's station). I went into (R4's) room, and (R4's) roommate (R9) is in the first bed which is near the door. I went into my son's (R4's) room and he (R4's) usually facing me. (R4) wasn't. I hollered to (R4), and (R4) didn't say anything. (R4's) face was facing the window. I walk over next to (R4) and I can see food hanging from his mouth and saliva. I shook (R4) a little bit. (R4's) head was wobbly. Something was wrong. I called out, 'I need help.' (R4's) eye lids were closed. (R4's) not responding. The door was open, and no one was responding. I walked over to the door and yelled '(R4's) not breathing.' Then they (staff) responded. I said, 'Can you get the food out of (R4's) mouth?' The nurse (V9, Licensed Practical Nurse, LPN) said that R4 is a DNR (Do Not Resuscitate). I said that DNR is not related to food to be taken out of his mouth. V9 said, 'That's not possible.' There were 2 nurses there, and 2 Certified Nursing Assistants, CNAs. I said, 'Can't you do anything? Pull it out of (R4's) mouth?' V9 said that (R4) had passed. Food was hanging from (R4's) mouth. a grilled cheese sandwich was coming from the left side of his mouth. I took pictures. V27 stated that V27 said Do something. (R4's) still warm and that V9 said, We can't do anything. (R4's) a DNR. V27 stated, They finally pulled food out of (R4's) mouth, CNA was there too. Nurse (V9) brought a machine (vital signs) in and said '(R4's) gone.' V27 stated, It was after lunch around 2 pm. How long had (R4) been there like this? I don't know. (R4) can't feed (R4's) self. I had spoken with them (nursing staff) before about feeding (R4). They (staff) say 'Yes, (R4) does have a feeder. I would feed (R4). Sometimes (R4) could eat with right hand somewhat. When asked about R4's positioning when V27 entered R4's room on [DATE], V27 stated, (R4) was in bed. (R4) was not moved up. (R4) was in a reclined position. (R4) wasn't sitting up in the bed. Not totally all the way flat but close. When asked approximately how high was R4's head of bed position, V27 stated that it was 4 to 6 inches from flat. When asked to describe the food coming from R4's mouth, It seemed to be grilled cheese. It was chewed up with saliva. The half sandwich was on (R4's) left side.R4's left hand couldn't grasp much. The sandwich was on the left side between (R4's) body and left arm. There was no tray with food on it (table), (R4) had the sandwich. Photographs provided by V27 (from [DATE]) document R4 in a reclined head of bed position with R4's head turned to the left with R4's eyes closed and chewed up food (appears to be bread like) mixed with frothy saliva hanging out of R4's left side of mouth down to left side of chest. A half sandwich is noted on R4's left side in between R4's left arm and side with R4's left arm over R4's chest, and R4's right arm down on R4's right side. R4's bedside table is noted positioned over R4's lap in bed. R4's Power of Attorney for Health Care form (dated [DATE]) documents, in part, that V27 is R4's healthcare power of attorney. On [DATE] at 9:25 am, V37 (CNA) stated that V37 was working on [DATE], day shift from 7:00 pm to 3:00 pm, on R4's floor, and V37 was not R4's primary CNA. V37 stated that when V37 performs 1:1 feeding assistance for a resident, V37 will position the resident in a sitting position with head of the bed at a 90 degree angle and tell the resident that V37 will be back with the meal tray. V37 stated that V37 will then come back to the room with the tray; bring the table close to the resident; and V37 will face the resident while assisting to feed the resident. When asked why would V37 be facing the resident during 1:1 feeding assistance, V37 stated, To make sure they don't choke or pocketing of food on side of the jaw. Like half breathing. When facing the resident, I can catch the resident with the food versus facing the same way towards the TV (television). V37 stated that V37 would then stop the feeding and get the nurse immediately. V37 stated that V37 had provided positioning assistance in bed for R4 to eat in the past with R4's head of bed in a 90 degree position and tilting R4's foot of bed up so R4 won't slide down with contracted legs. V37 stated that on [DATE] for the lunch meal, V37 passed V37's assigned residents' lunch meal trays to V37's residents. V37 stated that V37 later went back to the unit's dining room to get coffee for some residents, and when V37 was walking out of the dining room into the hallway, V37 was able to clearly view into R4's room where I (V37) can see (R4) laying back and eating. V37 stated, I didn't know what (R4) was eating, but (R4) was chewing on something. Did someone give (R4) the tray? Who's given it? (R4) is in there eating. (R4) wasn't sitting up. Everyone knows (R4) needs to be sitting up. When asked what did V37 do once V37 saw R4's head of bed down while eating on [DATE], V37 stated, I am thinking who's in there feeding the resident. I asked nurse (V9, LPN), 'who is in there feeding with (R4's) head back?' (R4's) laying back and eating. I guess (V27, Family Member) is in there. I see (V27) in there, and (V27) just arrived. When asked how did you know that V27 just arrived in R4's room on [DATE], V37 stated, (V27) was putting down (V37's) purse. V37 stated that V37 continued to deliver the coffee to V37's residents when V27 called out, (R4) is choking. On [DATE] at 7:30 am, V9 (LPN) stated that V9 started working in the facility in [DATE] and floats to all of the units. V9 stated that V9 was R4's assigned nurse on [DATE] from 7:00 am to 3:00 pm. V9 stated that R4 was on a no added salt diet with regular texture and thin liquids. When asked about R4's feeding assistance level, V9 stated, I want to be able to say he feeds (R4's) self. R4 always has tray in room feeding (R4's) self. If the food is not to (R4's) liking, (R4) would wait for (V27) to come into bring (R4) food. V9 stated that on [DATE], V9 had entered R4's room about 1:30 to 1:45 pm, and that R4 was alert and communicating, then V9 exited the room. V9 stated that V27 came around 2:00 pm. V9 stated, (R4) had a peanut butter and jelly sandwich. (R4) was given it but (R4) could not consume peanut butter and jelly from my understanding. (R4) was already gone. It was an eminent thing. When asked do you mean R4's death, V9 stated, Yes. It was that quick. V9 stated, Staff brought (R4) the sandwich. I cannot recall who. V9 stated when V27 arrived to R4's room on [DATE] around 2:00 pm, (V27) alerted me (V9) that (V27) felt (R4) needed help with breathing. (V27) said '(R4) did need help.' When asked where was V27 located when V27 is saying this to V9, V9 stated, I am 5 inches away from room. Nurse's station is right outside (R4's) door. (V27) just walked out, and said, 'I believe (R4) is in need of help. Something's wrong with (R4)'. V9 stated that V9 responded immediately and assessed R4's body. V9 stated, (R4's) body was warm, I felt for a pulse, and assumed there would be a pulse. Blood pressure we could not get already. When asked who was in R4's room with you, V9 stated that it was V36 (LPN), V33 (CNA), V34 (CNA) and V27. V9 stated that V20 (R4's assigned CNA) was initially with another resident. V9 stated that V9 was touching (R4's) body during assessment, and (R4) was still warm as if (R4) was still alive. When asked did R4 have food particles coming from R4's mouth, V9 stated, It was on the side of (R4's) chest, not out of (R4's) mouth or anything. When asked did V9 render any care to R4 then, V9 stated, I did a (oral) sweep only, as if (R4) had choked. (R4) did not choke. (V27) felt that (R4) had choked. I just did that (sweep) for (V27), not because (R4) had choked. V9 stated that V9 and V36 checked for R4's pulse and blood pressure and were not able to feel a pulse or obtain a blood pressure reading at R4's time of death on [DATE] at 2:00 pm. V9 stated that R4 had a code status of DNR; therefore, V9 could not provide CPR (Cardiopulmonary Resuscitation) to R4. When asked did R4 require supervision while R4 was eating, V9 stated, No, (R4) did not. In R4's Health Status/Progress Note, dated [DATE] and timed 2:00 pm, V9 (LPN) documents, in part, Note Text: Writer (V9) observed resident (R4) with head of the bed raised, no BP (blood pressure) and low pulse and unresponsive. Family (V27) at facility upon observation of resident (R4). In R4's Health Status/Progress Note, dated [DATE] and timed 2:00 pm, V9 (LPN) documents, Note Text: Resident (R4) pronounced deceased per RN (Registered Nurse). R4's Physician Orders for Life-Sustaining Treatment (POLST), signed and dated [DATE], documents, in part, that R4's advance directives for code status lists Do Not Attempt Resuscitation/DNR with Comfort Measures Only (Allow Natural Death). On [DATE] at 11:10 am, V36 (LPN) stated that V36 worked on [DATE] for the day shift and that V36 was not R4's nurse on [DATE] or had interacted with R4 prior to this date. V36 stated that V36 responded to R4's room when V27 stepped out to say that R4 was choking. V36 stated that R4 was foaming at the mouth, and (R4) had a half-eaten sandwich in the left hand. Peanut butter and jelly sandwich on the side of (R4) leaned up against (R4's) mouth. V36 stated that V9 informed V36 at R4's bedside that R4 was a DNR, and V36 checked to palpate for R4's pulse; checked for a blood pressure reading and checked for spontaneous breathing with V36 finding no pulse, blood pressure or respirations for R4. On [DATE] at 9:36 am, V8 (Former Consultant Dietitian) stated that V8 began employment in the facility in [DATE], and V8's last date of employment at the facility was [DATE]. V8 stated that V8 remembers R4 and was following R4's dietary needs due to R4 having a pressure ulcer wound and weight loss. V8 stated that R4 had double protein at all meals and calorie and protein supplements. V8 stated, I was very attentive to (R4's) weight loss because (R4) was not providing much assistance to feed (R4's) self. V8 stated that on floor rounds during meal service, V8 did observe R4 receiving one-to-one (1:1) feeding assistance by nurses and CNAs. When V8 observed, on occasion, R4 with a meal tray in front of R4 without staff in R4's room, V8 stated that V8 would ask the nurse on duty about R4 being assigned to 1:1 feeding assistance, and that the nurse would say, 'Yes, (R4) got a tray. We will stop to feed (R4). V8 stated, Some (staff) didn't know that (R4) was assigned 1:1. V8 stated that V8 did not have full access to the physician orders in the electronic health records (EHR) system where nurses and/or physicians will document the 1:1 feeding assistance order. V8 stated that V46 (Former Assistant Director of Nursing, ADON) and V47 (Former Director of Nursing, DON) confirmed that R4 was 1:1 feeding assist. When asked what were V8's expectations of nursing staff with R4's 1:1 feeding assistance, V8 stated that V8 I expect the staff to be feeding (R4). (R4) does not communicate the best. Nurses or CNAs do 1:1 feeding. When I (V8) would see the tray in room, I would ask nurse about 1:1 feeding. Nurse would say (R4's) calming down. Take breaks. When asked to explain the 1:1 feeding assistance process, V8 stated, Staff will set up the tray. Elevate the head of bed. Put resident in a sitting position to prevent choking when eating. Help feeding with spoon or whatever utensils. They will check for pocketing of food or swallowing problems or food spilling out of the mouth. When asked if this (pocketing of food, swallowing problems, or food spilling out of mouth) occurs, what should happen, and V8 stated, I would expect them to stop and notify me and notify speech therapy. For (R4), I would have taken action to downgrade to mechanical soft diet. If there is an issue, we wouldn't want (R4) to choke. I would wait for speech therapy to do full evaluation. They may determine (R4) needs downgraded. For high risk for choking, I change diet to mechanical soft. I was never informed of this (with R4). When asked about care planning dietary interventions for R4, V8 stated that the dietary care plans were updated by V21 (Dietary Manager). R4's Dietary Progress Notes, [DATE] at 6:23 pm, V8 documents, in part, that R4's past medical history includes multiple sclerosis, pressure induced deep tissue damage, dysphagia, anorexia and protein calorie malnutrition. V8 documents that R4 has a weight change of -7.5% change with comparison weight from [DATE]. V8 documents that R4's diet is no added salt, regular texture and thin liquids with supplements of double protein and high calorie and protein supplement drinks. V8 documents that R4 requires 1:1 assistance to eat. V8 documents that R4 requires 1:1 feeding assistance in additional authored dietary progress notes on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. R4's Weights Summary documents, in part, weights on [DATE] of 142 pounds, on [DATE] of 127 pounds, on [DATE] of 117 pounds and on [DATE] of 107 pounds. On [DATE] at 1:34 pm, V21 (Dietary Manager) stated that V21 became the dietary manager in the facility in [DATE] and that V21's responsibilities include doing care plans and assessments. When asked who is responsible for updating dietary care plans, V21 stated, I am since [DATE]. When asked did V21 update R4's care plan, V21 stated, I don't know for (R4's) care plan. That was (V8's) thing to do. V21 stated that R4 did receive double protein at each meal and that R4 had a grilled cheese sandwich added to lunch and dinners. R4's undated Meal Ticket documents, in part, that R4 receives double protein for breakfast, lunch and dinner; R4 receives added grilled cheese (sandwich) with meal for lunch; and R4 receives added grilled cheese (sandwich) and mash potatoes for dinner. R4's Complete Care Plan (R4's care plan closed date [DATE] with reason for close as deceased ) documents focuses which had been resolved and focuses that are canceled on [DATE] due to R4's care plan being closed. R4's care plan focus of nutritional problem with weight loss, initiated on [DATE], documents, in part, interventions of (R4) would like a grilled cheese with each meal to assist in bettering (R4's) nutrition and RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (whenever needed). R4's care plan focus of self care deficit (ADLs Mobility) generalized weakness, initiated [DATE], documents, in part, interventions of Head of Bed elevated and Set up tray at mealtimes with no one-to-one feeding assistance documented. On [DATE] at 10:45 am, V46 (Former ADON) stated that V46's employment with the facility ended in [DATE] after being the ADON in the facility for 5 years. V46 stated that V46 remembers R4 and that R4 had an overall decline with refusals of medications and weight loss. When asked if R4 was a 1:1 feeding assistance with eating, V46 stated, Yes, I (V46) did know (R4) did. Times one staff to monitor at meals. When asked what is monitor, V46 stated, To assist with feeding. V46 stated that there should be a physician's order that is placed in the EHR for 1:1 feeding assistance which is important so staff, including rotating nurses and CNAs, can see the plan of care. When asked if V46 spoke with V8 (Former Consultant Dietitian) about R4's 1:1 feeding assistance, V46 stated that V46 cannot recall an exact conversation with V8, but R4 was a 1:1 feed prior to V46 leaving the facility. V46 stated, (R4) needed feeding assistant with diagnosis of multiple sclerosis. (R4) was weaker over time. One-to-one feeding for R4. Everyone was on board. I definitely know (R4) was a 1:1 feeding. V46 stated that in morning standup up meetings with nursing staff on R4's floor, the nurse or the CNA couldn't attend the brief meeting due to feeding R4 one-to-one in R4's room. When asked the process of 1:1 feeding, V46 stated that staff will reposition the resident to a high fowler's position (head of bed elevated); staff will read the meal ticket; set up the tray and describe to the resident what they are eating; and staff will assist with feeding the resident. V46 stated that staff will wait for resident and not rush resident while eating. V46 stated that 1:1 feeding assistance ends when the resident is done eating. V46 stated that 1:1 feeding assistance also includes staff sitting with the resident while the resident is using utensils to feed self, so the staff will guide the resident and supervises the entire meal. V46 stated that staff are looking for any observation of not properly chewing and swallowing food and choking. V46 stated that if that occurred, then the nurse will downgrade the diet immediately and notify the physician. When asked if R4 was eating in bed in a reclined position, what could occur, and V46 stated, (R4) could definitely aspirate or choke. Food wouldn't go down properly. On [DATE] and [DATE], multiple attempts were made to contact V47 (Former DON) by phone with no success. R4's Order Summary Report for discontinued orders documents, in part, diet orders with order date of [DATE] for no added salt diet with regular texture and thin liquids, and order date of [DATE] with no added salt diet with regular texture and thin liquids with double protein with meals. No physician order for R4's one-to-one feeding assistance is listed for R4. On [DATE] at 12:23 pm, V2 (DON) stated that V2 started the position of Director of Nursing on [DATE] and was familiar with R4. When asked if R4 required supervision while eating, V2 stated, Not to my knowledge, (R4) did not. When asked when would V2 expect your staff to provide supervision for a resident eating, V2 stated, Any meal, supervision, if you notice a patient can't do something; they need to be monitored. When asked if there is an order for 1:1 feeding assistance, how does the nursing staff know of it, and V2 stated, 1:1. There's an order, and it's on the dietary ticket. 1:1 feeding in (EHR). Each staff sees in (EHR). V2 stated, If it's something like supervision, staff are made aware. Dietary ticket. It's available in (EHR). When asked what was R4's assistive level of eating, V2 stated, Everyone did (R4's) tray set up. (R4) was encouraged to eat. On [DATE] at 2:43 pm, when asked how should R4 be positioned for eating, V2 stated that staff make sure the head of bed is elevated. The tray is in front of (R4) and opened up all of (R4's) drinks and milk. Make sure to set food where (R4) is able to reach it. When asked the elevation height of R4's head of the bed, V2 stated, I would like it to be high fowlers (,d+[DATE] degrees) to prevent and make sure that resident is not exposed to choking. When asked about R4's continuing weight loss, V2 stated, I (V2) may have been notified of weight loss, but I can't recall. If necessary to, I look at a weight. I think with (R4), (R4) was kind of up and down. On [DATE] at 3:14 pm, V20 (CNA) stated that V20 started working in the facility in [DATE] and that V20 was R4's assigned CNA on [DATE] for the day shift 7:00 am to 3:00 pm. V20 stated that on [DATE] for lunch service, (R4) was my resident. I (V20) was on break. I didn't give (R4) (R4's) tray. When asked to describe what normally happens when V20 would serve R4's meal tray to R4, V20 stated, Set (R4's) tray up for (R4). If it's not in reach, set tray up and utensils where (R4) can pick it up. Sit (R4) up. Head of bed up. When asked did V20 ever witness R4 spilling food on himself while feeding, V20 stated, I have seen (R4) spill stuff on (R4). The day that (R4) choked, I witnessed a sandwich in (R4's) mouth. When asked on [DATE], when V20 returned from V20's break, what happened, and V20 stated, Like I always do. I look at my residents when I came back to make sure they are okay. Everything was okay. If they might need help. I go and check. Everyone was okay. I was in the process of making sure (R4) was okay. I went to the breakroom to braid (R11's) hair. I didn't go in (R4's) room. I asked (V33) to go to check on my residents. I want to see how everyone was doing. (V33) checked on my residents. (V33) said they were okay. 20 minutes later, (V27) came hollering and screaming. I went and (R4) had a grilled cheese in (R4's) mouth. V20 stated that when V20 got to R4's room, V9 was saying that R4 was a DNR. V20 stated, (V27) was saying can we do something. Nothing but to wipe (R4's) mouth. (V27) was taking pictures. Other aide (V34) and nurses (V9, V36) already in there. They were taking food out of (R4's) mouth. (R4) was pocketing food from the mouth. When asked to describe what V20 observed with R4 on [DATE] responding to V27's call for help, V20 stated, I see food particles. (R4) had sandwich coming from (R4's) mouth. I knew it was grilled cheese. When asked was R4 a 1:1 feed assistance, V20 stated, Not that I know of. When asked how would V20 know if R4 was 1:1 feed assistance, V20 stated, Nurses tell you. Tell on your set. Nurses tell you everything who going to be fed. On [DATE] at 4:24 pm, V33 (CNA) stated that V33 was working on [DATE] during the day shift on R4's floor and was not assigned as R4's primary CNA. V33 stated on [DATE], Passing lunch trays was busy that day. V33 stated that V20 (CNA) passed R4's lunch meal try to R4 (despite V20 denying this). When asked on [DATE], what brought V33 to R4's room, V33 stated, I (V33) was taking my break in the dining room and that's when another CNA (V34) come in and said that (R4) was not breathing. We all went in there. V33 stated that V33 could see that R4 was not breathing and that V33 could see food on (R4's) chest. Breadcrumbs like sandwich. V33 stated that V27 stayed in the room with R4 and staff, and did record R4. On [DATE] at 8:32 am, V34 (CNA) stated that on [DATE], V34 was working the day shift (7:00 am to 3:00 pm) and working on the assigned set of residents next to R4's room. V34 stated that V34 had not seen R4 earlier in the lunch meal with R4's food tray. V34 stated that around 2 pm, V34 was getting ready with linens in the hallway to perform resident care for R16, and V27 called out for the nurse for R4. V34 stated that V34 responded to R4's room and that V9 was trying to remove food from R4's mouth. On [DATE] at 3:45 pm, V35 (CNA) stated that V35 worked on [DATE] on the day shift on R4's floor and did pass R4's lunch tray to R4 on [DATE]. When asked about R4's passing on [DATE], V35 stated that V35 was rendering patient care and did not respond to R4's room on [DATE]. Facility document titled CNA Daily Assignment Sheet and dated [DATE] for day shift (7:00 am to 3:00 pm) documents, in part, V9 (LPN) assigned as R4's nurse (per room number), and V20 (CNA) assigned as R4's CNA (per room number). V33 (CNA), V34 (CNA), V35 (CNA), V36 (LPN) and V37 (CNA) are also listed as working on R4's unit on [DATE] for day shift. In the section listed as Feeders, R4's room number is not documented. On [DATE] at 12:33 pm, V2 (DON) stated that the process for a receiving an order from a doctor is that the nurse will place the doctor's orders into the residents' EHR. When asked how the nurses can receive doctor's orders, V2 stated that doctor's orders can be verbal, telephone or written. When asked if a dietitian gives a recommendation for a resident to the nurse, like double portions, supplements or 1:1 feeding assistance, what is the process, and V2 stated, Nurse will let the doctor know to get the order for the diet recommendation. V2 stated, Usually, the dietitian communicates with either the doctor or a nurse. It depends on the dietitian. I know they (dietitians) definitely communicate with the physician. V2 stated, If the dietitian tells a nurse, then the nurse will call the doctor. V2 stated, The dietitian communicates with the physician. Then the physician would call the nurse to enter it into the system (EHR). R4's Order Summary Report, dated [DATE], document no physician order for one-to-one feeding assistance. R4's diet order, with order date of [DATE], documents No Added Salt (NAS) diet. Regular texture, Regular Thin Liquids consistency, Double protein with meals. R4's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 9 which indicates that R4 has moderate cognitive impairment. R4's Functional Abilities and Goals for eating is coded as Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R4's MDS, dated [DATE], documents, in part, that R4's discharge reporting is death in facility. On [DATE] at 10:08 am, V25 (Restorative Nurse) stated that V25 has been the restorative nurse in the facility since February 2024, and that V25 was not sure of R4's diet for the restorative assessment of [DATE]. V25 stated that the [DATE] transferred over to the MDS quarterly assessment for R4 ([DATE]). When asked what does touch assistance mean, V25 stated that the staff hand R4 the spoon, saying Here's your spoon, I need you to eat today. Optimum goal is the intake. We want the resident to take in more. V25 stated that the staff will pass the juice or cup to the resident, set up the tray close to the resident and encourage the resident to eat. V25 stated to make sure resident is in sitting position where resident is able to eat and not have airway restricted. When asked about supervision by staff, V25 stated that staff have to make sure resident is putting food in mouth correctly and not pocketing and that staff would be there intermittently, often to supervise. When asked what is considered 1:1 feeding assistance, V25 stated that it's spoon feeding the resident with staff doing the work. V25 described R4's eating assessment as R4 mostly using right hand with a modified spoon (weighted) and that R4 took (R4's) time a lot to eat. When asked if V25 stayed the entirety of R4's meal during the assessment, V25 stated no and that it was a random visit. R4's Wound and Skin Alteration Review, dated [DATE], documents, in part, that R4 has a stage 3 pressure ulcer to the left heel with skin treatment including diet/hydration program. On [DATE] at 12:08 pm, V31 (Attending Physician) stated that V31 made rounds on R4 in the facility, and the last time that V31 visited and saw R4 in the facility was end of [DATE]. When asked about R4 being a resident in the facility with what kind of needs did R4 have, V31 stated that R4 had advanced multiple sclerosis and (R4) needed nursing home care which (R4's) family could not provide. When asked about R4's weight loss interventions, V31 stated, (R4) was being seen by the dietitian, and recommendations were being taken from dietitian. When asked if a dietitian makes a recommendation for a resident, how is V31 made aware, and V31 stated, The nurse will call me to go over the dietitian's order. I will give my order, and they (nurses) will carry it out. When asked was V31 made aware of dietitian's recommendation for 1:1 feeding assistance for R4, V31 stated, Yes. When asked did V31 provide an order for R4's 1:1 feeding assistance, V31 stated Yes. When asked if V31 expects the facility to have executed V31's order for 1:1 feeding assistance for R4, V31 stated, Yes. Correct. When asked the expectation of facility staff in performing R4's 1:1 feeding assistance, V31 stated, When (R4) is eating, one to one assistance is required. The CNA must be at the bedside and feeding (R4) with the appropriate utensils and monitoring (R4) at the bedside until the meal is over. V31 stated that R4 had multiple sclerosis which could affect R4's swallowing. If R4 is chronically aspirating, aspiration leads to pneumonia, then infection, which can lead to death. When asked would V31 expect R4 to have choking as a natural disease process, V31 stated that if R4 was having difficulty swallowing food, the consistency of R4's food would need to be evaluated. V31 stated that R4 required 1:1 feeding. V31 reiterated that R4 could aspirate food, lead to pneumonia, then infection and death, and needed 1:1 feeding. When asked if choking is a natural cause of death for R4, V31 stated, No. On [DATE] at 10:40 am, when asked about which nurse V31 (Attending Physician) gave R4's 1:1 feeding assistance orders to, V31 stated that V31 does not recall the specific nurse when V31 gave the verbal order. When asked why was R4 in need of a 1:1 feeding assistance order, (R4) was not able to feed (R4's) self. V31 stated that it was combination of R4 not being able to mechanically feed himself and issues with (R4's) swallowing. When asked if R4 had a previous downgrade of R4's diet from the regular texture, thin liquids (that R4 was receiving when R4 passed in the facility), V31 stated, It's the dietitian who decides if (R4) is tolerating the consistency and is to recommend order and that the DON can put in the downgraded diet order. When asked if R4 was receiving 1:1 feeding assistance on [DATE], could R4's death of choking been prevented, Yes, with one-to-one feeding and it depends on the meal, the type of food. On [DATE] at 11:03 am, V1 (Administrator) clarified with this surveyor by stating that the provided job description for Charge Nurse covers all staff nurses who work in the facility on all of the floors/units. Facility job description updated [DATE] for Charge Nurse who reports to the DON documents, in part, Job Summary: Organize and assign all jobs to be done on his/her shift so that the workload is evenly divided among his/her employees on the basis of staff size and qualifications . care for the clinical nursing needs of residents on his/her wing . Requirements: . 2. Excellence in all aspects of quality nursing including exceptional care . Main Duties: A. Support the facility's philosophy of care and strive to achieve its goals and objectives . D. Supervise all aides in performing their duties by checking their work closely to ascertain that assignments have been completed . G. Assist in updating the Care Plan every ,d+[DATE] days depending on the resident's conditio [TRUNCATED]

Based on interview and record review, the facility failed to protect a resident (R3) from physical abuse from staff which affected one resident (R3) out of three residents reviewed for abuse. This failure caused R3 to suffer bilateral mandibular fractures to R3's face requiring oral and maxillofacial surgery. Findings include: R3's Brief Interview for Mental Status dated 07/18/24 shows that R3 has a BIMS score of 15 which indicates that R3 is cognitively intact. R3's face sheet shows that R3 has a diagnosis which includes but not limited to chronic systolic congestive heart failure, chronic obstructive pulmonary disease, asthma, presence of automatic implantable cardiac defibrillator, essential primary hypertension, polyneuropathy in diseases classified elsewhere, acute kidney failure, seizures, hyperkalemia, polyneuropathy due to other toxic agents, diarrhea, hypotension, opioid dependence. R3's Initial Facility Reported Incident dated 07/14/24 at 8:39 pm, documents in part R3 informed staff that R3's assigned Certified Nursing Assistant (CNA) V6 displayed behaviors inconsistent with facility standards. V6 was immediately suspended pending investigation. R3 was assessed for injuries. R3's family and physician were notified of the allegations and assessment findings. The local policy were notified of the allegations. A full investigation has been initiated and a final report will follow timely. R3's Final Facility Reported Incident dated 07/19/24 at 11:21 pm, documents in part Analysis and Conclusion: R3 informed the visitor that a guy with tattoos on his neck punched R3 in the face and knocked R3's tooth out . R3 was admitted to the local (sic) with bilateral mandibular fractures . V6 attempted to redirect R3 in R3's room to calm down. R3's behaviors escalated and R3 grabbed V6 and began tussling with R3. V6 is no longer employed at the facility. On 07/30/24 at 10:21 am, R8 (R3's Roommate) stated that R8 recalls R3 having an altercation with a male staff a few weeks ago. R8 stated that R8 was resting in R8's bed and heard a verbal altercation between R3 and a male Certified Nursing Assistant (CNA). R8 stated that when the male CNA left R3 and R8's room, R3 stated that R3 got hit in the mouth by the male staff and R8 observed blood on the floor near R8's bed. R8 was unable to give a description of the male CNA. On 07/31/24 at 9:30 am, V3 (Human Resource Director) was questioned regarding V6 (CNA) employment status at the facility and V6 stated that R6's reason for termination was abuse allegation involving R3 that was substantiated. On 07/31/2024 at 10:02 am, V6 (Certified Nursing Assistant, CNA) stated that about two weeks ago V6 observed R3 sitting on the edge of R3's bed in R3's room when V6 brought R3's meal tray into R3's room. V6 stated as V6 was sitting R3's meal tray on R3's over bed table, R3 shoved R3's meal tray as V6 was attempting to set R3's meal tray down, spilling R3's meal tray onto V6's clothing. V6 then explained that R3 then stood up about one foot in front of V6 and spit onto V6 clothes, shirt, neck, and face. V6 stated that V6 then turned around and left R3's room to go clean up himself (V6). V6 stated that as V6 left R3's room V6 heard R3 cussing and very mad. V6 then stated that after V6 cleaned the spit and food off V6, V6 returned to R3's doorway and observed R3 still cussing and mad. V6 stated that V6 then informed V7 (Licensed Practical Nurse, LPN, R3's nurse) that R3 was agitated and to check on R3. V6 then explained that V6 was not certain when V7 went to check on R3. V6 stated that one hour and a half later after the V6 interaction with R3 spitting on V6, V2 (Director of Nursing, DON) called the facility and informed V6 that R3 stated that V6 put his hands on R3 and instructed V6 to make a statement regarding the interaction with R3 and to clock out and leave the facility. V6 stated that V6 followed V2 instructions and left the facility. V6 also explained that V6 was not R3's assigned CNA on 07/14/24 and that V6 was only bringing R3, R3's meal tray. V6 denied physically assaulting or having a verbal altercation with R3. V6 stated that on 07/15/24 V2 informed V6 that R3 suffered a broken jaw injury to R3's jaw. V6 denies having any knowledge as to how R3 sustained a broken jaw. On 07/31/24 at 10:35 am, V7 (Licensed Practical Nurse, LPN) stated that a few weeks ago during V7's 3:00 pm - 11:00 pm shift at the facility, while V7 was passing medications, V30 (Certified Nursing Assistant, CNA) informed V7 that as V30 was walking pass R3's room, V30 saw R3's mouth bleeding. V7 stated that V7 asked V12 (LPN) to come with V7 to assess R3. V7 stated V7 assessed R3 with injuries to R3's face. V7 stated that V7 observed R3's mouth bleeding with lacerations to R3's lower lip, R3's mouth with a tooth missing that looked as if R3's missing tooth came from R3's lower mouth, and the right side of R3's face swollen. V7 stated that R3 informed V7 that a male staff member with tattoos (V6, CNA) beat up R3 and hit R3 in the mouth. V7 stated that V6 was the staff with tattoos identified by R3 and that V7 then followed the facilities protocol for abuse by calling V1 (Administrator), the on-call physician for R3, the local police and phoned V2 (Director of Nursing, DON) who then called the building and gave directives for V6 to leave the facility. V7 then stated that V6 was not an assigned CNA working on V7's unit. V7 said they never spoke with V6 and never reported any changes in R3 condition such as agitation, R3 shoving R3's lunch tray or spitting on V6 or V7, and ever seeing V6 working on V7's unit on 07/14/24. On 07/31/24 11:35 am, V28 (R3's physician) stated that V28 did not receive the call that R3 was in an altercation with a staff member at the facility. V28 stated that V28 was informed regarding R3's altercation with a staff member after V28 came to visit R3 at the facility and learned that R3 was in the local hospital with bilateral mandibular fractures due to an altercation with a staff member at the facility. V28 stated that V28 did not have any further details due to V28 learning about the altercation two days after R3 was sent to the local hospital. V28 denied that R3 was a combative resident, ever displayed self-inflicting injuries and that R3 was always pleasant. V28 was asked regarding how a resident could sustained a bilateral mandibular fracture and V28 stated, If a resident suffers a hard blow/strike to one side of the jaw the impact could fracture the other side of the resident's mouth as well. On 07/31/24 at 11:51 am, V2 (Director of Nursing, DON) stated that the altercation with R3 and V6 took place on Sunday 07/14/24 and that V2 was not in the facility and did not observe the altercation. V2 stated that V25 (Restorative Nurse) informed V2 that V25 observed blood on the floor in R3's room and that R3 stated to V25 that R3 was hit by a staff member V6 (CNA) who R3 named [NAME]. V2 stated that V2 instructed V25 to inform V6 that V6 was involved in an investigation and to leave the facility. V2 stated that V2 then informed V1 of the abuse allegation. V2 also stated that V2 questioned V7 (Licensed Practical Nurse, LPN, R3's nurse) what transpired between R3 and V6 and that V7 stated that V7 did not witness anything between V6 and R3. V2 stated that V7 explained that V7 was down the hallway from R3's room passing medications prior to V7 learning about the altercation with R3 and V6. V2 explained that R3 was alert and oriented and not known to be a combative resident with staff or other residents and was easily able to be redirected. On 07/31/24 at 2:27 pm, V1(Administrator) stated that V1 is the abuse coordinator and it is V1's first week working at facility. V1 received a call from V2 stating there was a possible abuse case at the facility. V1 stated that V1 instructed V2 to send the person in question home, interview the resident immediately, and if there was a physical harm to call the police as well as to send the resident out to the local hospital. V1 stated that V1 was informed that the staff member involved in the abuse allegation was V6 (CNA) and that V6 had already left the facility before V2 (DON) could instruct V6 to leave. V1 stated that V1 was informed that a family member reported to a nurse on the unit that R3 was bleeding and hurt. V1 stated that a police report was conducted, and the incident was labeled as a Simple Battery V1 explained that the local hospital determined that R3 suffered bilateral jaw fractures. V1 then explained that V1 concluded V1's investigation with R3 and V6 by substantiating abuse due to R3 being an alert, oriented resident, V6 being on the schedule during the time of the incident, R3 being able to describe V6 as the male staff with tattoos and as the person who assaulted him (R3). V1 stated that V6 fit the description of R3's perpetrator. V1 also stated that R8 (R3's Roommate) could not give an accurate definition but stated that R8 heard the argument between R3 and V6 on 07/14/24. R3's progress notes dated 07/14/24 at 8:17 pm, authored by V7 (Licensed Practical Nurse, LPN) documents in part, Reported physical altercation, observed facial injury. Head to toe observation shows right jaw swelling, laceration to inner lip with blood present . Cold compress applied to jaw. Abuse protocol initiated; administration & management made aware via phone. CPD (Chicago Police Department) phoned, is in route to the facility. The facility's document dated 07/15/24 and titled Corrective Action Notice documents in part: V6 failed to follow abuse policy of the facility on 07/14/24, violation of union policy of Abuse page (pg.) 38#7 first offense discharge. Termination. Unable to serve to employee due to refusing to come to facility after completion of investigation. R3's police report record dated 07/14/2024, documents in part Incident: Simple Battery. R3's hospital record dated 07/15/24 documents in part chief complaint: Trauma. R3 brought in by Emergency Medical Service (EMS) from nursing home when R3 got into a fight with a staff member and got punched in the face. Per EMS R3 has bilateral mandibular jaw fx (fractures). R3's hospital record dated 07/15/24 documents in part: Principle Problem: Bilateral mandibular fracture, closed, initial encounter . Assault . Minimally displaced oblique fractures of the left mandibular symphysis and posterior right mandibular body are in unchanged alignment. Fracture line extends to the roots of the left mandibular central and lateral incisors . Operating Room (OR) with OMFS (Oral and Maxillofacial Surgery) . Subjective: . Head to toe trauma examination redemonstrated pain and swelling and tenderness to the mandibles and difficulty moving jaw. The facility's document dated January 4, 2018, and titled Abuse Prevention Program Facility Policy and Procedure documents in part: Introduction: abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. V1. Protection of Residents: the facility will take steps to prevent potential abuse while the investigation is underway. Internal Investigation: 7. Final investigation report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within 5 working days of the reported incident. The final investigation reports shall contain the following if the allegation is determined to be valid and the perpetrator is an employee, include on a separate sheet the employees name, address, phone number, title, date of hire, copies of previous disciplinary actions, and current status.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to conduct a thorough assessment, failed to implement care plan interventions, failed to timely notify the Physician/Nurse Practitioner of resident change in condition, failed to document orders received, failed to request appropriate orders, and failed to determine the root cause of pain for one of four residents (R1) reviewed for change in condition. These failures resulted in R1 sustaining pain rated 50 (on a 1-10 scale), emotional distress (crying), WBC (White Blood Cell) count 17.4 (High), UTI (Urinary Tract Infection), and fecal impaction. The facility also failed to ensure that R1's (3/29/24) referral for Neurosurgery consult was transcribed in the physician orders and failed to ensure that orders for R1's GI (Gastrointestinal) consult were obtained prior to surveyor inquiry. Findings include: On (6/11/24) IDPH (Illinois Department of Public Health) received allegations that R1 was not sent to the ER (emergency room ) in a timely manner for head and abdominal pain. R1's diagnoses include but not limited to encephalopathy, spina bifida, pain in unspecified joint, cutaneous abscess of right axilla, constipation, and UTI (Urinary Tract Infection). R1's Physician Order Sheets include (10/8/21) Tramadol 50 mg (milligrams) every 6 hours as needed for pain. (3/11/24) pain assessment every shift, record actual score (0-10) every shift. R1's care plan includes (6/14/21) resident is at risk for alteration in comfort. Interventions: Complete pain assessment. Administer medication as ordered and monitor for effectiveness of relief. Notify medical doctor if current pain medication management is not effective. (7/7/23) Resident is taking medication to treat constipation. Interventions: monitor, document, report to medical doctor signs/symptoms of complications related to constipation. R1's (June 2024) Medication Administration Record affirms on 6/6/24 at 1:53am, R1 received Tramadol (Opioid Analgesic) for pain rated 5. On 6/8/24 at 1:45pm, R1 received Tramadol for pain rated 4. On 6/9/24 at 10:33am, R1 received Tramadol for pain rated 5. [R1's pain was rated 0 prior to 6/6/24 therefore change in condition occurred at this time]. R1's progress notes state (6/9/24) 8:07am, resident expressed to writer that she has pain over entire body, and she would like to go to the hospital. Writer offered pain medication, but resident denied. The resident was assessed by the writer, vital signs within normal limits [Physical Assessment was excluded]. Call placed to on-call service for (Physician) and was made aware that NP (Nurse Practitioner) would return a call to the facility. [A return call from the NP was not documented]. (6/11/24) 11:51am, Resident complained of general malaise, pain, and a boil under the left arm. Writer contacted NP and new orders were given to send resident to the hospital for evaluation [2 days after initial request for evaluation]. Reason for transfer: General Malaise, complaints of pain, boil under left arm, and shunt pain. 2:10pm, ambulance personnel arrived at the facility to escort resident to the hospital. (6/12/24) Patient was admitted for abdominal pain and UTI. On 6/13/24 at 3:02pm, surveyor inquired about R1's (6/9/24) change in condition, V4 (Family) stated She (R1) has problems with her stomach, bowel movements, headaches, and she said that she couldn't see one day last week. She was in a lot of distress both physically and emotionally. Yesterday, she was hysterical because of the pain and feelings of abandonment. She was going to have an upper and lower GI (gastrointestinal) test and I think she's going to have surgery as well. R1's (4/1/24) BIMS (Brief Interview Mental Status) determined a score of 11 (moderate impairment). On 6/17/24 at 2:32pm, R1 was alert, oriented, and appropriate during interview. Surveyor inquired about R1's (6/9/24) change in condition, R1 began to speak, and an overwhelming feces odor was noted. R1 stated I was born with spinal bifida and have a VP (ventriculoperitoneal) shunt (cerebral shunt that drains excess cerebrospinal fluid). I was sick and kept having headaches, I thought my shunt was malfunctioning. I went out to an appointment about a month ago to see the neurosurgeon for my head, but they (staff) took me to the wrong office, it was the one for seizures (neurologist), so they had to bring me back and reschedule. I don't know when it was rescheduled for. Before I was sent out to the hospital, I got my stool (feces) pulled out here (facility) they (staff) only removed some of it. I was in pain for 2 weeks, I was having pain in my stomach and having headaches. Surveyor inquired how much pain R2 was experiencing prior to hospital transfer (based on a 1-10 scale), R1 responded I was crying I was in so much pain, it was 50. I asked to be sent to the hospital and the Nurse Practitioner said to keep giving me the stool softener pill and pain medicine. The Tramadol (Pain Medication) was constipating me. I was crying, throwing up a little bit and having pain so I asked my Nurse to send me out. Surveyor inquired if R1 remains constipated, R1 replied Yes, the bowel smell that's coming from my mouth means I'm constipated. The plan is to have a bag placed for my bladder (urostomy) and place a colostomy bag for my bowel. R1's (6/11/24) history & physical states patient with history of VP shunt and chronic constipation presenting to the Emergency Department with report of abdominal pain now for about the past 2 weeks. Patient states she has some pain in the right side of her abdomen which is typically the case when she has a UTI. She reports that she normally gets pain in her mid-abdomen when she is constipated and that is present. [Physical exam abdominal: there is abdominal tenderness]. Patient also notes that she has been having chronic, intermittent headaches not acutely changed. She notes that she has had a VP shunt for many years but has not been following up with a neurosurgeon. Urinalysis abnormal: turbid, WBC (White Blood Cells) many, bacteria many, urine yeast present. Abdominal CT (Computed Tomography) includes prolapse of the rectum by at least 9cm (centimeters). Fecal impaction at that site with rectal diameters up to 9.3 cm. Severe urinary bladder wall thickening, reflective of cystitis. There is urothelial thickening and enhancement at the right renal calyces, suggestive of an ascending urinary tract infection. [NAME] blood cells 17.4 (High). Clinical Impression: Abdominal pain, acute UTI, constipation, fecal impaction in rectum. On 6/17/24 at 2:53pm, surveyor inquired about R1's (6/9/24) change in condition, V6 (ADON/Assistant Director of Nursing) stated As far as I know, she said that she just didn't feel good and wanted to go to the hospital. Surveyor inquired why R1 was sent to the hospital 2 days after her request, V6 responded I wasn't aware that she requested to go to the hospital 2 days prior, so I can't answer that. Surveyor inquired if the Physician and/or Nurse Practitioner were made aware of R1's (6/9/24) change in condition and/ or request to go to the hospital, V6 accessed R1's electronic medical records and stated It says that a call was placed to the on-call doctor and the NP would call back. I see they gave pain medicine; I do not see a follow-up call. Surveyor inquired about the facility policy for resident change in condition, V6 responded The protocol is that you should alert the Physician or Nurse Practitioner, let them know what's going on, see if they want to get some labs or diagnostic tests or whatever. We follow through with that and document. Surveyor inquired if Physician or Nurse Practitioner notification was documented (6/9/24) in R1's medical records, V6 replied Unfortunately, I'm going to have to say no. Surveyor inquired about the plan for R1 post return to the facility, V6 stated She came back yesterday. It says that were going to be continuing with the current plan of care. [Surgical consultation for colostomy and/or urostomy were excluded]. On 6/18/24 at 10:17am, surveyor inquired about R1's (6/9/24) change in condition, V5 (Licensed Practical Nurse) stated When I (V5) went in the room, she (R1) said that she had pain all over her body and she wanted to go to the hospital. I did offer her pain medication; she didn't want it. I did call the on-call service and I was waiting for him (NP) to return the phone call. Surveyor inquired if the NP returned the (6/9/24) call, V5 responded He (NP) did call back I did not document that. He said don't send her out, offer pain meds again and if she refuses get a psych (Psychiatric) consult [labs and/or x-rays orders were not received to determine root cause of R1's pain]. I offered pain meds again, she accepted. The day she was sent out (6/11/24) she was complaining again, and she said that she wanted to go to the hospital. I called the NP, I didn't get an answer, so the ADON called and got a response, and she (ADON) got the order to send her to the hospital. Surveyor inquired about R1's (6/11/24) assessment, V5 stated She (R1) just said she was uncomfortable and just hurting everywhere and expressed she had pain from a boil. Surveyor inquired about the smell of R1's breath, V5 replied I didn't smell anything. Surveyor inquired if R1 reported abdominal pain on 6/11/24, V5 responded She didn't complain of abdominal pain [incongruent with R1's 6/11/24 history and physical]. Surveyor inquired what R1 was diagnosed with post (6/11/24) hospitalization , V5 replied I believe it was fecal impaction. Surveyor inquired about staff requirements for resident change in condition, V5 stated in part Alert the doctor, and we document it. Surveyor inquired if R5 documented the alleged (6/9/24) NP notification, V5 responded I got busy and I forgot to document that. On 6/18/24, surveyor inquired about R1's missed Neurosurgery appointment, V8 (Nurse Consultant) affirmed that she would check into it. At 12:09pm, V8 presented R1's encounter summary from hospital clinic and stated She (R1) was seen by the neurologist on 3/29/24 and there's a follow-up appointment with neurosurgery on 7/24/24. R1's (3/29/24) neurology consult includes Neurosurgery referral for headache disorder. Plan of Treatment: ambulatory referral to Neurosurgery. Order schedule: 7/24/24. [R1's physician orders exclude the Neurosurgery consult]. Surveyor inquired about R1's surgical consult for urostomy and/or colostomy placement, V8 affirmed that the facility was unaware that she needed a consult and would check into it. At 1:49pm, V8 stated The appointment for the GI consult is scheduled for 7/22/24 and affirmed it was scheduled after surveyor inquiry. On 6/18/24 at 2:10pm, surveyor inquired about staff requirements for outpatient referrals, V7 (Medical Director) stated We write the referral, and the expectation is that the staff execute the appointment. Surveyor inquired about staff requirements for resident change in condition, V7 responded They should call the primary care doctor immediately. Surveyor inquired what staff should be reporting to the Physician, V7 replied They should have vital signs and any pertinent physical exam findings. Surveyor inquired about potential harm to a resident with hydrocephalus status-post shunt reporting ongoing headaches and acute pain over their entire body, V7 responded a stroke. The resident admission packet (revised December 2023) states a facility must immediately inform the resident; consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s), when there is a significant change in the resident's physical, mental, or psychosocial status. When making notification, the facility must ensure that all pertinent information is available and provided upon request to the physician. The change in resident's condition policy (reviewed 2/1/24) states Nursing will notify the resident's Physician or Nurse Practitioner when: there is a significant change in the resident's physical, mental or emotional status: It is deemed necessary or appropriate in the best interest of the resident. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication. The communication with the resident and their responsible party as well as the Physician/NP will be documented in the resident's medical record. The (2/2024) pain management policy states pain management is a multidisciplinary care process that includes the following: observing for potential pain. Effectively recognizing the presence of pain. Identifying pain characteristics. Addressing the underlying causes of the pain. Monitoring effectiveness of interventions. Modifying approaches as necessary. Conduct a pain assessment upon admission to the facility, quarterly and with any significant changes in condition. Licensed Nurses may notify the healthcare provider of any new development of pain, change in pain, or change in condition that could potentially cause pain.

Based on observation, interview and record review, the facility failed to supervise and monitor two residents (R1 and R3) of 6 residents reviewed for supervision. These failures resulted in R3 eloping from the facility without staff knowing that R3 eloped and R1 having a fall after being left in the shower room unattended and sustaining a forehead laceration which required sutures and sustaining a non-displaced linear fracture of the right distal radius. Findings include: According to face sheet, R1 is a [AGE] year-old resident admitted to the facility on [DATE]. R1's face sheet documents the following diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, gastritis, unspecified, with bleeding, aphasia following cerebral infarction, essential (primary) hypertension, heart failure, unspecified, encounter for palliative care, dysphagia, oropharyngeal phase, acute respiratory failure with hypoxia. MDS section GG (dated 03/12/2024) documents that R1 requires substantial/maximal assistance for showers and transfers. (Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.). MDS section C (dated 03/12/2024) documents that R1 has a BIMS score of 10, indicating that R1 has moderate cognitive impairment. Care plan (dated 11/20/2023) documents that R1 has a self-care deficit (ADLs/Mobility) r/t hemiparesis/hemiplegia. The care plan documents that R1 is at risk for falls r/t weakness and impaired mobility and cognition. R1's Fall Risk Assessment (dated 01/23/2024) documents that R1 is a high fall risk with the score of 12. R1's Progress Note (dated 05/03/2024) documents, Upon arrival to 3 south, this writer was informed that the resident was on the floor by the housekeeper. This writer promptly responded. Resident observed on floor in 3-South, assisted bath-shower room. Head to toe assessment performed. Resident observed with laceration to right side of scalp, right shoulder bruise and right knee bruise. Resident transferred safely to wheelchair per 3 staff members due to space issue. Resident's vital signs- BP 150/98 P 101 R 20 O2 98% on room air, T 97.9. NP notified and orders to transfer resident to [community] Hospital ER obtained. Resident's daughter contacted and was notified. Director of Nursing made aware of incident & pending transfer. Resident exited via gurney per 911 paramedics. R1's Progress Note (dated 05/03/2024) documents, The writer called [community] hospital to follow-up on resident. The resident will be discharged back to Facility. ER nurse will call back with ETA. R1's Progress Note (dated 05/04/2024) documents, Resident returned from [community] hospital ER after been evaluated post fall yesterday morning. Brought back by two ambulance personnel and head to toe assessment was performed in which she has splint on her right-hand order of lidocaine patch was also brought back from the hospital. Quietly in bed sleeping. R1's Hospital Diagnostic Imagining Report (dated 05/03/2024) states: There appears to be a non-displaced linear fracture through the right distal radius laterally which is best seen on the oblique view. There are no fractures or dislocations of the right hand. Discharge instructions for Laceration Repair of the scalp: Your scalp wound was cleansed and closed with stitches, staples, rubber bands, or adhesive strips. Facility Final Incident Investigation Report (dated 05/10/2024) states: On 05/03/2024 at 9:10am, R1's assigned CNA. was assisting her with a shower. The CNA was assisting R1 with getting dressed after the shower was complete when R1 fell to the floor. The CNA immediately called for assistance. The nurse responded and assessed R1 injury noting a small cut to the right side of her head, bruising to her right shoulder, and bruising to her right knee. R1's NP was notified of the fall and post-fall assessment findings and the new orders were received to transfer R1 to the hospital for further evaluation and treatment. R1's daughter, was notified of R1's fall and transfer to the hospital. While in the hospital, R1 was diagnosed with a non-displaced linear fracture of the right distal radius. She returned from the hospital on 05/04/2024 with a splint and a Lidoderm patch for pain. On 05/21/2024 at 11:42am V12 (Licensed Practical Nurse) stated, R1 requires extensive care at times. For showers, R1 needs assistance. She can't do it by herself. R1 needs to be transferred into the shower chair and then transferred from the shower chair to her wheelchair. R1 needs to be dressed by staff and she needs help with everything. During the shower, you cannot leave R1 alone. We don't leave any resident alone during showers. For showers, R1 requires the assistance of 1 staff member. On 05/21/2024 at 11:46am, surveyor observed R1 on the 3rd floor, secured memory care unit. R1 was being monitored by staff while R1 was sitting in the day room participating in resident activities. R1 was observed to be working on a puzzle. R1 nodded her head in response to surveyor, indicating that R1 is doing fine. R1 was observed to be comfortable and safe within her environment. Surveyor inspected R1's room and noted that R1's bed was in a low position, and a landing mat was present at the resident's bedside. R1 was observed to be wearing a helmet for safety. On 05/22/2024 at 11:15am V20 (Housekeeper) stated, On 05/03/2024, I was cleaning a room and I heard a sound that sounded like boom. I went to the shower room to see where the sound came from. I opened up the door to the shower room and I saw R1 laying on the ground. I went to inform the nurse. R1 was in the shower room by herself. There was a shower chair in the shower room, and R1 fell from the shower chair. No staff where present in the shower room when I saw R1 on the floor. I went to inform the nurse and the nurse came to assess R1 immediately. On 05/22/2024 at 11:44am V19 (Nurse) stated, On 05/03/2024, I arrived on the unit and V20 (Housekeeper) said to me that he heard a fall. V20 alerted me and another nurse. I immediately went to the shower room, and I saw R1 laying on the floor. I assessed R1 from head to toe. R1 had a laceration to the right scalp, a bruise to her right shoulder and a bruise to her right knee. R1 was crying and R1 was in pain. R1 is not able to verbalize readily. R1 can nod her head in response to a question, and make her needs known for the most part. R1 is on the memory care unit. I was told by the other nurse that the certified nursing assistant (V23) who was assigned to R1, left R1 in the shower room unattended. This incident took place somewhere between 7am and 8am. I called R1's Nurse Practitioner, the ambulance and I called R1's daughter. R1's daughter said that she was on her way to the facility. The ambulance arrived right away. R1's daughter arrived almost at the same time as the ambulance. R1 was transported to the hospital. I believe R1 returned back to the facility that same evening. R1 is a resident that requires a lot of supervision. It is not appropriate and not safe at all to leave R1 alone in the shower room. Surveyor inquired about interviewing V23 (Certified Nursing Assistant assigned to R1 on 05/03/2024, at time the fall incident took place). On 05/22/2024 at 12:21pm V1 (Administrator) stated, V23 was terminated on 05/03/2024, the day of R1's fall incident. On 05/22/2024 at 12:48pm, V24 (R1's Physician) stated, R1 is a high fall risk. R1 requires assistance from nurses and certified nursing assistants. R1 is not safe to be in the shower room by herself. R1's fall on 05/03/2024 could have been prevented, this was a preventable fall. On 05/23/2024 at 11:37am V15 (Restorative Nurse) stated, R1 is a high fall risk due to having weakness and her health diagnosis. The fall prevention measures in place for R1 are floor mats at bed side for when R1 is in bed, a helmet, non-slip pad for R1's wheelchair, low bed and close monitoring. R1 needs to be up in a chair and R1 needs to be closely monitored when R1 is not in bed to prevent falls. R1 is not safe to be left alone in the shower room. According to face sheet, R3 is a [AGE] year-old resident admitted to the facility on [DATE]. R3's face sheet documents the following diagnoses including but not limited to: Syncope and collapse, essential (primary) hypertension, type 2 diabetes mellitus without complications, cardiac arrest, cause unspecified, cerebrovascular disease, unspecified. According to a nursing progress note (dated 04/19/2024), R1 is ambulatory and alert and oriented x3. According to progress notes, R3 eloped from the facility on 04/26/2024. R3's Care plan (dated 04/22/2024) documents that R3 is at risk for falls related to general weakness. The care plan documents that R3 has a self-care deficit (ADLs/Mobility) de-conditioning from recent hospitalization . R3's Progress Note (dated 04/26/2024) documents, Resident not present upon doing rounds at facility. CNA staff stated that resident was possibly at appointment and had not returned on shift. Resident was reportedly not seen prior to lunch and did not eat lunch. No f/u information was given or received from 1st shift nurse during report. Unable to f/u due to lack of information about appt that resident may have been at. Oncoming nurse aware that client has not returned to facility from whereabouts. R3's Progress Note (dated 04/27/2024) documents, Resident not received in report. R3's Progress Note (dated 04/27/2024) documents, Resident not observed on unit during routine rounds. Manager on duty made aware. All staff on unit initiated a thorough search of the unit. DON made aware and code yellow paged overhead. All staff completed a thorough search of the facility grounds. Staff unable to locate the resident. Police department notified. Resident physician notified. Resident's listed cell phone contacted, and family member answered the phone. Family notified of resident not in facility. Calls placed to area hospitals, shelters, and senior centers with no success locating resident. Writer spoke with resident's roommate who indicated that resident called his family to pick him up in the side parking lot. Resident packed his personal belongings and left the facility AMA. R3's Progress Note (dated 04/29/2024) documents, Resident remains absent from facility as of this time. Facility Final Incident Investigation Report (dated 04/29/2024) states: On 04/26/2024, around noon, R3 was observed by his roommate, R9, talking to his family on the phone about wanting to leave the facility. According to R9, R3 had been talking to his family on the phone throughout the afternoon. R3 appeared upset with his family because he wanted to leave immediately, however, they couldn't pick him up until they got off of work later in the evening. Nurse V25 (Licensed Practical Nurse) was R3's assigned nurse for 3-11 and 11-7 shifts. She was late for work, arriving at 4pm. She did not receive nurse-to-nurse handoff because the prior shift nurse had already left for the day. She did not complete routine rounds. Between 4pm and 5pm, R3 packed up his belongings and left the facility with his family. R3 left through the front door. His family picked him up in the side parking lot. Staff contacted the VA (Veteran Affairs) regarding R3 leaving the facility. The VA caseworker indicated that this is a common behavior for R3, he frequently admits to skilled nursing facilities and leaves AMA abruptly. The VA caseworker indicates they have had contact with R3, and he is safe in the community. On 05/21/2024 at 10:03am via telephone V4 (R3's friend) stated, R3 is fine. R3 did not like the facility and he left. R3 is fine and safe. I just talked to R3 a little while ago. R3 told them that he was going to get his mail and then he left the facility. R3 took all of his belongings when he left, and I picked him up from the side parking lot. R3 did not like the facility so he just left right out. On 05/21/2024 at 10:14am V3 (Nurse Consultant) stated, We did have one elopement. The elopement was R3. R3 left on 04/26/2024. R3 was an alert and oriented resident. R3 was admitted to the facility on [DATE]. R3 was alert and oriented and R3 left. We were able to determine that R3 left somewhere between 4 and 5pm on 04/26/2024. R3 left and did not tell any staff that he was leaving. R3's roommate told us that R3 was on the phone with his family, or someone that sounded like his family. The roommate told us that the person picking R3 up was going to pick him up after work, which is after 4pm. R3 packed up all his personal items and was picked up in the side parking lot of the facility. We talked to the Veteran Affairs (VA), and they were able to locate him after R3 left. R3 was not answering his phone after he left from the facility. We did a whole house education on supervision and elopements. We hired a second front door monitor because we had a bad survey related to substance abuse, so we placed a second person there for monitoring and supervision. It is believed that R3 walked right out the front door without being stopped. R3 is safe after he eloped from the facility. On 04/26/2024 at 7:30, there is a progress note that says that the nurse did rounds and R3 was not there. This nurse put the note in after the fact. It was during her shift that we determined that the resident eloped. The timeline of the progress notes does not reflect the timeline of the actual occurrence of R3's elopement. The date and time are not properly reflected in the progress notes. V5 was the nurse who initiated the code Yellow, That's a code for a missing resident. A search was done on all units and R3 was not found. On 05/21/2024 at 11:20am V5 (Licensed Practical Nurse) stated, I left here on 04/26/2024 at 3pm and R3 was still in the facility. R3 was still here when I left. On 04/27/2024 when I returned to work the next day, R3 was not here. R3 was not able to be located when I showed up to work the next day. R3 did not sign the Against Medical Advice (AMA) form with me. When I started my shift on 04/27/24, I noticed R3 was not here and I called a code Yellow, which means there is a missing resident. During the code, we were not able to find R3. R3's roommate stated that R3 packed his belongings and left with a family member. R3's roommate also left AMA, so the roommate is not at the facility anymore. I tried to reach out to the resident via cell phone and R3 did not answer. The police were called the same day when R3 was noted to be gone from the facility and a report was filed. Elopement Policy (undated) states: The facility has a plan in case of an elopement of a resident from the facility. This enables the missing resident to be found as quickly as possible and to maintain the resident's safety, dignity, and privacy; If the resident is not located the facility supervisor will designate an employee to notify the resident representative, attending physician, policy department, surrounding area hospitals, surrounding shelters, surrounding area senior shelters. Supervision and Safety Policy (undated) states: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. Resident supervision is a core component to resident safety.

Based on observations, interviews and record review the facility failed to ensure that one resident's (R4's) pain was managed as per facility policy. This failure has affected one of four residents reviewed for pain management and caused R4 to endure pain consistently at a level of 8 out of 10 on the pain scale. Findings include: R4 is a [AGE] year old with diagnosis including but not limited to: Muscle wasting and atrophy, muscle weakness, fracture of orbit and traumatic subdural hemorrhage with loss of consciousness of unspecified duration. R4 has a BIMS (Brief Interview for Mental Status) Score of 15, which indicates cognitively intact. On 4/15/2024 during investigation, R4 was observed lying in bed with a frown on his (R4's) face. On 04/15/2024 at 10:20 AM, V5 CNA (Certified Nurse Assistant) asked for permission and rolled R4 on his right side to check his back. Surveyor observed a Lidocaine patch on R4's back with the date of 4/12/2023 written on it. At that time, V5 CNA said, It looks like R4's pain patch was last changed on 4/12/2024. 04/15/2024 at 10:22 AM, R4 said, My pain level is about an 8 (on 1-10 pain scale). I don't recall getting my pain patch for a couple of days now. At that time, V4 LPN (Licensed Practical Nurse/LPN) said, R4 complained to me of back pain of 8 out of 10 and I gave R4 oral pain medication. R4 said the oral medication doesn't work much. I (V4) wasn't aware that R4 did not have on his lidocaine patch because the lidocaine patch is scheduled for the night shift nurses. The night shift nurses put R4's pain patch on his back every morning at 6 AM and write the date in which the patch was applied on the patch. I will call the Doctor to request a stronger oral pain medication as needed. 04/15/2024 at 12:10 PM, V2 DON (Director of Nursing) said, R4's pain patch should absolutely be applied at the time and day that it is supposed to per order. If R4 hasn't had a pain patch since 4/12/2023, that is a medication error. If a patients' pain is not managed, it could spike the vitals and is unacceptable because the patient is uncomfortable when pain is not managed. Unmanaged pain could affect their daily activities such as even eating. A patient may not want to eat if they are in pain. On 4/16/2024 at 11:23 AM, V13 (LPN) went with Surveyor to R4's room. Upon checking, it was noted that there was no lidocaine patch on R4's back. On 4/16/2024 at 11:23 AM, V13 (LPN) said, R4 doesn't have a patch on but I can help his nurse put on his patch. On 4/16/2024 at 11:25 AM, V14 (LPN) said, R4 said that he (R4) was in pain earlier but that he did not want the acetaminophen because it did not work. R4's pain is at an 8. I was going to go back and offer R4 pain medicine again. The night nurse V15 (LPN) worked with R4 last night and coded the Lidocaine was a 9, which means that the lidocaine was not given. There is no progress note as to why V17 did not give the lidocaine, but the medication is available on the medication cart. On 4/16/2024 at 11:35 AM, R4 said, no one offered me a pain patch this morning. V15 (LPN) was unable to be reached during survey. On 4/17/2024 at 12:20 PM V17 (LPN) said, I was R4's nurse on 4/13 and 4/14 overnight shifts. I am scheduled to give R4's lidocaine patch at 6 AM right before the end of my shift. R4 usually doesn't refuse his pain patch. Surveyor asked if V17 administered R4's pain patch on the mornings of 4/14/2024 and 4/15/2024. On 4/17/2024 at 12:25 PM V17 (LPN) said, I think that maybe I was moving too fast and forgot to put the lidocaine patch on R4's back. I did sign the medication out, but I don't remember giving the medication. On 4/18/2024 at 4:11 PM, V20 (Nurse Practitioner) said, I was just informed that R4's pain is consistent. I have scheduled an oral medication for R4 to take daily. If the pain is not managed, it could cause frustration and worsened back pain. R4's Physician Order Sheet documents, Lidocaine patch 5% apply to lower back topically in the morning for pain 3/10/2024 through 4/15/2024; Lidocaine patch 5% apply to lower back topically one time daily for pain 4/16/2024 through current. R4's Medication Administration Record documents, No documentation of Lidocaine patch administered on 4/13/2024; V17 (LPN) documented that Lidocaine patch was administered on 4/14/2024 and 4/15/2024; V15 (LPN) documented '9' for Lidocaine patch on 4/16/2024. R4's care plan documents, Focus: alteration in comfort secondary to pain. R4's pain related to lower back pain; Goal: R4 will be free of pain as evidenced by R4's subjective statement; R4 is at increased risk for alteration in pain/discomfort; Interventions: administer analgesic medication as ordered per plan of care. R4's pain level summary documents, 4/13/2024 pain level of 10 on scale of 1-10; 4/15/2024 pain level of 8 on 1-10 scale; 4/16/2024 pain level of 8 on 1-10 scale. R4's Pain Review dated 4/15/2024 documents, R4 has had pain in the last 5 days almost constantly; pain level of 8 on a 1-10 scale; current prescribed pain medication Lidocaine patch effective and decreases pain from an 8 to a 3 on a 1-10 pain scale. Facility policy titled Pain Management and Assessment documents, residents will receive necessary comfort, exercise greater independence and enhance dignity through optimizing their ability to perform activities of daily living using a resident centered individualized approach to pain control.

Based on observation, interview and record review, the facility failed to implement necessary treatment and services consistent with professional standards of practice to promote healing and prevent new ulcers from developing for a resident identified at risk. The facility failed to: 1. Failed to initial or sign on the electronic treatment administration record (eTAR) after each treatment for 3 (R1, R4 and R5) residents with pressure ulcers. 2. Failed to revise care plan to reflect alteration of skin integrity, approaches, and goals for care for 1 (R5) resident with multiple facility acquired pressure ulcers. 3. Failed to do weekly wound assessment for 3 (R1, R4 and R5) residents with pressure ulcers. 4. Failed to complete Braden scale assessment upon admission for a total of four consecutive weeks for 1 (R1) resident with multiple pressure ulcers. 5. Failed to complete nutritional consultation or assessment for 1 (R1) resident with multiple pressure ulcers. 6. Failed to ensure treatment orders for 1 (R5) resident with multiple facility acquired pressure wounds. 7. Failed to monitor wound dressing to ensure it was intact and adhering for 1 (R4) resident with pressure ulcer. These failures affected 3 (R1, R4 and R5) out of 3 residents reviewed for pressure ulcers. R1 with 2 stage 3 pressure ulcers to left elbow and coccyx, R4 with Stage IV pressure ulcer to sacrum, and R5 with multiple facility acquired Stage III pressure ulcers to left posterior thigh, right heel, right and left ischium. The findings include: R1's health record documented admitted on 1/8/24 with diagnoses not limited to Encounter for orthopedic aftercare following surgical amputation, Muscle wasting and atrophy, Dysphagia oropharyngeal phase, Type 2 diabetes mellitus with other circulatory complications, Acquired absence of left leg below knee, Peripheral vascular disease, Sepsis, Unspecified personality and behavioral disorder due to known physiological condition, Depression, Schizophrenia, Acquired absence of right leg below knee, Other polyosteoarthritis, Gastro-esophageal reflux disease without esophagitis, Anemia. R1's health record showed discharge date on 1/27/24. R4's health record documented initial admitted on 2/11/22 with diagnoses not limited to Other chronic osteomyelitis, right ankle and foot, Methicillin resistant staphylococcus aureus infection, Local infection of the skin and subcutaneous tissue, Gangrene, Non-pressure chronic ulcer of other part of left foot with necrosis of bone, Pressure ulcer of sacral region stage 4, Peripheral vascular disease, Hypertensive heart disease with heart failure, Opioid use, Burn of third degree of left foot, Burn of third degree of right foot, Resistance to vancomycin vre of the wound, Insomnia, Cocaine use, Anemia, Major depressive disorder, recurrent, Heart failure, Schizophrenia, Sepsis, Cellulitis of left lower limb, Homelessness unspecified, Primary osteoarthritis. R5's health record documented initial admitted on 11/07/14 with diagnoses not limited to Unspecified injury at unspecified level of cervical spinal cord, Paraplegia, Neuromuscular dysfunction of bladder, Type 2 diabetes mellitus with unspecified complications, Pressure ulcer of other site, stage 3 (left posterior thigh left ischial tuberosity right ischium), prostatic hyperplasia without lower urinary tract symptoms, Vitamin d deficiency, Methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere, Peripheral vascular disease, Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, Gout, Essential (primary) hypertension, Chronic kidney disease, Major depressive disorder, Gastro-esophageal reflux disease without esophagitis, Nutritional anemia, Other hereditary and idiopathic neuropathies, Extended spectrum beta lactamase (esbl) resistance. On 2/14/24 at 10:04am observed R4 lying in bed, alert and verbally responsive, appears comfortable, with air mattress in place. Wound care observation conducted with V4 (Wound Care Director) assisted by V41 (Wound Care Nurse). Observed R4 open his incontinence brief, clean and dry. Observed open wound on sacral area with no dressing in place. V4 stated that maybe the CNA (Certified Nursing Assistant) had removed the dressing during care. V4 stated the sacral wound is classified as Stage IV acquired in the facility. Observed wound bed about 80% pinkish and 20% granulating tissue, no yellow slough noted. Observed V4 cleanse the wound with NSS (normal saline solution) then applied calcium alginate and covered with dry dressing. At 10:19am observed R5 lying on bed, alert, and oriented x 3, verbally responsive, air mattress in placed. R5 refused wound care observation. He stated that wound care was already done by staff. R5 agreed wound to be seen by surveyor with V4. Observed V4 opened dressing on left posterior thigh, observed with open wound. V4 stated it is classified as Stage III. Observed wound bed 70% pinkish to reddish and about 30% yellow slough. R5 refused other wounds to be seen by surveyor. At 10:24am V43 (Certified Nursing Assistant/CNA) said she is assigned to R4, and her shift started at 7:00am. She stated that R4 uses urinal, and she did not change R4 yet and is about to check for incontinence episode. V43 said she did not remove or touch R4's wound dressing on the buttocks. At 10:48am V44 (Consultant Dietician) stated that residents with pressure wounds have metabolic stress in the body, the body is losing a lot of fluids and proteins, could have muscle wasting, dehydration, at risk for developing more pressure ulcers due to weight loss from the other wounds not healing so nutritional assessment or evaluation is needed. He said that caloric needs changed when there is an existing or non-healing wound. V44 said interventions with additional nutritional supplements or additional protein in the diet is important for wound healing. V44 stated that resident with a pressure ulcer is needing more calories and more protein to create / restore the tissue to promote wound healing. V44 stated that if nutritional supplements were missed or not given this could put resident at risk for weight loss, wound could get worst or could delay wound healing. Reviewed R1's EHR (electronic health record) with V44 and said he tried to see R1 but there was no wound assessment at the time when he was in the facility, so R1 was not seen. V44 stated not able to find any nutritional assessment / evaluation documentation in R1's EHR so it was not done. At 12:58pm Reviewed EHR with V4 (Wound Care Director) for the following residents: 1. R5 - V4 stated he has multiple acquired Stage 3 pressure wounds to right heel, right ischial, left posterior thigh and Left ischium that were not healed and no change in wound status. V4 stated that wound assessments should be done weekly and per EHR wound documentation was done on 12/25/23 then 1/21/24, it does not indicate that it was being done on a weekly basis. 2. R4 - V4 stated that he has an acquired Stage IV pressure wound to sacrum, not healed, no change in wound status. 3. R1 - V4 stated that he was admitted with 2 stage 3 pressure wounds to left elbow and coccyx and surgical wound related to Left AKA. V4 said that she saw wound documentation for R1 on 1/21/24 for coccyx, no wound documentation for left elbow and coccyx upon admission on 1/8/24 and 1/15/24. V4 said Braden scale assessment was done on 1/8/24, no Braden scale assessment done on 1/15/24 and 1/22/24. V4 Stated I don't know why Braden scale and wound assessment were not done as she was not doing wounds at that time. She said that she is trying to catch up with assessments. V4 said that skin assessment is done to document any skin breakdown or skin condition upon admission. V4 said that Braden scale is a risk assessment that would include shearing/friction, mobility, and moisture. V4 stated that the wound care team signs the electronic treatment administration record (ETAR) after providing the treatment to resident to make sure that it was done. She said that if ETAR was not signed it means that treatment was not provided. V4 said if treatment was not provided or missed, this could potentially lead to wound infection, delay wound healing or worsening of wound. V4 stated that the purpose of wound dressing is to keep the wound from being infected or contaminated. She said that if dressing fell off or was soiled and removed, there is PRN (as needed) order and treatment should be done by floor nurse. V4 said that nutritional supplements are important to build protein that helps in wound healing. V4 stated that wound treatment for R1, R4 and R5 wounds should have an order in the resident's EHR. At 2:42pm V36 (Assistant Director of Nursing/ADON, RN) said wound dressing should be monitored and should be in place to keep the wound from debris, contamination that could possibly be at risk for infection and could worsen/damage/delay wound healing. V36 said Braden scale is an assessment for friction, mobility, moisture, mobility to predict risk for skin breakdown so it will guide the staff on how many times the resident needs to be changed or needing repositioning. V36 said wound assessment should be done on a weekly basis to assess progress of existing wound, if it is not done weekly, not able to evaluate if the treatment is effective or working or if needs to be changed or additional interventions should be implemented. V36 said nutritional supplements are very important in maintaining proper nutrients in repairing, rebuilding, and restoring skin tissues to aid or help in wound healing. She said TAR/MAR (Treatment Administration Record/Medication Administration Record) should be signed after providing treatment and after medication administration to prove that treatment was provided, and medications/nutritional supplements were given. V36 said if it was not signed or not documented, it was not done or was not given. V36 stated that if treatment is missed or not provided, this could lead to wound infection, worsening of the wound or delay wound healing. V36 said if nutritional supplements are not given, this could delay wound healing or worsen the wound. R1's EHR was reviewed with V36, V36 stated that R1 was transferred to hospital on 1/27/24 due to purulent drainage on left AKA (above the knee amputation) and was admitted to hospital with possible wound infection. At 4:49pm V39 (Wound Nurse Practitioner/NP) stated that he is following R4 and R5 every other week and both residents are at risk for skin breakdown due to contributing factors which are immobility, incontinence, and multiple comorbidities. He said that he was not familiar with R1 and R1 was not seen for wound evaluation. V39 stated that if there is a missed treatment or treatment not done, this could potentially worsen the wound, delay wound healing or could lead to infection. He stated that wound dressing is important to be maintained to prevent wound contamination that could potentially delay wound healing or worsening of wound. V39 stated that nutritional supplements are very important for wound healing, help the body rejuvenate, repair damage tissues and aid in healing process. On 2/15/24 at 10:52am V40 (Nurse Practitioner/NP) was interviewed via phone and stated that she is familiar with R1, R4 and R5. V40 said if wound treatments were missed or treatments were not done, this could potentially delay wound healing, worsening of the wound or could lead to infection. V40 said that wound dressing should be maintained to prevent contamination of the wound that could possibly lead to infection, delay wound healing if wound dressing is not maintained. V40 said nutritional supplements could play a part together with wound healing. She said that if nutritional supplements are not given as ordered could potentially delay wound healing or worsen the wound. MDS (Minimum Data Set) dated 1/14/2024 showed R1's cognition was moderately impaired. R1 needed set-up/clean-up assistance with eating; Partial/moderate assistance with oral hygiene; Total assistance/Dependent with toileting and personal hygiene, shower/bathe self, lower body dressing, chair/bed transfer and Substantial/maximal assistance with upper body dressing. MDS showed R1 was always incontinent of bowel and bladder. R1 had 2 Stage III and 1 Unstageable pressure ulcers that were present upon admission. MDS also showed R1 had surgical wound. R1'S POS (Physician Order Sheet) showed the following orders but not limited to: - Clean LT (left) elbow with NSS, skin prep peri-wound apply foam dressing one time a day every Mon, Wed, Fri AND as needed if soiled or falls off. - Clean Coccyx with wound cleanser, skin prep peri-wound apply Hydrocolloid one time a day every Mon, Wed, Fri AND as needed if soiled or falls off. - Skin prep staples to LT (left) AKA LOTA (leave open to air) one time a day AND as needed Apply dry dressing if drainage present. - Readycare 1.7 two times a day for low BMI(Body Mass Index) for age 120 ml. - Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for Wound care. - Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for Wound care. - Critical Care Active Protein two times a day for Wound care give 30cc PO. R1'S MAR (Medication Administration Record) for the month of January 2024 showed: - Critical Care Active Protein and Readycare 1.7 were not signed that it was given on 1/15/24 and 1/20/24. R1's TAR (Treatment Administration Record) for the month of January 2024 showed: Treatment to Coccyx and Left elbow were not signed that treatments were provided on 1/26/24. R1's wound assessment dated [DATE] documented in part: Stage III to Coccyx measuring 0.5 X 0.7 X 0.3cm. No wound assessment for left elbow on 1/21/24. No wound or skin assessment found in R1's EHR upon admission on 1/8/24 and weekly thereafter on 1/15/24. Per V4, wound assessment should be done upon admission then weekly. No wound NP notes found in R1's EHR. R1's Braden scale assessment dated [DATE] Scored 14 (moderate risk). No Braden scale assessment found on 1/15/24 and 1/22/24 found on R1's EHR. Per V4, Braden scale is done weekly x 4 weeks. R1's care plan dated 1/10/24 documented in part: The resident has stage 3 pressure ulcer related to history of ulcers, Immobility, DM. Care plan interventions included but not limited to Administer treatments as ordered and monitor for effectiveness. MDS dated [DATE] showed R4's cognition was intact. R4 needed set-up/clean-up assistance with eating; Substantial/maximal assistance with oral, personal and toileting hygiene and Total assistance/dependent to staff with shower/bathe self, lower body dressing and chair/bed transfer. MDS showed R4 was always incontinent of bowel and bladder. MDS also showed R4 had Stage IV pressure ulcer that was present upon admission. R4's POS included the following orders but not limited to: - Sacrum: Cleanse with wound cleanser skin prep peri-wound/Alginate silver/dry dressing one time a day. - Critical Care Active Protein three times a day Give 30ml PO. - Multi-Vitamin/Minerals Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth in the morning for Nutritional Supplement. - Vitamin C Oral Tablet (Ascorbic Acid) Give 1 tablet by mouth one time a day for Wound care. R4's MAR for the month of December 2023 and January 2024 showed: Critical Care Active Protein were not signed that it was given on 12/3/23, 12/19/23. 12/22/23, 12/23/23, 12/30/23, 12/31/23 and 1/13/24. MAR showed Multi-Vitamin/Minerals Tablet and Vitamin C Oral Tablet were not signed that medications were given on 1/13/24. R4's TAR for the month of December 2023, January and February 2024 showed: Treatment to Sacrum were not signed that treatment was provided on 12/17/23, 12/20/23, 12/23/23, 12/24/23, 1/1/24, 1/14/24, 1/23/24, 1/24/24, 1/26/24, 1/30/24, 2/3/24, 2/5/24 and 2/11/24. R4's wound assessment dated [DATE] documented pressure injury to sacrum measuring 2.0cm x 0.6cm x 0.2cm. Per wound nurse Sacrum was classified as Stage IV acquired in the facility. R4's EHR reviewed with V4 and said it is indicated that there was no wound assessment documentation found on 12/7/23, 12/14/23, 12/21/23, 1/3/24, 1/10/24, 1/17/24 to Sacrum Stage IV pressure wound. R4's wound NP notes dated 2/12/24 documented in part: Sacral is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2cm length x 0.6cm width x 0.2 cm depth. R4's Initial Braden scale assessment dated [DATE] scored 13 (moderate risk) and latest assessment dated [DATE] showed 14 (moderate risk). Care plan dated 1/2/24 documented in part: R4 has pressure ulcer on sacrum r/t Immobility. R4 Care plan interventions included but not limited to: - Administer medications as ordered. - Administer treatments as ordered and monitor for effectiveness. - Monitor dressing to ensure it is intact and adhering. Report lose dressing to Treatment nurse. MDS dated [DATE] showed R5 was cognitively intact. R5 needed set-up/clean up assistance with eating; Supervision/touching assistance; Total assistance/Dependent to staff with toileting hygiene, shower/bathe self, lower body dressing, chair/bed and toilet transfer and Substantial/maximal assistance with upper body dressing and personal hygiene. MDS showed he was frequently incontinent of bowel, with indwelling catheter. MDS showed 2 Stage III pressure ulcers that were not present upon admission. Wound report provided by facility dated 2/5/24 to 2/9/24 showed R5 has the following wounds: 1. Left posterior thigh - date identified on 4/14/21, facility acquired Stage 3 pressure ulcer. Last assessment date on 2/6/24 measured 3.0 x 4.0 x 0.2cm (Length x Width x Depth). 2. Right ischium - date identified on 12/11/23, facility acquired Stage 3 pressure ulcer. Last assessment date on 2/6/24 measured 2.0 x 1.0 x 0.2cm. 3. Left ischium - date identified on 1/8/24, facility acquired Stage 3 pressure ulcer. Last assessment date on 2/6/24 measured 1.0 x 1.0 x 0.2cm. 4. Right heel - facility acquired Stage 3 pressure wound. Last assessment date on 2/6/24 measured 4.0 x 3.2 x 0.2cm. Per V4, could not determine when it started. V4 said per documentation, on May 16, 2019, it was already an existing wound. R5's POS showed the following orders but not limited to: - left posterior thigh cleanse with normal saline, pat dry skin prep peri wound apply moistened collagen then calcium cover with dry dressing one time a day for Wound care AND as needed Clean LT posterior thigh with NSS apply skin prep to peri-wound apply Ag+ alginate, cover with dry dressing. - Cleanse Sacralcoxccygeal with Nss/skin prep/ pack with calcium alginate/boarder gauze one time a day. - Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth in the morning for Wound care. - Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth in the morning for Nutritional Supplement. - Critical Care Active Protein three times a day Give 30ml PO. No treatment orders for the following wounds: Right and left ischium and Right heel. R5's MAR for the month of December 2023 and January 2024 showed: Critical Care Active Protein were not signed that it was given on 12/22/23, 12/23/23, 12/31/23, 1/6/24, 1/14/24 and 1/17/24. MAR showed Multi-Vitamin/Minerals Tablet and Vitamin C Oral Tablet were not signed that medications were given on 1/17/24. R5's TAR for the month of December 2023, January and February 2024 showed: Treatment to Left posterior thigh and Sacrococcygeal wounds were not signed that treatments were provided on 12/23/23, 12/29/23, 1/14/24, 1/23/24, 1/24/24, 1/26/24, 2/3/24, 2/4/24 and 2/11/24. No treatment orders for the following wounds: Right and left ischium and Right heel. No wound assessment documentation found for right heel wound on 12/1/23 and 12/8/23, 12/15/23 in R5's EHR. No wound assessment documentation found for Left thigh, right ischium, and right heel on 12/22/23, 12/29/23, 1/5/24. No wound assessment documentation for Left thigh, right ischium, and right heel on 1/12/24, 1/19/24 and 1/31/24. Wound NP notes dated 2/5/24 showed R5 with multiple wounds documented in part: - Right Ischial is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2cm length x 1cm width x 0.2 cm depth. There is no change noted in the wound progression. - Left, Posterior Thigh is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3cm length x 4cm width x 0.2 cm depth. There is a Moderate amount of sero-sanguineous drainage noted which has no odor. There is no change noted in the wound progression. - Right Heel is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 4cm length x 3.2cm width x 0.1 cm depth. There is a Moderate amount of sero-sanguineous drainage noted which has no odor. R5's Initial Braden scale assessment dated [DATE] scored 11 (high risk) and latest assessment dated [DATE] showed 13 (moderate risk). Care plan dated 1/3/24 documented in part: R5 has a pressure ulcer to coccyx and left posterior thigh. R5 Care plan interventions included but not limited to: - Administer supplements to promote wound healing. - Assess and document on wounds weekly and as needed. - Administer treatments as ordered and monitor for effectiveness. - Change dressing as ordered. Facility's wound policy and procedures dated 1/1/24 documented in part: - To identify factors that places the residents at risk for the development of pressure ulcers and to implement appropriate interventions to prevent the development of clinically avoidable wounds. - To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. - To promote healing of existing pressure ulcers. - BRADEN scale should be completed for all residents upon admission/readmission for a total of four consecutive weeks, quarterly with each MDS assessment and when a significant change of condition occurs. - Identified risk factors should be addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented. - Upon identification of the development of a wound, the wound assessment will be documented. - Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. Findings from the weekly skin assessment should be documented/signed off by the licensed nurse. - Any skin impairments including pressure ulcers should be assessed and documented weekly by the wound nurse or designee. Documentation should cover all pertinent characteristics of existing pressure ulcers including location, size, depth, maceration, color of the ulcer and surrounding tissues and a description of any drainage, eschar, necrosis, odor, tunneling or undermining, if warranted. - A nutritional consultation should be completed for residents who are at risk for malnutrition. - The goals of wound treatment are to: Protect the ulcer from contamination and promote healing. - Measurements are taken weekly.

Based on interview and record review the facility failed to ensure that necessary treatment and services consistent with professional standards of practice to prevent wound infection were implemented for 1 (R1) resident with a surgical wound due to left above the knee amputation. The facility failed to: 1. Failed to sign TAR (treatment administration record) that treatment was provided. 2. Failed to assess and monitor surgical wound upon admission and on weekly basis. 3. Failed to complete nutritional consultation / assessment. 4. Failed to complete Braden scale on a weekly basis. These failures resulted to 1 (R1) resident admitted to the hospital with diagnosis of wound infection. The findings include: R1's health record documented an admitted on 1/8/24 with diagnoses not limited to Encounter for orthopedic aftercare following surgical amputation, Muscle wasting and atrophy, Dysphagia oropharyngeal phase, Type 2 diabetes mellitus with other circulatory complications, Acquired absence of left leg below knee, Peripheral vascular disease, Sepsis, Unspecified personality and behavioral disorder due to known physiological condition, Depression, Schizophrenia, Acquired absence of right leg below knee, Other polyosteoarthritis, Gastro-esophageal reflux disease without esophagitis, Anemia. R1's health record showed discharge date on 1/27/24. On 2/14/24 at 10:48am V44 (Consultant Dietician) stated that if nutritional supplements were missed or not given it could put a resident at risk for weight loss, wounds could get worse, or it could delay wound healing. Reviewed R1's EHR (electronic health record) with V44 and he stated he tried to see R1 but there was no wound assessment at that time when he was in the facility, so R1 was not seen. V44 stated he was not able to find any nutritional assessment / evaluation documentation in R1's EHR. At 12:58pm reviewed R1's EHR with V4 (Wound Care Director) and the EHR stated that he was admitted with a surgical wound related to Left Above Knee Amputation (AKA). She said that she saw wound documentation for R1 on 1/21/24 but there was no documentation regarding the surgical wound. No wound documentation upon admission on 1/8/24, 1/15/24 and 1/22/24. V4 said Braden scale was done on 1/8/24 only, no Braden scale done on 1/15/24 and 1/22/24. V4 Stated I don't know why Braden scale and wound assessment were not done as she was not doing wounds at that time. She said that she is trying to catch up with assessments. V4 said that skin assessment is done to document any skin breakdown or skin condition upon admission. V4 said that Braden scale is a risk assessment that would include shearing/friction, mobility, and moisture. V4 stated that wound care team sign electronic treatment administration record (ETAR) after providing the treatment to resident to make sure that it was done. She said that if ETAR was not signed it means that treatment was not provided. V4 said if treatment was not provided or missed, it could potentially lead to wound infection, delay wound healing or worsening of wound. V4 said that nutritional supplements are important to build protein that helps in wound healing. At 2:42pm V36 (Assistant Director of Nursing/ADON, RN) said Braden scale is an assessment for friction, mobility, moisture, mobility to predict risk for skin breakdown so it will guide the staff how many times the resident needs to be changed or needing repositioning. She said wound assessment should be done on a weekly basis to assess progress of existing wound, if it is not done weekly, the facility is not able to evaluate if the treatment is effective or working or if needs to be changed or additional interventions should be implemented. V36 said nutritional supplements are very important in maintaining proper nutrients in repairing, rebuilding, and restoring skin tissues to aid or help in wound healing. V36 said TAR/MAR (Treatment Administration Record/Medication Administration Record) should be signed after providing treatment and after medication administration to prove that treatment was provided, and medications/nutritional supplements were given. V36 said if it was not signed or not documented, it was not done or was not given. She stated that if treatment is missed or not provided, this could lead to wound infection, worsening of the wound or delay wound healing. V36 said if nutritional supplements are not given, it could delay wound healing or worsen the wound. R1's EHR reviewed with V36 and V36 stated that R1 was transferred to the hospital on 1/27/24 due to purulent drainage on left AKA (above the knee amputation) and was admitted to hospital with possible a wound infection. At 4:49pm V39 (Wound Nurse Practitioner/NP) said that he was not familiar with R1 and R1 was not seen for wound evaluation. V39 stated that if there is a missed treatment or treatment is not done, it could potentially worsen the wound, delay wound healing or could lead to infection. V39 stated that nutritional supplements are very important for wound healing, help the body rejuvenate, repair damaged tissues and aid in healing process. On 2/15/24 at 10:52am V40 (Nurse Practitioner/NP) was interviewed via phone and stated that she is familiar with R1. V40 said if wound treatment was missed or treatment was not done it could potentially delay wound healing, worsening of the wound or could lead to infection. V40 said nutritional supplements could play a part together with wound healing. She said that if nutritional supplements are not given as ordered, it could potentially delay wound healing or worsen the wound. MDS (Minimum Data Set) dated 1/14/2024 showed R1's cognition was moderately impaired. R1 needed set-up/clean-up assistance with eating; Partial/moderate assistance with oral hygiene; Total assistance/Dependent with toileting and personal hygiene, shower/bathe self, lower body dressing, chair/bed transfer and Substantial/maximal assistance with upper body dressing. MDS showed R1 was always incontinent of bowel and bladder. R1 had 2 Stage III and 1 Unstageable pressure ulcers that were present upon admission. MDS also showed R1 had surgical wound. R1's POS (Physician Order Sheet) showed the following orders but not limited to: - Skin prep staples to LT (left) AKA LOTA (leave open to air) one time a day AND as needed Apply dry dressing if drainage present. - Readycare 1.7 two times a day for low bmi (Body Mass Index) for age 120 ml. - Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for Wound care. - Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for Wound care. - Critical Care Active Protein two times a day for Wound care give 30cc PO. R1's MAR (Medication Administration Record) for the month of January 2024 showed: - Critical Care Active Protein and Readycare 1.7 were not signed that it was given on 1/15/24 and 1/20/24. R1's TAR (Treatment Administration Record) for the month of January 2024 showed: Treatment to left AKA was not signed that it was done on 1/14/24 and 1/26/24. No wound or skin assessment found in R1's EHR upon admission on 1/8/24 and weekly thereafter on 1/15/24 and 1/22/24. Per V4, wound assessment should be done upon admission then weekly. No wound NP notes found in R1's EHR. R1's Braden scale assessment dated [DATE] Scored 14 (moderate risk). No Braden scale assessment on 1/15/24 and 1/22/24 found on R1's EHR. Per V4, Braden scale is done weekly x 4 weeks. R1's Care plan dated 1/10/24 documented in part: R1 has amputation of L AKA (left above the knee amputation). Care plan interventions included but not limited to: Monitor site for s/s infection. Dressing change per MD order. Skin/Wound Note dated 1/27/2024 documented in part: R1 was observed with a left AKA with sutures purulent drainage, no odor, resident stated he has no pain, wound was cleaned with nss pat dry, covered with dry dressing. R1's progress notes 1/28/2024 documented in part: R1 has been admitted with a diagnosis of possible wound infection. R1's hospital records dated 2/13/24 documented in part: - R1 admitted : 1/27/24 - R1 presented for stump wound drainage and erythema. - Diagnoses: Infection of amputation stump of left lower extremity, Surgical wound dehiscence of left amputation stump. - R1 had stump revision on left on 1/29/24 by ortho. Facility's wound policy and procedures dated 1/1/24 documented in part: - To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. - To promote healing of existing non pressure ulcer. - BRADEN scale should be completed for all residents upon admission/readmission for a total of four consecutive weeks, quarterly with each MDS assessment and when a significant change of condition occurs. - Upon identification of the development of a wound, the wound assessment will be documented. - Any skin impairments including surgical wound should be assessed and documented weekly by the wound nurse or designee. Documentation should cover all pertinent characteristics of existing pressure ulcers including location, size, depth, maceration, color of the ulcer and surrounding tissues and a description of any drainage, eschar, necrosis, odor, tunneling or undermining, if warranted. - A nutritional consultation should be completed for residents who are at risk for malnutrition. - Measurements are taken weekly.

Based on observation, interview and record review, the facility failed to provide individualized fall prevention interventions as indicated in a residents' care plan for a cognitively impaired resident who had repeated falls; and failed to properly assess the fall risk of a resident. These failures affected two residents (R11 and R16) of three residents reviewed for falls. As a result, R11 fell , sustained a left hip fracture, and was sent to the hospital. Findings include: 1. On 1/22/24 at 10am, V8 (Administrator) presented the facility's report of R11's fall dated 11/11/23, that was sent to the State Agency. This report states that R11 fell in the dining room while staff were passing trays and was sent to the hospital. R11's Hospital Records written by V30 (Trauma Center/emergency room Physician), dated 11/12/23 documents: (R11) was a trauma level 2 patient that was transferred status post fall from wheelchair at the nursing home. Patient found to have left hip fracture. Assessment and Plan states that R11 had left hip fracture status post mechanical at the nursing home and sustained left comminuted intertrochanteric fracture. On 1/22/24 at 12:34pm, R11 was observed in the dining room sitting in a recliner chair with the non-skid socks upside down on both feet. The smooth side was on the sole of the feet while the non-skid side was on top of the foot, for both right and left feet. V14(CNA) was asked if the socks were properly placed on R11's feet? The Surveyor asked about which side of the socks was supposed to touch the floor, and inquired if this fall prevention intervention was communicated to her(V14) and if she(V14) was aware of the reason for the non-skid socks? V14 then adjusted the socks on R11's feet. On 1/23/24 at 12:40PM, V18(Nurse Consultant) presented the facility's incident reports of R11's fall events dated as follows: 8/10/23 - R11 observed on the floor in the dining room. 10/27/23 - R11 fell to the buttocks while being transferred into the shower room in wheelchair. 11/11/23 - R11 fell in the dining room and was sent to the hospital by ambulance. On 1/22/24 at 11:30am, V27(Fall/Restorative Nurse/LPN/Licensed Practical Nurse) was interviewed about R11's fall prevention interventions. V27 stated that R11 is at high risk for falls. V27 added, We have interventions in the care plan. R11's records reviewed include but are not limited to the following: Face sheet shows that admission diagnoses include but are not limited to Dementia, Major Depressive Disorder, and Hypertension. Fall Risk Review forms dated 8/12/23 and 10/27/23 both show that R11 is at risk for falls. MDS (Minimum Data Set) section GG dated 11/16/23 shows that R11 requires moderate assistance for functional ability activities and transfers. MDS section C dated 11/21/23 shows BIMS (Basic Interview for Mental Status) score of 7 out of 15(severe cognitive impairment). Care plan Intervention dated 9/11/23 states in part: Ensure that R11 is wearing appropriate footwear (Specify and describe correct client footwear i.e., brown leather shoes, tartan bedroom slippers, black non-skid socks). R11's records show the following as dated below: On 8/10/23 at 8:00pm, V26(RN/Registered Nurse) documented in part: Resident found on floor in dining room, head to toe assessment done, neuro checks started, family made aware. For the fall event of 8/10/23, Nursing Assessment record titled Predisposing Factors dated 8/10/23 states that R11's wheelchair was not locked, and no staff witnessed the fall. On 10/27/23 at 9:20pm, V16(LPN) documented in part: Witnessed fall to buttock during transfer in w/c(wheelchair); Writer called in by CNA, head to toe observation performed. Noted red areas/scrapes to right lower side and back, no bleeding/drainage observed; area cleaned and skin protecting ointment applied. ROM (range of motion) observed as prior to fall without change. On 11/11/23 at 3:26pm, V16(LPN) documented in part: Fall in the dining area; resident observed seated on floor with left leg bent and yelling from pain. Resident assisted by 3 staff into wheelchair to nurses' station. Appropriate staff made aware; PCP (Primary Care Physician) made aware, ordered to send to ER (emergency room ) for evaluation; ambulance phoned for transport. On 11/14/23 at 10:51pm: V16(LPN) documented in part that R11 was readmitted from Hospital; Diagnosis of left intertrochanteric femur fracture. On 1/23/24 at 12:46pm, V16(LPN) was interviewed regarding how R11's falls happened on 2 out of the 3 incidents that V16 was the nurse. V16 stated that she(V16) was R11's nurse when the falls dated 10/27/23 and 11/11/23 happened. V16 explained that she does not remember if the fall of 8/10/23 was observed, but she(V16) was at the nursing station when the fall of 11/11/23 happened in the dining room, and she(V16) believes that there was staff in the dining room scheduled to monitor residents in the dining room. At this time, V16 showed the surveyor the dining room monitoring schedule for the day. On 1/23/23 at 4:39pm, V21(NP/Nurse Practitioner) was interviewed regarding R11's frequent falls and why the nursing staff should follow the care plan for fall prevention, especially for a resident like R11 whose third fall resulted in a fracture. V21 stated that staff should follow the fall care plan to help reduce falls and injuries, and the interventions stated in the care plan should be followed, so the resident will not hurt themselves. The surveyor asked V21 about R11's fall risk and the importance of proper Fall Risk Assessment, high risk or low risk? V21 stated that R11 is definitely a high risk for falls because of weakness and because of history of falls. R11's care plan dated 9/11/23 signed by V28(LPN) inaccurately stated that R11 is at Low Risk for falls, even though the fall report dated 8/10/23(a month earlier) written by V26(RN/Registered Nurse) stated that R11 is at high risk for falls due to impaired mobility requiring wheelchair use and due to impaired cognition. 2. On 1/22/23 at 12:39pm, another resident, R16, was observed in the wheelchair with a pair of regular white socks with smooth bottom. Inquired from V15(Activity Staff/CNA) if V15 was aware that R16's care plan states to wear proper footwear for safety and fall prevention. V15 stated The socks are smooth on the bottom; not non-skid socks. On 1/22/24 at 1:55pm, V18(Nurse Consultant) stated that she(V18) is standing in for the Director of Nursing. V18 presented records that show that R16 had a fall on 6/17/2020 and another fall on 7/18/2019. No details of these falls were provided because the electronic health records system had some changes, according to V18. On 1/23/24 at 11:32am in the third-floor dining room, R16 was observed in a wheelchair that was not locked. V29(CNA) was asked why the wheelchair was not locked since R16 is at risk for falls. V29 attempted to lock the wheelchair but was not successful. V29 stated This wheelchair is old, that's why it cannot lock. I will inform Restorative staff. On 1/23/24 at 1:45pm, V18 stated that the wheelchair should be locked to reduce the risk of falling. Regarding the non-skid socks, V18 stated that the reason for the non-skid socks is to prevent falls by providing better traction on a smooth floor. V18 added that the correct way to wear the socks is to have the bottom treaded part at the sole of the foot and not on top of the foot. R16's records reviewed show the following: Face sheet that list diagnoses which include but are not limited to Epilepsy, Schizophrenia, Glaucoma, and Bipolar Disorder. MDS section GG dated 11/21/23 shows that R16 requires moderate assistance for functional ability activities and transfers. MDS section C dated 8/29/23 shows BIMS score of 4 out of 15(severe cognitive impairment). Care plan Intervention dated 9/19/23 states that R16 should wear proper footwear for safety. Facility's Fall Prevention and Management Policy dated 6/1/23 states: Initial Assessment: a). All residents will undergo a comprehensive fall risk assessment upon admission. b). Assessments will include factors such as medical history, mobility, medications, cognitive status, and previous fall history. 2. Individualized Care Plans: a). Individualized fall prevention care plans will be developed based on the resident's risk assessment. The Fall prevention care plan will be communicated to all staff members involved in the resident's care.

Based on interviews and record reviews, the facility failed to ensure that the resident's environment remains free of accidental hazards for one resident (R6) who had 13 disposable shaving razors stored at bedside; failed to provide supervision and interventions for two residents (R10 and R13) with substance abuse; and failed to provide adequate supervision for a cognitively impaired resident (R3) and assess and diagnose the resident (R3) for a history of substance abuse which resulted in R3 overdosing on opiates in the facility. R3 was intubated and admitted to the hospital with a diagnosis that included but not limited to Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose and opiate abuse. These failures resulted in an Immediate Jeopardy. This was identified as an Immediate Jeopardy situation which began on 09/27/23 when R3 became unresponsive. On 10/11/23 at 3:05pm, V1 (Administrator) was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 10/16/23 based on an acceptable removal plan. The deficiency remains at the second level of harm until the effectiveness of the implementation of the removal plan is determined. Findings include: 1) R3's medical record indicate, R3 is a [AGE] year-old male resident that was admitted to the facility initially on 08/30/23 with diagnosis information list that includes but not limited to Schizophrenia unspecified, Major Depressive Disorder, recurrent, unspecified, Hyperlipidemia unspecified, Essential (Primary) Hypertension, Chronic Atrial Fibrillation unspecified, Chronic Obstructive Pulmonary Disease unspecified. R3's medical record Progress Note by V6 LPN (Licensed Practical Nurse) documented in part that on 09/27/23 at 10:15am upon rounding, R3 was found unresponsive. Rapid Response (referring to code call to all present staff in the facility) notified and R3 was transferred to the local hospital. R3's EMS (Emergency Medical Services) report documented in summary that on arrival to the location (facility) at 11:01am, EMS crew found [AGE] year-old male (R3) lying supine on the top of his bed. Initially patient (R3) was completely unresponsive. His eyes were pinpointed and not responding to the light. (R3's) skin was cold and diaphoretic. The respiratory rate was severely decreased and inadequate. According to the nurse, who called 911 that morning, patient was not taking any narcotic based medications because patient's current medical conditions do not require any strong painkillers. Patient (R3) was found unresponsive approximately 20 to 30 minutes earlier. The nurse stated that the patient is usually ambulatory at the scene (facility) and very active. ALS (Advance Life Services) Care was initiated at bed side including initial dose of Narcan 2 milligrams followed by EKG and vital signs monitoring supportive oxygen, and IV access. Patient removed from the scene and situated on ambulance stretcher in the treatment compartment of unit 76. The second dose of 2mg of Narcan was administered. Shortly later it was noticed that patient (R3) respiratory rate increased to about 24 and SPo2 reading increased from initial 66% on room air to 97%. At this point, patient was still completely unresponsive with GCS of three. On-route to (local hospital) ALS care continued. The third dose of 2 milligrams of Narcan IV was administered due to patient's altered mental status. Shortly after it was noticed that patient opened his eyes and started talking. Patient (R3) admitted snorting one line of heroin sometime earlier this morning. Patient stated he had been using heroin over the past [AGE] years. R3's hospital record showed documentation that R3 arrived at the hospital in altered mental status and that on 09/27/23 at 11:39am R3 was started on mechanical ventilation with high respiratory rate and will be admitted to ICU (Intensive Care Unit) for further management of hypercapnic respiratory failure likely secondary to opiate abuse. R3's hospital record also showed assessment documentation dated 09/27/23 timed 8:30pm that documented in part that R3's laboratory and radiology result showed R3 presented to the hospital with altered mental status, found to be hypercapnic respiratory failure requiring intubation, Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose, opiate abuse, healthcare acquired pneumonia, AKI likely prerenal, COPD, chronic atrial fibrillation, schizophrenia, depression, hypertension, history of substance abuse, with plan to continue mechanical ventilation and started on Zosyn (Antibiotics). On 10/02/23 at 12:16pm, V4 SSD (Social Services Director) stated in part that R3 went out to the hospital unresponsive. R3 did not have community pass, R3 is only able to go out with family due to his Brief Interview for Mental Health (BIMS) 04. That due to the BIMS score, R3 did not qualify for independent pass. V4 stated that R3 was not on the substance abuse list. R3's MDS (Minimum Data Set) assessment dated [DATE] scored R3's BIMS (Brief Interview for Mental Status) as 04 indicating that R3 is cognitively impaired. R3's medical record Order Summary Report and the MAR (Medication Administration Record) dated 09/01/23 to 09/30/23 showed no order for any narcotic medication. On 10/02/23 at 12:40pm, V8 CNA (Certified Nurse's Aide) stated that she (V8) is familiar with R3 and she was the CNA (Certified Nurse's Aide) assigned to care for R3 on 09/27/23. V8 stated that she made rounds when she got on the floor and R3 was alert. Then when breakfast came to the floor, I (V8) got (R3's) breakfast tray as R3 was in bed. V8 stated, I (V8) tapped R3 and told R3 that the breakfast tray is here. R3 turned around that morning. R3 did not eat much because normally R3 will eat everything in the tray. V8 stated after a while I (V8) came back to check on R3 and R3 said he was not that hungry. V8 stated, I (V8) took the tray and left. After I (V8) started my resident AM morning routine care, I went into the room and R3 was not responding, not moving and will not answer to name call. The nurse (V6) was passing medicine in the hallway, so I alerted (V6) and we called a Rapid Response (referring to all staff in the facility at the time where called/paged to the scene of incident). On 10/04/21 at 10:06am, ten (10) residents were noted smoking in the smoking patio with no staff monitoring or supervision. At 10:07am, this observation was brought to the attention of V49 (Activity Aide) who was standing inside away from the patio. At 10:08am, V49 stated, I'm supposed to sit out there (in the patio) while they were smoking. On 10/04/23 at 10:15am, R3 was noted in bed. R3 was not easily arousable and was with oxygen at 3 liters via nasal cannula. V6 (LPN) who was present when this observation was made stated that R3 returned during the night around 2:00am on 10/04/23 and was very sleepy now. V6 stated R3 had not received any medicine that morning because the medications had not arrived to us (referring to the facility). When the surveyor asked to see R3's medication orders, V6 could not produce any medication order for V6 in the computer. V6 stated, I (V6) don't know why there is no medication orders and will have to check from V46 (LPN) who admitted R3 back to the facility. At 10:17am, the surveyor asked whether R3 had gone out or received a visitor on the day of the incident (09/27/23). V6 stated that after making her rounds and before R3 was sent to the hospital, V6 saw R3 go downstairs with the elevator, but did not see R3 return to the floor because she was passing medicine. V6 stated she did not see any visitor visiting R3 and that R3 normally goes downstairs to smoke. Like I said before (referring to 10/02/23 interview), I did not give any medication to R3 that day and R3 was not on any narcotic medication. On 10/04/23 at 10:09am, Surveyor asked V52 RDO (Regional Director of Operations) about facility surveillance video footage. V52 stated, we (facility) used to have that but not anymore. It is an old system, and it is not functional. On 10/04/23 at 11:19am, V46 (LPN) stated that, I (V46) have only been here (Employed at the facility) two weeks. There are some (residents) on the second floor that are always drinking on the first floor. Some go out in the front of the facility and there is no staff monitoring outside. They can get whatever they want when it comes to weed or alcohol. V46 stated that in this type of nursing home (referring to the facility) and in this area it is not uncommon. It is normal to see these types of residents overdose on illicit drugs. I (V46) have helped at least two residents in caring for them (residents) from overdose. The surveyor asked V46 what they meant in caring for them. V46 stated giving them Narcan from them having overdosed on illicit drugs. When asked to identify the two residents, V46 stated she couldn't remember who they are (referring to the residents). We (Facility) have Narcan stored on the medication carts in case of overdose. On 10/04/23 at 12:49pm, V45 (Activity Director) stated in part that the activity aide opens the patio at 9am to 10am, 12pm to 1pm, 3pm to 4pm and the night shift (3pm to 11pm) CNAs (Certified Nurse's Aides) open the patio at 7pm to 8pm. The surveyor asked V45 how the resident is being monitored during the smoking time. V45 stated that there should be two activity aides one in the patio and one by the door to the patio. The activity aide is never to leave the residents out in the patio by themselves without visually monitoring what they (residents) are doing. They (activity aides) are to make sure the residents are all inside the facility after smoking time and lock the patio. V45 stated that if they (referring to the residents) are still outside in the patio there should be an aide out there with them. And if they are in sessions (psycho-social groups) and out in the patio there should be a social worker present out there (patio) with the resident. Both V48 and V49 (Activity Aides) are assigned to monitor the resident today during smoking time. On 10/04/23 at 2:58pm, V4 (Social Services Director) stated that the residents are all over the building and there is no way she (V4) would know where the residents are getting the drugs from. V4 stated, there is no reason to monitor any of the resident unless that resident is identified as a problem with substance abuse. On 10/11/23 at 8:53am, V2 DON (Director of Nurse's) stated in part that she (V2) has no idea how they (referring to residents) get the substance they abuse. V2 stated that they always deny the use (of illicit drugs). V2 stated there was no reason to suspect drug and substance abuse. V2 claimed it was never clarified. Despite that the hospital records reviewed by the surveyor do show substance abuse. V2 further stated that R3 was going to deny use of drugs any way. That the paramedics just assumed that R3 was on drugs, and they gave R3 Narcan and R3 did not respond to it. V2 stated that normally they will respond to Narcan. When asked what Narcan medication is, V2 stated that it is a medication used in adverse effect of opiates. V2 stated after the paramedics gave Narcan, R3 was still unresponsive, normally the resident will respond to Narcan with substance abuse. Upon request, the facility was unable to present any recorded documentation of a visual account of R3 trying to leave the facility with visitors or family. The facility was unable to present any individualized plan of care upon R3's return to the facility on [DATE] for substance abuse and diagnosis that will address the use of opiates as recorded in R3's hospital documentation to increase the level of supervision for R3. No plan of care centered on addressing R3 endangering health condition. No plan presented to address systemic approach to enable other residents that are cognitively impaired in ensuring safety throughout the facility environment. On 10/11/23 at 12:43pm V54 NP (Nurse Practitioner) stated, I (V54) saw (R3) when he was first admitted , and he had a diagnosis of schizophrenia. There was no diagnosis of substance abuse. V54 stated that she went through the admission papers from the hospital R3 was admitted from. R3's diagnosis were COPD, Congestive Heart failure ECHO 22%. V54 stated that she was told R3 went to the hospital on 09/27/23 and that he was assessed on 10/10/23 after returning to the facility from the hospital. V54 stated that she was told that R3 went to the hospital and was diagnosed with altered mental status secondary to opiate abuse, COPD, Respiratory problems. The surveyor asked V54 what in her professional opinion did that mean? V54 stated it means he altered himself mentally and he had respiratory failure, COPD, CHF, and he was diagnosed with opioids abuse. V54 stated opioid abuse meant R3 used and abused opioids. When asked what Narcan is used for, V54 stated Narcan is a reversal medication for heroin overdose. The surveyor asked V54 where in her professional opinion she thought R3 got the opioids from, V54 stated that R3 could possibly get the drugs from anyone, family member or friends. On 10/11/23 at 2:02pm, V1(Administrator) presented R3's updated face sheet documentation that showed a re-admission diagnosis of Unspecified Bacteria Pneumonia onset dated 10/03/23 with no diagnosis addressing the use of opioids. R3 plan of care presented did not show any plan of care for substance abuse, V1 stated this is just a suspicion. On 10/11/23 at 3:06pm, V53 (Regional Nurse Consultant) who was present when the IJ template was presented to V1 stated, I (V53) can agree with the supervision tag but for assessment and diagnosis there is no reason for that. V53 asked, Do you (referring to the surveyor) mean we (facility) should add the diagnosis of substance abuse? Surveyor indicated that it wasn't in her place to provide advice. On 10/17/23 at 10:31am, upon inquiry from the surveyor, both V1 (Administrator) and V2 (DON) stated that the camera system is down and does not work. On 10/17/23 at 11:13am, V40 (Laundry Aide) stated in part that residents are going about in the facility drunk and using drugs, and when these observations are brought to the administration, they just downplay it (referring to the concerns). On 10/17/23 at 2:34pm, interview with V54 (NP) regarding R3's diagnosis not including incident of opioids abuse, V54 stated, normally R3 should have the diagnosis that showed substance abuse and as it is now it has not been included. V54 then stated, but I don't do that (Referring to diagnosis list), the MDS people (referring to MDS Coordinator) will have to add the diagnosis. On 10/17/23 at 2:58pm, interview with V2 regarding supervision of resident going in and out of the facility, V2 stated that they (facility) were trying to switch from the old security company and were hiring security staff for the day shift. On 10/17/23 at 3:05pm, V1 stated, yes, we are hiring now for all shifts (referring to the security staffing). Surveyor observed residents outside in the front of the facility with no staff supervision on three days of the survey, 10/02/23, 10/03/23 and 10/04/23. The facility policy on Supervision and Safety dated 3/15 documented in part that the facility strives to make the environment as free from hazards as possible and resident safety and supervision are facility-wide priorities. Resident supervision is a core component to resident safety, staff are to increase safety factors as much as possible. Staff are to make visual rounds on residents minimally every two hours and more often, if necessary, based on resident's assessment needs. The facility Care Plan policy dated 1/23 documented in part that all residents will have comprehensive assessments and an individualized plan developed to assist them in achieving and maintaining their optimal status. Procedure listed includes but not limited to care plans reviewed and discussed individually, all concerns, problems, needs. The facility policy on Admission of Resident dated 1/23 documented in part that the purpose of the policy includes but not limited to gathering information as a basis for planning individualized therapeutic care and to ensure adherence to facility policies. Procedure includes but not limited to using information obtained, contact the physician (attending) ensuring that admission orders cover all aspects of required care and treatment. The 10/16/2023 approved Removal Plan is as follows: What action(s) were accomplished for the resident(s) identified as being affected by the jeopardy? 1. On 9/27/23 charge nurse/V6, transferred R3 to the ER for further evaluation and treatment of his change in condition. R3's NP/V54, and son were notified of change in condition and hospitalization . This was initiated and completed on 9/27/23. 2. Upon return from the hospital on 10/4/23, R3 was assessed by V4 Social Service Director for his risk for substance abuse upon return to the facility. This was initiated and completed on 10/4/23. 3. The facility's Certified Alcohol and Drug Counselor (CADC)/ V50, met with R3 on 10/4/23 to review the facility's substance abuse program including substance abuse recovery groups and the importance of reporting any urges or cravings to use illicit substances to staff. This was initiated and completed on 10/4/23. 4. R3's care plan was updated to reflect suspected episode of substance abuse with a goal that R3 will remain free from substances through the next review. Risk factors for substance abuse were reviewed by the interdisciplinary team including V2 Director of Nursing, V1 Administrator, V4 Social Service Director, V50 Certified Alcohol and Drug Counselor, and V53 Regional Nurse Consultant. The interdisciplinary team identified and implemented interventions to prevent R3 from using and overdosing on illegal drugs. The care plan was initiated and implemented on 10/4/23. 5. An in-person care plan meeting was held on 10/6/23 to discuss R3's change in condition, hospitalization , substance abuse concerns, and plan of care. R3, R3's son, and V2 Director of Nursing attended the care plan meeting. This was initiated and completed on 10/6/23. 6. On 10/12/23 a random room search was performed in R3's room with no findings. This was initiated and completed on 10/12/23 by V50 Certified Alcohol and Drug Counselor. What action(s) will be accomplished for the identified jeopardy? 7. A system to ensure all residents are closely monitored will be accomplished through staff education on the facility policy for safety and supervision. Staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and business office manager will be educated by the Administrator, on providing adequate supervision for cognitively impaired residents to prevent illegal drug use and/or overdose. This education includes ensuring a facility-oriented approach to safety to address risks for groups of residents including residents who are confused and residents with substance abuse disorders/history. Education will review the importance of identifying safety risks and environmental hazards on an ongoing basis. Staff will be educated that resident supervision is a core component of resident safety and that supervision is determined by the individual resident's needs. Staff must intervene immediately and notify the charge nurse whenever drug transactions or drug use between residents, staff, or visitors is noticed. Staff must decrease risk factors as much as possible and provide redirection when necessary. All staff must receive this education in person before working their next scheduled shift. This education will take place in the orientation process for new hires. Education began on 10/11/23 and will be completed on 10/12/23. 8. A system to ensure that residents with a history of substance abuse are properly assessed and diagnosed will be achieved through staff education with the social services department. Social workers will be educated by the Administrator, on the requirement of assessing and identifying diagnoses of substance abuse disorders upon admission to the facility. The presence of substance use disorders will be assessed through resident/family interviews and record reviews. Upon admission, the assessment will be documented through the completion of the Social History assessment in the resident's electronic health record. If a resident is identified as a substance abuser after initial admission to the facility, the assessment and documentation will be completed in the electronic health record on a Social Service Initial Interview for SMI/Substance Abuse Disorder Assessment. Upon identification of a substance abuse disorder, a care plan will be developed to provide interventions for staff to adequately supervise and provide care to reduce the risk of substance use and/or overdose. Social Services assesses residents to determine appropriate placement into programs offered at the facility with an on-staff Certified Alcohol and Drug Counselor and/or drug counselor groups from a local Hospital. All staff will receive this education in person before working their next scheduled shift. Staff will sign a record of education to verify that this education has been received. This education will be included in the orientation process for new hires. Education will begin on 10/11/23 and will be completed by 10/12/23. 9. A system to identify residents who may be engaged in illicit drug activity will be achieved through staff education regarding the signs and symptoms of substance abuse. V2 DON, will provide education to staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and business office manager. This education will include observing signs and symptoms of substance abuse including frequent leaves of absence from the facility, odors, needle marks, and changes in resident behavior such as drowsiness, slurred speech, lack of coordination, and mood changes, particularly after interaction with visitors or absence from the facility. Staff will be educated to report any signs or symptoms of substance abuse to the charge nurse. The charge nurse will complete an assessment and contact the physician. All staff will receive this education in person before working their next scheduled shift. Staff will sign a record of education to verify that this education has been received. This education will be included in the orientation process for new hires. Education will begin on 10/11/23 and will be completed by 10/12/23. 10. A system to ensure contraband is not brought into the facility will be achieved through staff education. Education will be provided by V1 Administrator, to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and business office manager. This education will review the facility contraband policy and include that upon reasonable suspicion that a resident is bringing drugs into the facility, the Administrator must be contacted to discuss a room search. If the Administrator is not available, the Director of Nursing must be contacted to discuss the appropriateness of a room search. Social services will perform the search immediately after the decision has been made that a search is required. If a social worker is not available to perform an immediate search, the search will be conducted by the charge nurse. Contraband will be removed from the resident's possession and provided to the Administrator for destruction. If the Administrator is not available, the contraband items can be provided to the Social Services Director. All staff will receive this education in person before working their next scheduled shift. Staff will sign a record of education to verify that this education has been received. This education will be included in the orientation process for new hires. Education will begin on 10/11/23 and will be completed by 10/12/23. 11. An ad hoc Resident Council meeting was held on 10/10/23 to discuss the facility policies regarding the management of substance abuse as well as the plan for staff education regarding facility policies and procedures for substance abuse management including: i. Providing adequate supervision for cognitively impaired residents, per the plan of care based on individualized needs. Adequate supervision includes visually monitoring whereabouts in the facility to prevent opiate overdoses. ii. Properly assessing and diagnosing residents for a history of substance abuse 1. Social Services completes an admission assessment to identify a history of substance abuse and residents engaged in illicit drug abuse activity. Assessments are updated when illicit drug activity is identified, or a previously unknown history of substance abuse or illicit drug abuse activity is identified. iii. Staff will identify residents who may be engaged in illicit drug activity through active monitoring for signs and symptoms of intoxication including frequent leaves of absence from the facility, odors, needle marks, and changes in resident behavior such as drowsiness, slurred speech, lack of coordination, and mood changes, particularly after interaction with visitors or absence from the facility. Staff will be educated to report any signs or symptoms of substance abuse to the charge nurse. The charge nurse will complete an assessment and contact the physician. Displaying signs and symptoms of substance abuse will cause suspicion for possession of contraband. Room searches will be conducted for individuals that are suspected of possessing contraband. The Chicago Police Department will be called to assist if contraband is suspected, and residents do not comply with search. Police will also be notified of any illegal drugs identified during room searches. iv. Social Services assesses residents to determine appropriate placement into programs offered at the facility including Certified Alcohol and Drug Counselor programs, provided by our on-staff Certified Alcohol and Drug Counselor and/or drug counselor groups from a local Hospital counselor. How the facility plans to monitor the system performance? 12. A QA Tool was developed to ensure residents with a history of substance abuse are properly assessed and identified. This will be completed by V1 Administrator five times a week for a minimum of four weeks. The audit will include follow-up resident/family interviews, ensuring the Social History assessment is accurate and documented in the resident's electronic health record, and review of pre-admission hospital documentation. This audit will be reviewed during monthly QAPI and will continue until the QAPI team has determined that the facility is in substantial compliance. The QA audits will begin on 10/12/23 with an expected completion date of 11/9/23. 13. A QA tool was developed to ensure residents who may be engaged in illicit drug activity are identified. This QA tool will be completed by V2 Director of Nursing five times a week for a minimum of four weeks. The QA tool will include staff interviews to ensure their understanding of how to monitor substance abuse and what process to follow if substance abuse is suspected. The QA tool will also include resident assessments to ensure no signs or symptoms of substance abuse are present. The QA tools will be reviewed during monthly QAPI and will continue until the QAPI team has determined that the facility is in substantial compliance. The QA audits will begin on 10/12/23 and are expected to be completed 11/9/23. 14. A QA tool was developed to ensure contraband is not brought into the facility. This QA tool will be completed by V1 Administrator five times weekly for a minimum of four weeks. The QA tool will review whether a suspicion for contraband has been identified, whether the Administrator was notified appropriately, whether Social Services or designee immediately initiated the search as appropriate, whether contraband items were identified, and whether staff appropriately handled the removal of contraband items. The results of the QA tools will be reviewed during the monthly QAPI and will continue until the QAPI team has determined that the facility is in substantial compliance. The QA audits will begin on 10/12/23 and are expected to be completed 11/9/23. 15. A QA tool has been developed to ensure all residents are closely monitored based on their level of need. The QA tool will be completed by V2 Director of Nursing five times weekly for a minimum of four weeks. The QA tool will review whether the required level of supervision for a resident is identified in the plan of care, and whether staff are providing the required level of care. The results of the QA tools will be reviewed during monthly QAPI and will continue until the QAPI team has determined that the facility is in substantial compliance. The QA audits will begin 10/12/23. 16. The QAPI process has been initiated to include competencies, education, and monitoring tools as specified. The QAPI process began on 10/12/23 and includes the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Wound Care Coordinator, Human Resource Director, Social Services Director, Dietary Manager, Housekeeping Director, Maintenance Director, MDS Coordinator. QAPI will be ongoing until the team has determined that the facility is in substantial compliance. On 10/17/23, the surveyor made observations, conducted interviews, and reviewed documentation to confirm the removal plan was initiated: - R3 returned to the facility on [DATE] at 12midnight. - V1 (Administrator), V2 DON (Director of Nurses) stated R3's care plan is not revised and there was no reason to assess and have a diagnosis to identify R3 for substance abuse because it was just a suspicion. - Abatement plan staff interviewed for in-service conducted with no concerns. The following staff were interviewed regarding the in-service. 1. V48 (Activity Aide) at 12:24PM 2. V4 (SSD) at 12:26pm 3. V5 (LPN) at 12:29pm 4. V59 (CNA) at 12:33pm 5. V60 (CNA) at 12:34pm 6. V50 (Duet manager) at 12:36pm 7. V13 (LPN) at 12:38 8. V61 (CNA) at 12:40pm 9. V62 (LPN) at 12:45pm 10. V64 (CNA) at 12: 47am 11. V65 (CNA) at 12:49pm 12. V16 (CNA) at 12:51pm 13. V66 (CNA) at 12:53pm 14. V58 (RN) at 12:47pm 15. V7(LPN) at 1:01pm - On 10/17/23 at 2:30pm, the facility did not have any new admissions that were presented. - On 11/02/23 at 5:01pm, V53 (Regional Nurse Consultant) provided a revised care plan for R3 which included an added diagnosis of Poisoning by heroin, Accidental (unintentional), Initial Encounter. This was after repeated discussions with both V1 and V53 of the missing diagnosis in the care plan for the substance abuse goals initiated for R3. Diagnosis which would alert staff to increase the supervision level in the facility in protecting R3. 2) On 10/02/23 at 11:05am, on the 3rd floor North wing, R6 was noted sitting in the wheelchair and on the side table multiple disposable shaving razors were noted on the bedside table and some in the shower basin on the side table. At 11:07am, when this was shown to V21 LPN (Licensed Practical Nurse), V21 stated that the residents are allowed to keep the disposable razors at bedside, but not in this amount. V21 counted them and stated they should be used with supervision. The surveyor then asked what the facility policy on hazards and supervision is, V21 stated that sharp objects should not be kept at the bedside because some other resident can walk into the room and pick them up and cut themselves. On 10/02/23 at 2:26pm V2 DON (Director of Nurse's) stated in part that no sharps including disposable razors should be kept at the resident bedside, and that they should be used with staff supervision. The facility policy on Supervision and Safety documented in part that the faci[TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to ensure one resident (R22) was free from severe physical abuse and emotional trauma caused by three staff members. This failure resulted in R22 sustaining a right black eye, scratches under the eye and a scratch on top of R22's head after being repeatedly punched by staff members. The staff failed to recognize abusive behavior towards R22. Staff continued to work in the facility; facility staff failed to assess and monitor R22 for injuries. This was identified as an immediate jeopardy which began on 10/12/23 when R22 was attacked by three facility staff members. On 10/19/23 at 2:06 PM the Administrator and Nurse Consultant were notified and presented with the immediate jeopardy template. The immediate jeopardy began on 10/12/23. The facility presented a removal plan on 10/20/23 at 10:16 AM that could not be accepted. The facility sent a revised plan on 10/20/23 at 3:00 PM. The facility's removal plan was accepted on 10/20/23 at 4:44 PM. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. Findings include: According to interviews with V1 (Administrator) and V55 (Laundry Aide), on 10/12/23 and 10/13/23, V21 (Licensed Practical Nurse), V56 (Licensed Practical Nurse), and V57 (Certified Nursing Assistant) physically attacked R22 by punching and hitting R22 multiple times while R22 was sitting in a wheelchair in the hallway. The attack was witnessed by V55 (Laundry Aide). Progress note dated 10/13/23, LATE ENTRY, created 10/16/23, reads in part: On 10/13/23 the Administrator received a report from housekeeping that the resident (R22) was involved in an incident where staff allegedly exhibited inappropriate behavior towards R22. On 10/13/23 at approximately 2:20pm, the writer observed bruising on R22's face. According to facility daily staff schedules and attendance/timecard documents, all three staff members involved, continued to work their shifts on 10/12/23 (day of the incident). V56 worked a second shift on that day. All three staff returned to work on 10/13/23 and worked on R22's floor/unit. On 10/13/23 surveyor observed and interviewed V21 and V56 while on R22's floor/unit. There was no documentation in R22's electronic medical record on 10/12/23 detailing an incident involving abuse, or that R22 was sent out to the hospital, that the physician, law enforcement, or family were notified. On 10/13/23 at 2:33 PM, R22 stated, I can walk a little but not that long. I can get in the wheelchair by myself. They took my wheelchair. The white girl at the desk took it. She took the chair to keep me from getting up and walking. I been in this bed two days. I don't know why she don't want me to walk. The white lady nurse poked me in the eye and back of my head with a writing pen. I don't know why, maybe I was getting smart with her. On 10/13/23 at 2:33 PM, surveyor observed R22's right eye was black with a scratch underneath. Observed scratches on the top of R22's head, right side. On 10/13/23 approximately 3:15 PM, R22 said she looked like you (surveyor), she poked me with a pen. V57 (Certified Nursing Assistant) told me not to talk to you. Facility Incident Investigation final report, 10/19/23, reads in part: Right eye ecchymosis and right forehead bump all consistent with strike from fall. The facility is unable to substantiate abuse as there is no credible evidence that abuse occurred related to several conflicting descriptions of the events occurring on October 12. Two resident Witness Statements included with the final report say they witnessed staff hit R22. R22 Order Listing Report/Physician Order Summary, printed 10/19/23, reads in part: Monitor discoloration to facial area, last order date 10/16/23. R22 Treatment Administration Record, 10/23, reads in part: Monitor discoloration to facial area one time a day, start date 10/17/2023. R22 Order Listing Report/Physician Order Summary, printed 10/19/23, reads in part: Send out for CT (Computed Tomography) scan, last order date 10/13/23; STAT facial bone x-ray, last order date 10/13/23. Hospital record, 10/13/23, physical exam of R22 reveals bilateral orbital ecchymosis. Diagnostic Imaging Report, 10/13/23, CT (Computed Tomography) scan of the brain without contrast, there is mild swelling and hematoma in the right frontal scalp. On 10/13/23 at 3:22 PM, V1 (Administrator) stated V55 (Laundry Aide) reported to V1 that V55 heard three staff members beat up R22. V1 reports that V55 said V55 was on the floor (3 North) and saw part of it, V55 told me V55 was passing out laundry, R22 was in the medication line and tried to jump in front of R26. R22 stuck R22's leg out to trip R26. V57 (Certified Nursing Assistant) intervened to move R26 out of the line. R22 was swinging at V57 and hit V57's ear. Nurses, V21 and V56, came over to assist V57 because R22 was swinging on V57. V55 said she observed the nurse(V56) hit R22. V55(Laundry Aide) said it happened yesterday (10/12/2023). V55 said she attempted to report it yesterday but said I wasn't here in my office. V1 stated, I was here all day yesterday. V55 said there were other residents in the hallway when it happened. I interviewed residents on the unit. They said they saw R22 swinging at V57. V1 said, Nobody said they witnessed the staff fight/hit R22. V55 was not working today (10/13/2023). V55 came in, off-duty, to report. V55 came in between 12:50 PM to 1:10 PM. V1 said, No other staff reported this. I sent the reportable today at approximately 3 PM. V56 was suspended today pending investigation. R22's 10/13/23 facesheet documents R22 is [AGE] years old. R22 has diagnoses not limited to dementia, mood disorder, difficulty in walking, unsteadiness on feet, bipolar disorder, osteoarthritis, seizures, major depressive disorder, Alzheimer's disease, acute systolic (congestive) heart failure, type 1 diabetes mellitus. MDS, 7/3/23, documents R22 has a BIMS (Brief Interview for Mental Status) of 06 suggesting R22 has severely impaired cognition, does not have hallucinations or delusions and R22 uses a wheelchair. R22's care plan initiated 4/26/22 documents in part: Dementia. The resident has impaired cognitive function/dementia or impaired thought process related to dementia; with an intervention to communicate with the resident/family/caregivers regarding residents' capabilities and needs; R22's care plan initiated 4/5/23 documents in part: Resident may be at risk for potential abuse related to behavior problem; with an intervention assure resident that they are in a safe and secure environment with caring professionals; R22's care plan initiated 4/5/23 documents in part: Resident may be at risk for potential abuse related to mental/emotional challenges; with intervention report any unusual behavior or incident to supervisor; R22's care plan initiated 2/25/21 documents in part: The resident is/has potential to demonstrate physically aggressive behaviors related to anger, poor impulse control; with intervention when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. On 10/17/23 at 10:30 AM, V1 (Administrator) stated V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse), and V57 (Certified Nursing Assistant) were suspended for the abuse investigation. V1 stated the facility cameras do not work. On 10/17/23 at 1:55 PM, V1 (Administrator) stated V1 is not sure if staff have CPI (Crisis Prevention & Intervention) training cards. All staff are trained on de-escalation. Residents are not supposed to be physically held down by staff. That would only happen if a physician gave an order for restraint. But we don't do that, we are a restraint free facility. If a resident is being held down that is a restraint, that is abuse. I am the Abuse Coordinator. If staff witness abuse, they are to report it to me. Staff are in-serviced on abuse at least quarterly. Abuse is a reportable incident it should be immediately reported to IDPH (Illinois Department of Public Health). We have two hours to submit a reportable. The three staff involved worked in the facility on 10/13/23 (the day after the abuse incident). I did not know about the incident on 10/12/23. I found out about the incident on 10/13/23. On 10/17/23 at 3:05 PM, V2 (Director of Nursing) stated I was not told on Thursday, 10/12/23, about an incident involving abuse. I was made aware on Friday, 10/13/23. In the morning meeting, I was told by V1 (Administrator) that V55 (Laundry Aide) told V1 they witnessed abuse from the nursing staff. The alleged nurses said residents were in line for medications. R22 attempted to kick a resident and V57 (Certified Nursing Assistant) tried to stop R22. All three staff, V21 (Licensed Practical Nurse), V57, and V56 (Licensed Practical Nurse) stated no one physically touched R22 outside of trying to grab R22's hand to stop R22 from hitting another resident. V57 said V57 grabbed R22's hand to stop R22 from hitting a resident. We do not restrain here. It can be abuse if they cannot release themselves from the restraint. We call a code if a patient is hurting self and others. We remove them to keep them safe. We usually use verbal redirection. R22 is verbally aggressive, threatening, has attempted to hit people. R22 is usually re-directable. Yes, staff get behavior management and de-escalation training/CPI (Crisis Prevention & Intervention) training. On 10/17/23 at 10:55 AM, V55 (Laundry Aide) stated I was on the floor, 3 North, on Thursday morning (10/12/23), maybe 10:30 AM to 11 AM. I know it was before 12 PM. I was delivering clothes. The residents were lined up for medication. I saw R22. R26 said Why you kick me. R22's leg is always extended out. There are no foot props on R22's wheelchair. R22 said I didn't kick you. V21 (Licensed Practical Nurse) asked who kicked you. V21 said I'm sick of R22. R22 got to go. V57 (Certified Nursing Assistant) moved R22 out of the line, moving toward R22's room. R22 was swinging back, saying Leave me alone. V57 took a pen out of V57's pocket and started stabbing R22 in the neck and head. V55 grabbed surveyors ink pen and demonstrated what V55 witnessed. V55 said and demonstrated that V57 clicked the pen to eject the ink cartridge as if to write and made stabbing motions. V55 said R22 was trying to block V57. V21 had R22's arm folded/pinned back. R22 was saying Let me go. V56 (Licensed Practical Nurse) started punching R22 in the face so hard. It was horrible. V55 stood up and demonstrated a fighting/boxing stance with both fists up. V55 said that is how V56 was fighting R22, like a boxer. Nobody came to stop it. They kept beating R22. They had no remorse that R22 was a helpless old man. V57 stabbed R22, had to be about 30 times. They did not investigate if the other resident was kicked. They don't like R22 for some reason. I don't know why. V57 said That's why your kids don't come see you, and don't answer the phone. V55 said Every time I close my eyes, I see this. I'm not sleeping, eating. I'm scared for R22. At the end, I told V21 to clean V21's face because there were some scratches. V57 said Aint (sic) sxxt wrong with me, I'm straight. R22 never touched V57 because V57 kept backing up. R22 was in the wheelchair the whole time. R22 has mobility issues. R22 can't get up right away. After, I saw V68 (Restorative Aide) and V69 (Restorative Aide). They told me to report what I saw. Later, I saw V68. V68 said she saw R22 and R22's head was bandaged, and eye was black and R22 was just lying in the bed. I told my coworker that they just beat R22 for no reason. My coworker told me to go tell the Administrator. The Administrator was not in the office. Just seeing that traumatized me. I couldn't work the rest of the day. What I witnessed was total abuse. I don't know who is the Abuse Coordinator. I don't see how this place is still open. I would never want nobody's parent to go through that. They always trying to cover up something. They did not try to talk to R22. V29 (Housekeeper) was on the floor at that time. I saw R25 on the floor at that time. Since I did not find the Administrator, I called my boss, V33 (Housekeeping Director), to report what I saw. I told V33 a resident was abused by two nurses and a CNA (Certified Nursing Assistant). I couldn't find the Administrator. I left that day around 1 PM to 1:30 PM. V55 said V55 has been at the facility since 2019. During the interview, V55 was observed crying/tearful and shaking. On 10/17/23 at 11:40 AM, V33 (Housekeeping Director) stated I was off that day (10/12/23). V55 (Laundry Aide) called me at home crying. V55 said V55 seen something V55 thought V55 would never experience. V55 saw two nurses and a CNA brutally attack a resident. One was bending R22's hand back, one was restraining R22 in the chair and hitting R22 in the face, one was poking R22 with a pen. V55 said V1 (Administrator) was not in the office. I reached out to V1 to tell V1 what I was told. I text V1 that my Laundry Aide witnessed abuse of a resident. V1 text me back that V1 knew of an incident that R22 fell out of the bed. I notified V38 (Human Resource Director) on that Friday morning (10/13/23) around 8:30 AM. When I told V1 the story on Friday, V2 (Director of Nursing) was in the office and V2 was saying I don't believe that. V2 was trying to brush it off. I have been in-serviced on abuse, drug abuse, and abatement plan. The Administrator is the Abuse Coordinator. I've heard staff talking to residents recklessly saying things like That's why your family don't visit you. I've heard V57 say that to a resident. I have not witnessed staff cussing at residents. On 10/17/23 at 11:55 AM, V38 (Human Resource Director) stated V33 (Housekeeping Director) said V33's staff member (V55) witnessed a resident being abused. We went to the morning meeting on Friday (10/13/23). I told V33 to tell V1 (Administrator). After V33 talked to V1, I saw V33 and V33 said they V1 and V2 (Director of Nursing) said the resident had a fall. Everybody has the abuse tag attached to their badge. I have not received reports of staff being under the influence of alcohol or drugs. On 10/17/23 at 1:30 PM, V29 (Housekeeper) stated I am the housekeeper for 3 North. Friday (10/13/23) I was in R22's room sweeping. A nurse came into the room to change R22's head bandage. The nurse said to R22, You got your ass whooped. R22's head was wrapped in gauze and R22's right eye was black. I asked R22 who beat R22 up. R22 said The CNA, nurse, she on the clock now. [All three staff members named in the incident were working 10/13/23 the day after the abuse incident.] R22 is not cooperative, R22 is verbally aggressive when R22 don't get R22's way. R22 is in a wheelchair. R22's left leg don't really work. The left leg gets under the chair and slows R22 down. Nurses get impatient and push R22 out the way. I've seen V21 (Licensed Practical Nurse) deny R22 to use the phone when R22 has asked. I didn't report because it happened already. I have been in-serviced on abuse. The Administrator is the Abuse Coordinator. We report abuse to the Administrator. I have witnessed staff cussing at residents, especially V57 (Certified Nursing Assistant). On 10/17/23 at 2:30 PM, V54 (Nurse Practitioner) stated it was reported that R22 had a fall on Thursday (10/12/23). They didn't see bruising or trauma on Thursday. Friday (10/13/23), according to staff, R22 had bruising on orbit around the eye, and I ordered to send R22 out. They thought bruising was from the fall. They notified me on Thursday of a fall but no notable trauma. Nothing to send out for on Thursday. They did not notify me of R22 being hit/abused. It is absolutely not okay for staff to hit a resident. R22 can be a little agitated at times, needs redirection. R22 was too aggressive on the dementia unit and was moved. R22 has cognitive impairment. Some dementia residents don't feel this is their normal and are aggressive. That is still no reason for staff to hit a resident. I don't condone for any resident to be hit, aggressive or not. Staff have not told me about behaviors from R22 lately that I would want to do urine testing. R22 uses a wheelchair, has an unsteady gait, is very tall. R22 can fall if R22 does not use the wheelchair. R22 is on blood thinners and can bruise easily. I noticed right orbit bruising. I did not order for head to be wrapped, there was no reason. R22 has one red area on top of the head, maybe a birthmark and has random scratches. R22 has low platelet count so bruises easier from any trauma, including being hit. On 10/19/23 at 8:06 AM, V68 (Restorative Aide) stated I was informed about a resident being hit by V55 (Laundry Aide). V55 told us (myself and V69) V55 saw a staff member hit a resident. I told V55 to talk to the Administrator who is the Abuse Coordinator and the Director of Nursing. On 10/19/23 at 8:10 AM, V69 (Restorative Aide) stated V55 (Laundry Aide) told me V55 saw a resident being hit by a staff member. V55 was distraught/emotional. V55 did not know what to do. We (I and V68) directed V55 to the Administration office. On 10/19/23 at 8:40 AM, V19 (Wound Care Coordinator) stated I've been here as the treatment nurse for over ten years. R22 had a body assessment done on Monday (10/16/23). Monday was the first time I saw R22. Monday the nurse on the floor notified me that R22 needs a body check. I noticed discoloration (redness), yellowing, bruising around both eyes, minor abrasions to neck (right side) and head had abrasions back of the head, right side. They were new, fresh. On 10/19/23 at 9:35 AM, V20 (Treatment Nurse) stated R22 doesn't have any wounds. I am familiar with R22 because I used to work the floor. R22 has no open wounds, no drainage. R22 has discoloration and yellowing of the right side of the face, eye and eyebrow area and forehead. On 10/19/23 at 10:02 AM, V4 (Social Service Director) stated I am familiar with R22. V1 (Administrator) told me on Friday about the abuse allegation. R22 has a diagnosis of confusion. R22 states R22 has been attacked but cannot say by who or when. If you ask R22 again R22 will say that R22 fell . On 10/19/23 at 10:21 AM, V33 (Housekeeping Director) stated I text V1 (Administrator) on 10/12/23 at 4:40 PM It was brought to my attention of abuse to a resident, R22 in room ###. R22 has a black eye. V1 replied on 10/12/23 at 5:06 PM Thank you for reporting R22 had a fall. On 10/19/23 at 12:27 PM, R25 said R22 hit the staff. Staff hit R22 back. I was trying to stay out of it and walked the other way. On 10/19/23 at 12:33 PM, R26 said R22 swung at me. V57 grabbed R22's wheelchair and pushed R22 toward R22's room. R22 swung back and hit V57. V56 and V21 grabbed R22's arms, one on each side. V57 was in front of R22. They pulled R22 into R22's room, that's the last I saw. On 10/20/23 at 9:34 AM, V21 (Licensed Practical Nurse) stated V21 was in the process of setting up the medication cart. I heard a commotion in the hallway. As I was coming out of the nourishment room, R22 was kicking and flailing trying to hit staff [V57 (Certified Nursing Assistant) and V56 (Licensed Practical Nurse)]. I don't know why R22 was trying to hit them. I was told later, R22 had an altercation with another resident, R26, and they were trying to separate them. This happened in the hallway. There were other residents present. I tried to help get R22 to R22's room. The three of us (myself, V56 and V57) took R22 to R22's room. R22 was still flailing at us. R22 was in a high-back wheelchair at the time. R22 can take a few steps on R22's own, from what I've seen. I've seen R22 stand and get into R22's wheelchair or into the bed on R22's own. I walked out after getting R22 into the room. I went to the bathroom to gain my composure and wash my face. I don't know when the other two staff left R22's room. R22 is a psych patient and getting them into their own rooms is sometimes calming to the resident. R22 is very strong. I was trying to hold R22's left arm. I grabbed R22's left arm so R22 couldn't hit me. Because it was going so fast, I did not see the other two staff hold R22 anywhere. I'm not sure of all R22's diagnoses but I would not be surprised if R22 has dementia. R22 definitely is psych but I don't know 100% if R22 is a dementia patient. I did not hit R22, and I didn't witness the other two staff hit R22. I didn't see anyone punch R22 or stab R22 with an ink pen. I looked at R22 as I walked out of the room. I did not see any injuries on R22. R22 was not my resident. For the rest of the shift when I passed R22's room I did not notice anything out of the ordinary, but I did not go into the room. This happened on Thursday (10/12/23). I worked the next day, Friday (10/13/23), on R22's floor. R22 was not my resident. I can't recall seeing R22 on Friday. On Friday, you (surveyor) asked if I knew of an incident of staff being abusive to a resident and I said no. The Abuse Coordinator is the Administrator. Types of abuse are verbal, physical, sexual, financial, emotional. I don't remember the last in-service on abuse. I do remember that if I witness abuse, I report it to the Administrator. On 10/20/23 at 10:11 AM, V56 (Licensed Practical Nurse) stated I was doing my medication pass. I heard loud voices, a verbal altercation. I saw R22 kicking and swinging at R26 and at V57 (Certified Nursing Assistant). I do not know why. I can't say if V57 tried to hold R22 down or if V57 hit R22. I was at my cart. I don't know what was going on over there. My cart was on the other side of the nursing station. They were away from me near the other side of the nursing station. I was on one side of the nursing station, and they were on the other. R22 can become aggressive and upset as R22's normal behavior. R22 was in R22's wheelchair. R26 was standing. R22 can walk slowly, unsteady, but majority R22 uses the wheelchair. I went over to assist in stopping R22 from harming self or others. I don't know if anyone was hit. I was pushing R22's chair forward to R22's room. Usually, when you get R22 away from what made R22 act out and into R22's room, R22 calms down. I don't recall if we pushed R22 into the room or just to the threshold of room and I left. From what I remember, myself and V21 (Licensed Practical Nurse) pushed R22 into R22's room. From what I remember, V57 did not help to wheel R22 into the room. I don't know where V57 was. I don't know if R22 was hit in the process. From the time the incident started to the time it ended, I didn't see any staff hit R22, punch R22 or stab R22 with an ink pen. I did not see any injuries on R22. I was not holding any extremity. I don't recall if V21 was holding an extremity. The Abuse Coordinator is the Administrator. If I witness or am involved in abuse, I am supposed to report it to the Administrator. I can't say when I was in-serviced on abuse. Types of abuse are isolation, if a resident doesn't feel safe, lack of care, resident struck by another resident or staff, verbal. On Friday, you (surveyor) asked if R22 reported anything to me and I told you no. On 10/20/23 at 10:47 AM, V70 (Certified Nursing Assistant) stated when I arrived at work on 10/12/23, Thursday, at 8 AM, I did rounds. I saw red marks on R22's face. I went to the nurse. V56 (Licensed Practical Nurse), and V57 (Certified Nursing Assistant) said R22 had a fall overnight. When I asked R22 about R22's face, R22 said I'm cool, I'm fine. R22 was my resident that day. On 10/20/23 at 4:26 PM, V68 (Restorative Aide) stated I saw R22 about an hour to two hours after I talked to V55 (Laundry Aide). I did not go all the way into R22's room. R22's head was wrapped up with a white gauze bandage. R22 was laying in the bed with back to me. I did not see R22's face. I asked R22 what was going on/what was wrong? R22 said R22 wasn't feeling good. On 10/20/23 at 4:52 PM, V57 (Certified Nursing Assistant) stated we [me, V21 (Licensed Practical Nurse) and V56 (Licensed Practical Nurse)] heard a verbal altercation in the hallway. Went to see what was going on. R22 was swinging at R26. We intervened to hold R22's hand to stop R22 from swinging and to hold R22. We were telling R22 to stop swinging. R22 was swinging at us too. We sent both R26 and R22 to their rooms to separate them. We were blocking R22's swinging/hits. We did not hold R22 down. I did not punch or hit R22. I did not stab R22 with any object. I didn't see nobody hit R22. I didn't see anything happen after they went to their rooms. R22 was not my resident that day. The Administrator is the Abuse Coordinator. I don't recall the last in-service on abuse, but I know about abuse. Physical, mental, financial are types of abuse. If I witness abuse, then I'm supposed to report immediately to the Abuse Coordinator, the Administrator. No, I do not cuss at the residents. No, I do not use foul language at the residents. R22 was in the wheelchair. R22 could roll self to the room. R22 went to the room on R22's own. Facility daily staff schedule dated 10/12/23, 7 AM-3 PM, indicates V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse) and V57 (Certified Nursing Assistant) were scheduled to work on 3 North. Facility daily staff schedule dated 10/12/23, 3 PM-11 PM, indicates V56 (Licensed Practical Nurse), was scheduled to work on 3 North. Facility daily staff schedule dated 10/13/23, 7 AM-3 PM, indicates V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse) and V57 (Certified Nursing Assistant) were scheduled to work on 3 North. Attendance/Timecard document, printed 10/17/23, indicates that on 10/12/23, V56 (Licensed Practical Nurse) was clocked in for 15:00 hours, V21 (Licensed Practical Nurse) was clocked in for 9 hours, V57 (Certified Nursing Assistant) was clocked in for 7:30 hours. Attendance/Timecard document, printed 10/17/23, indicates that on 10/13/23, V56 (Licensed Practical Nurse) was clocked in for 7:30 hours, V21 (Licensed Practical Nurse) was clocked in for 7:45 hours, V57 (Certified Nursing Assistant) was clocked in for 6:15 hours. Corrective Action Notices, dated 10/13/23, indicate V56 (Licensed Practical Nurse), V21 (Licensed Practical Nurse) and V57 (Certified Nursing Assistant) were suspended pending investigation for alleged abuse toward a resident. Facility Incident Investigation initial report, 10/13/23 (one day after the incident), alleges resident abuse. Chicago Police Department report documents date of occurrence as 10/12/23. On 10/13/23 at approximately 5 PM, surveyor observed two police officers enter the facility. Surveyor asked V1 (Administrator) if the police officers were there for the incident surveyor was investigating and V1 said yes. Facility Abuse Prevention Program Facility Policy and Procedure, 1/4/18, documents in part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. During orientation of new employees, the facility will cover at least the following topics: what constitutes abuse, neglect, exploitation, mistreatment and misappropriation of resident property; staff obligations to prevent and report abuse, neglect, exploitation, mistreatment and misappropriation of resident property; dementia knowledge, awareness, management and prevention of abuse/mistreatment; how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff; how to recognize and deal with burnout, frustration, and stress that may lead to inappropriate responses or abusive reaction to residents; an employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement; the time frames for reporting; and managements obligation to prohibit retaliation against anyone who makes a report. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. Reports should be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the administrator or the person designated to act on behalf of the administrator in the administrator's absence. If the resident complains of physical injuries or if resident harm is suspected, the resident's physician will be contacted for further instructions. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator. Incidents or allegations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be reviewed by administration and shall be investigated as indicated and appropriate. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. This report shall be made immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The facility shall also contact local law enforcement authorities in the following situations: Suspected physical abuse involving physical injury inflicted on a resident by a staff member or a visitor. Facility Behavior Management for Agitated Behavior, 4/14, documents in part: Allow time to calm down with 1:1 explanation of why behavior is inappropriate and unacceptable in a calm, soft voice. Document all interventions attempted and administered and the resident's response to medical interventions. According to the Facility Assessment, 5/16/2023, the facility offers mental health and behavior care. Manages the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. Abatem [TRUNCATED]

Based on interview and records review, the facility failed to provide adequate and sufficient care for one resident (R1) of 3 reviewed for two person-assist for bed mobility. This failure resulted in R1 falling out of bed and sustaining a subdural hematoma. Findings include: R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic Myeloid Leukemia, BCR/ABL-Positive, Not Having Achieved Remission, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Site, Other Specified Symptoms and Signs Involving the Digestive System And Abdomen, Pain in the Right Knee. Facility Incident Investigation Report (dated 08/23/2023) regarding R1 documents in part: Resident has impaired mobility and cognition requiring total staff assistance with mobility and transfers. Resident is able to move in bed but requires staff assistance for safety. MD notified of fall and injury with orders to send resident to the hospital for further evaluation. Resident was admitted to the hospital with a diagnosis of Subdural Hemorrhage. Minimum Data Set Section G (MDS) (dated 05/31/2023) scored R1 as (3) requiring 2-to-3-person physical assistance for bed mobility. MDS section C (dated 05/15/2023) scores R1 as having a BIMS score of 4, indicating that R1's cognition is impaired. R1's Fall Care plan (dated 01/17/2023) documents that R1 is at risk for falls r/t poor safety awareness, poor balance, unsteady gait. R1's fall care plan documents that R1 exhibits impaired bed mobility r/t CVA and R1 is not able to position/ reposition self when in bed or sitting. Fall Risk Assessment (dated 05/26/2023) prior to fall incident on 08/20/2023 scored R1 as (14) a moderate risk for falls. Fall Prevention Program (dated 02/28/2014) states: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. On 08/29/2023 at 12:38pm V4 CNA (Certified Nursing Assistant) stated, On 08/20/2023 I was going to change R1, and all her care items were gathered at her bedside table. R1 was in the bed with R1's top half of her body centered in bed, and R1's legs were more near the edge. I was on R1's left side of the bed. I turned to grab the items that were needed to provide the care for the resident. I had to step away to be able to reach them, and that's when R1 fell out of the bed. R1 requires a two-person assistance for ADL care, and at the time R1 fell , I did not have any other staff member in the room with me. I did not reposition R1 before I stepped away to grab the care items. That day, there were several CNAs scheduled to work on that unit, however, there were multiple call offs. I was the only CNA who was working the 3-south unit and there was not enough staff to help me. For the 3rd floor/3 south unit, there should have been 4 certified nursing assistants, but it was only me and the restorative aide. R1 requires the assistance of 2 staff members, and we were short that day, so I had to change R1 by myself. R1 requires 2 CNAs because R1 moves a lot and it is unsafe, but I was the only on the floor, so I had to change the resident by myself. On 08/29/2023 at 1:01pm V3 RN (Registered Nurse) stated, On 08/20/203, the last time I saw R1 was when I administered R1 her morning medications. The CNA on duty came to inform me that R1 fell . I was at the nurse's station when V4 came to inform me of the fall. We were working short that day because we had multiple call offs from CNAs who were scheduled to work on the 3-south unit. V4 and a restorative aide were the only ones who were working on the unit, so it was really hard for the two of them to care for all these residents. V4 was the only CNA at the bedside doing R1's care because there was no other CNA to assist V4 with changing R1. R1 requires the assistance of 2 CNAs for ADL care. R1 slid out of the bed and after the fall, I saw that R1 had a knot on her forehead. I notified R1's physician and family and I sent the resident out to the hospital, after initiating neuro-checks. R1 sustained a subdural hematoma from the fall. On 08/30/2023 at 11:37am, V5 (Staffing Coordinator) stated, On 08/20/2023, for the unit of 3 south, there were 5 certified nursing assistants scheduled and we had 4 call offs. On that shift there was only a total of 1 CNA working the 3-south unit during the 7am-3pm shift. A restorative aide was pulled to work the 3-south unit. We are not utilizing a staffing agency. The new company that owns the building does not want to utilize a staffing agency. Sometimes a staffing agency is needed during times where there are a lot of call offs. The facility is attempting to hire more staff, both nurses and CNAs. On 08/30/2023 at 12:10pm, V7 (Restorative Director) stated, R1 does not walk. R1 is chair bound and requires total staff assistance of 2 people for transfers. R1 requires a 2 person assist for bed mobility. R1 requires the assistance of 2 CNAs when being changed. On 08/31/2023 at 9:54am V2 (Director of Nursing) stated, The facility has an issue with employee call offs. There are a lot of call offs. The staffing coordinator will have the schedule filled appropriately and all of a sudden, we will have many call offs. The facility does not use a staffing agency because the corporate office decided not to use the agency. We do a good job covering the shifts by offering bonuses and the corporate office feels like a staffing agency is not needed. On 09/05/2023 at 2:33pm V15 (Nurse Practitioner) stated, I am aware that R1 had a fall on 08/20/2023. R1's fall could have been avoided. R1 moves and scoots all over in bed. I know the resident really well. R1 has leukemia. R1 scoots all over the bed and R1 does not walk. If there were 2 staff members the fall could have been avoided potentially because when R1 is changed, she definitely needs the assistance of two CNAs. R1 shifts her weight a lot. It is not safe for one CNA to provide ADL care. R1 is not appropriate for one staff member for ADL care and changing the resident. One CNA can wash the resident's face or provide assistance with feeding the resident, however, when R1 is being changed, the resident requires the assistance of 2 CNAs. R1's Progress Note (dated 08/20/2023) documents, Nurse alerted to residents' room, resident laying on her back on floor. CNA stated, Resident rolled from bed during ADL care, head to toe observation done and resident alert per usual mental status, large hematoma to left side of forehead with no bleeding, cold compress applied, pain level evaluated, denies pain and discomfort, ROM preformed, resident able to move all extremities, resident sent to ER. Family and MD made aware. Progress Note (dated 08/20/2023) documents, Call placed to ER to get updated status on resident, was made aware that resident was transferred to Community ER. Call placed to Community ER x3 to get updated status; each attempt was unsuccessful, due to no one answering the ER phone. Endorsed to oncoming nurse to follow up with status. Progress Note (dated 08/20/2023) documents, Report from Community ER stated that the Resident has been admitted after evaluation. DX subdural hematoma. Review of the schedule 3 south 7am-3pm (dated 08/20/2023) indicated that there was only one certified nursing assistant working and one restorative aide.

Based on interviews and record reviews, the facility failed to protect 2 (R2 and R10) of 3 residents reviewed for abuse in a total sample of 13. These failures resulted in R2 sustaining an injury to the back of the head and R10 being verbally abused. Findings include: 1.) On 10/12/2022 at 12:42 PM, R2 stated, I confronted R1 in the dining room on the 3rd floor about stealing my pants, and I told him to give them back. R1 got in my face, and he grabbed me, then pushed, me. I fell and hit the back of my head on a table. My head was hurting really bad, and I was bleeding from the back of my head. When I got up, R1 pushed me again. The nurse cleaned the blood off my head. The ambulance came took me to the hospital. They put stitches in the back of my head at the hospital and they sent me back to the facility. On 10/12/2022 at 11:00 AM, V21 (Licensed Practical Nurse) stated, I saw R2 getting up off the floor in the dining area. I saw R1 push R2 after he got up off the floor. R2 did have cut on the back of his head, and it was bleeding. I told the doctor about the incident, and I was instructed to send R2 to the hospital to get evaluated. R1 is known to be verbally abusive and aggressive. On 10/11/2022 at 01:20 PM, V4 (Certified Nursing Assistant) stated, I saw the incident between R1 and R2. I saw R1 push R2. R2 fell back and hit his head on one of the tables. When R2 got up, he had a gash on the back of his head that was bleeding. R1 can be verbally aggressive with other residents and staff. On 10/11/2022 at 1:11 PM, V3 (Certified Nursing Assistant) stated, I saw the end of the incident with R1 and R2. R1 was about to hit R2, and I told R1 to stop. R2 had an injury to the back of his head. I did see blood coming from the back of R2's head. R1 was sent to be assessed by his nurse. R1 is usually angry, and he can be verbally aggressive to staff and residents. On 10/13/2022 at 02:03 PM, V1 (Administrator) stated, I completed the abuse investigation for R1 and R2. R1 said he grabbed R2 and when he let R2 go, R2 fell backwards and hit his head. I did substantiate the abuse because R2 did fall, and he had an injury to his head. R2 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's emergency room records dated 08/21/2022 were reviewed. Records read: Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound repaired with: Sutures. Number of Sutures: 2. R1 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's behavior incident report dated 08/21/2022 was reviewed. Report reads: Nursing Description: Per staff resident observed grabbing his peer to remove him from a chair he was sitting in previously. Resident Description: Resident stated his peer accused him of taking clothes from him and attempted to punch him. Resident stated, I grabbed hm and when I let go, he fell and hit his head on table. Abuse investigation for R1 and R2, dated 08/21/2022, reads: On 08/21/22, R1 and R2 were involved in a physical altercation in the dining room .R1 grabbed R2, and when he let him go; R2 lost his balance and fell . R2 fell and hit his head on the table. R2 had a small amount of blood coming from the back of his head .the allegation can be substantiated because the staff and other residents witnessed the incident and R2 sustained and injury. 2.) On 10/11/2022 at 12:42 PM, R10 stated, V17 (PCT/[CONDITION(S)] Tech) was verbally abusive to me during my [CONDITION(S)] sessions. V17's verbal abuse was getting to be too much, so I filed a grievance against her in August of this year. When V17 would do my [CONDITION(S)], she would yell at me, and she would tell me to stop looking at her while she was hooking me up to the [CONDITION(S)] machine. During one of my [CONDITION(S)] sessions in August, V17 snatched on my [CONDITION(S)] cord, and I told her to stop. V17 yelled at me and told me to shut up and stop talking. I did not feel safe receiving [CONDITION(S)] from V17. V17 would talk about my clothes and call me a rich lady all the time. I told her to stop saying that because I didn't like it, and she wouldn't stop. After I filed the grievance against V17 she told me I always go and tell the boss on people. V17 came to my room and told me she has someone that would hurt me and my son if I got her fired. On 10/12/2022 at 12:32 PM, R13 stated, V17 did yell a lot but I ignored her. On 10/12/2022 at 10:08 AM, V16 (Regional Nurse Consultant) stated, I interviewed R10 about the verbal abuse incidents that happened with her and V17 in August. After the investigation was completed, it was determined that R10 was verbally abused by V17. We used R10's statements to determine that verbal abuse did happen between her and V17. V17 was terminated from the [CONDITION(S)] center after the investigation was completed because verbal abuse was substantiated. The investigation showed that V17 was very condescending towards R10, and she made inappropriate comments to R10. I found out that V17 went to R10's room and confronted R10 about reporting her for abuse. R10 stated that V17 threatened her with physical abuse when she came to her room. During my interview with R10, R10 did report that V17 forcibly pulled on R10's HD catheter during one of her [CONDITION(S)] sessions. R10 said that V17 told her that she makes everyone in the [CONDITION(S)] unit feel bad because R10 comes to [CONDITION(S)] all dressed up. R10 said V17 kept calling her a rich lady. R10 also reported that V17 would tell her to shut up when she tried to defend herself. On 10/12/2022 at 10:22 AM, V18 (PCT/[CONDITION(S)] Tech) stated, V17 has had complaints against her from other residents for being verbally aggressive. I have heard V17 being verbally aggressive to the [CONDITION(S)] residents. I did hear V17 talk about R10. V17 did talk about R10's clothes and she did call her a rich lady. On 10/12/2022 at 10:35 AM, V19 ([CONDITION(S)] RN) stated, V17 is known to speak roughly to the residents, and she can be rough when she is setting up her [CONDITION(S)] equipment. On 10/13/2022 at 02:03 PM, V1 (Administrator) stated, I did submit an investigation for R10's abuse investigation. The [CONDITION(S)] center substantiated verbal abuse and I substantiated abuse for R10's investigation. R10 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R10 is cognitively intact, according to R10's most recent minimum data set. Abuse investigation for R10, dated 08/17/2022 reads: The allegation is substantiated because, R10 and other residents stated that V17 has a history of fussing and raising her voice at the residents, which is inappropriate and verbal abuse. Per V16, V17 has been permanently removed from her position. V17's termination letter was reviewed. Termination letter reads: This letter is to inform you that your employment is being terminated effective immediately. Your termination is the result of a comprehensive investigation, which included a multitude of interviews with various patients and staff members, which ultimately concluded that you committed multiple instances of unprofessional conduct, violations of patient care policies, and violations of Employee Handbook requirements. Combined with a previous record of unprofessional conduct, we regret that the [CONDITION(S)] center is left with no choice but to terminate your employment. Facility abuse policy reads: This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Verbal abuse is the use by a licensee, employee or agent of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident.

Based on interview and record review, the facility failed to monitor, assess, and provide drug addiction services to a known drug addict. This failure resulted in a resident obtaining heroin while still a resident in the facility and overdosing twice. The second heroin overdose led to severe diffuse [CONDITION(S)] injury with elevated intracranial pressure. R1 expired in a local medical hospital after the second heroin overdose. This failure affects one of three residents (R1) reviewed for drug supervision in a total sample of five residents. Findings include: R1 was a [AGE] year-old male. R1 ' s diagnoses are but not limited to right side of the body paralysis, diabetes, high blood pressure, heart failure, [CONDITION(S)], [CONDITION(S)], psychoactive substance abuse, [CONDITION(S)], [CONDITION(S)], depression and auditory hallucinations. R1 was admitted to the facility on [DATE]. R1 ' s BIMS (Brief Interview for Mental Status) dated [DATE], notes that R1 was alert. R1's MDS (Minimum Data Set) dated [DATE], notes R1 uses a wheelchair to ambulate. Progress note dated [DATE], notes R1 is a new admit to the facility with past medical history of substance abuse, major depression and [CONDITION(S)]. Progress note dated [DATE], notes writer was currently at nursing station receiving report by previous shift nurse. R1 was observed in dining room while being supervised by nursing staff. R1 appeared to be diaphoretic (sweaty), nonverbal, and pupils noted fixed and slow to response. R1 fell out of wheelchair and hit R1 ' s head. R1 ' s vitals were taken. R1 was then assisted by nursing staff. R1 received [MEDICATION(S)] (used to treat narcotic overdose), administered to right nasal. R1 was given oxygen. 911 was dialed and R1 was sent out to local hospital to perform brain scan for further evaluation. R1 was not admitted to the local hospital. R1 returned to facility in stable condition. R1 was discharged and was diagnosed for opioid abuse. R1 admitted to heroin use. Staff will continue to follow up. Progress note dated [DATE], notes writer called to R1 ' s room and observed R1 sitting in wheelchair. Writer called R1 ' s name, but R1 unresponsive. R1 transferred to bed; CPR (cardiopulmonary resuscitation) initiated at this time. 911 phoned and as needed [MEDICATION(S)] administered three times. CPR continued. AED (automated external defibrillator) applied. Intravenous fluids provided and CPR continued. Writer phoned local hospital and was informed R1 ' s admitting diagnosis is [CONDITION(S)]. On [DATE], at 12:12PM, V1 (Administrator) stated, I do not know if R1 overdosed. What staff told me is that they had to call a code on R1. 911 came. The staff did use [MEDICATION(S)] on R1 because R1 has a history of substance abuse. This is hearsay. I was told by V5 that they did not find any drug paraphernalia in R1 ' s room or on R1. 911 came and staff were still working on R1. 911 took R1 out of the facility. I got a call from the (DON) Director of Nursing. The sister stated it was drugs. From what I know, R1 has never presented as someone that uses drugs in the facility. On [DATE], at 12:26PM, V2 (Director of Nursing) stated, I know it was a code because I went to the code. V7 (R1 ' s Family Member) left a message for me to give V7 a call. Once I spoke to V7, V7 stated R1 is supposed to have 24 hours of supervision. How was R1 getting high in the building? There was no indication that R1 was using drugs. R1 was not on the duet (drug) unit. R1 was on the second floor. R1 had none of those indications. The hospital suspected drug use. Staff is not suspicious of R1 or any drugs. Residents that have addictions get a behavior contract and are monitored. Usually if they code with drugs, staff will find something, and nothing was found. I told V7 I would call V7 back on Tuesday. Staff was crying and did not know what happened. V6 was assigned to R1 and was baffled. R1 stays on the patio frequently. I have never seen R1 present as under the influence of drugs. On [DATE], at 1:41PM, R4 stated, It happens every other week because someone is in the lobby. I don't know how they get it in here. They take drugs and come back in the facility and do it in the lobby. On [DATE], at 2:36PM, V3 (Social Services Director) stated, If a resident has a history of substance abuse, the resident is put on a behavior contract and goes to CACD (Certified Alcohol and Drug Counseling). I am not aware of R1 having a history of drug use at any time. If it is brought to our knowledge, then staff would do the follow up. Nursing will bring it up in morning meeting. If a resident admitted to using drugs in the facility, staff will sign them up, offer help, and tell them to go to the meetings. I was not aware of R1 using any drugs in the facility. On [DATE], at 2:45PM, V4 (Licensed Practical Nurse) stated, I came in making my rounds. Nursing staff told me R1 was unresponsive around dinner time. I put R1 in R1 ' s room. I laid R1 down and gave R1 [MEDICATION(S)] and oxygen. R1 woke up and was alert and oriented. R1 admitted R1 took heroin up R1 ' s nose. I asked R1 if it was for pain. R1 stated R1 did not know why R1 does it, R1 just does it. R1 stated R1 got it from outside of the building. I did not see any drug paraphernalia. I was working with R1 a lot. I let V8 (Registered Nurse) know about this incident and the interventions I did. I think R1 should have gone to the floor where people had drug problems. On [DATE], at 3:00PM, V7 stated, The doctor told me that R1 had an overdose. The ambulance stated they found the drugs on R1 ' s body. The Director of Nursing stated they saw R1 15 minutes prior to the code blue. R1 was ok. R1 went on the patio, and someone must have given R1 bad drugs that was laced with [MEDICATION(S)]. The floor nurse stated R1 was found in R1 ' s wheelchair unresponsive from bad drugs. Before R1 went to the facility, R1 was struggling with addiction. But R1 was clean for a year and half. The facility is supposed to be helping people with drugs. R1 brought some drugs. V5 told me that V5 worked on R1 for ten minutes. V5 stated R1 was on the back patio. The doctor told me that R1 was already dead when R1 left the nursing home. R1 is dead from the facilities' neglect. They should have been watching people more closely. I heard another man died because the resident could not breathe in the facility. On [DATE], at 3:10PM, V5 stated, What I remember prior to the code is R1 being out on the patio smoking a cigarette. Then, I had to work the floor and I went to the unit. About five minutes later, staff called the code. Of course, code procedures were done. Oxygen and IVs were done. 911 was called. 911 worked on R1 and got R1 out of the facility. I called R1's sister because R1 is a friend of mine. Of course, R1's sister did not take the news well. R1's sister asked me if I think R1 did any drugs. I stated I do not know; I saw R1 smoking on the patio prior. I was providing CPR to R1 for 15 minutes. I knew R1 had a history of drug abuse. I have not ever seen R1 exhibiting any drug behaviors. R1 would stay in front of the building but R1 would not go anywhere. R1 did need a pass to go out of the door. On [DATE], at 3:53PM, V6 stated, I was sitting down typing. I was working a double. Another one of my patients stated was calling R1's name and R1 was not answering. I got up and went in there. I ran in the room. R1 had R1's head in R1's lap like R1 was sleeping. I called R1's name. There was no response. I called a code blue. The nurse practitioner was in the building. CPR was being done. Another nurse called 911. CPR was continued. I went in the room at 3:30. 911 came out around 3:45PM. R1 was transferred to the hospital. I had to collect myself because R1 is very quiet. I never see R1 interact with R 's roommate or R1's peers. I called R1's sister. I did all my documentation. I called the hospital later and was informed of [CONDITION(S)]. I saw in R1's medical diagnoses that R1 had a history of drug abuse, but I had never seen any behaviors related to drug use. I never saw anything on R1's body or R1's hands. I never saw anything in R1's room. On [DATE], at 3:45PM, V8 stated, I was not in the building that day. I do not recall this event. On [DATE], at 1:15PM, V10 (Nurse Practitioner) stated, If a facility has services for residents that need help with addictions, then the resident should be given those services promptly. The facility was unable to provide any documentation that R1 was assessed for the drug addiction rehabilitation program or identified as a resident at risk for drug use while in the facility. Ambulance records dated [DATE], note R1 in care of ambulance. R1 full [CONDITION(S)]. Per staff R1 has a history of opioid abuse. R1 returned from outside pass. R1 found unresponsive and pinpoint pupils in room on the floor. Drug paraphilia at scene. Hospital records dated [DATE], notes R1 has a history of heroin use. R1 collapsed in front of the nursing station after coming back into the facility. It is believed that R1 went outside with a group of men to obtain drugs. R1 came back to the facility and passed out. R1 is presumed to have used heroin. R1 was without oxygen for twenty minutes. R1 expired in the medical facility on [DATE]. R1's brain scan notes severe diffuse [CONDITION(S)] injury with elevated intracranial pressure. [NAME] (Diffuse Axonal Injury) is the tearing of the brain's long connective nerve fibers when the brain is injured as it shifts and rotates inside the brain skull. Facility policy titled Contraband, dated ,d+[DATE], notes the policy provides a process for searching a resident's room and/or belongings when resident exhibits behaviors of self-harm or inflection of harm to others. Contraband is any item that is banned from the facility and/or is harm to the resident or others. Items include but not limited to illegal drugs or drug paraphernalia.

Based on interview and record review facility failed to follow their fall policy for one resident (R1) out of three residents reviewed for falls. This failure resulted in a facility staff member forgetting to implement one of the safety measures/precautions that was part of R1' plan of care; which was for R1 to wear a helmet/head gear while she's up out of bed and subsequently R1 sustained a head injury: Subarachnoid hemorrhage and fracture of zygomaticomaxillary, after falling onto the floor without her helmet on. Finding Include: R1's care plan initiated 1/9/20 denotes at risk for fall related to weakness; intervention initiated 12/15/20 R1 will wear helmet while out of bed. V3 (Licensed Practical Nurse) she stated 2/25/21 at 3:30pm worked on the floor with R1 for a few months and she had history of a couples of falls. V3 stated it was not until late December or January that they were using a helmet for R1 because she had a previous fall. V3 stated the helmet was an intervention they came up with to minimize any injuries if R1 fell . V3 stated V2 (Certified Nurse Aide) had worked with R1 before and V2 was responsible for putting R1's helmet on after R1 was cleaned, dressed and gotten up out of bed. V3 stated on that particular morning (2/17/21) was called to the hallway and saw R1 in the hallway on the floor with no helmet on and bleeding from her right upper cheek. V3 stated assessed R1 for range of motion, put ice pack to her upper jaw then called her doctor who ordered R1 to be sent out to the hospital for evaluation. 2/17/2021 09:00 R1's Health Status/Progress Note Text: Resident noted on floor in hallway with laceration to right cheek, area cleaned, steri strips placed over area, resident medicated for pain, able to move all extremities within normal range, ice pack applied to area. Np notified with order to send to Hospital for evaluation. R1's hospital record dated 2/17/21 denotes open tripod fracture of zygomaticomaxillary and Subarachnoid hemorrhage. Follow with orthopedic clinic 3/4/21. 2/19/2021 07:44 Restorative Nursing: Note Text is a readmit to the facility s/p hospitalization for a fall with tripod facial fractures and subarachnoid hemorrhage. Resident is alert to name only with confusion. Resident has a history of Dementia. V5 (Nurse Practitioner) she stated on 2/26/21 at 10:45am got a call the other morning (2/17/21) that R1 fell and told the facility to send R1 out for a Computed Tomography Scan (CT). V5 stated R1 had CT of the head and spoke to the ER physician whom told her from looking at the CT scan he saw small bleed inside her skull on the temporal side which another term Subarachnoid Hemorrhage. V5 stated the hospital kept R1 for observation to see if the bleed was going to get bigger. V5 stated the hospital watched R1 and the bleed inside the skull was not getting bigger or the pressure was not increasing. V5 stated that after R1 was in the hospital couple of days R1 returned to the facility with the head injury and fracture to her cheek bone area which medically called Tripod [MEDICAL CONDITION]. V5 stated the helmet does help minimize head injuries and a good tool if used properly. V5 stated the helmet can help minimize any impact if the resident falls. V5 stated if R1 had the helmet would have probably prevented the head injury she sustained. V2 (Certified Nurse Aide) she stated on 2/26/21 at 10:20 am on that morning of 2/17/21 just had given R1 a shower and was walking R1 out of the shower room when suddenly someone called for help and placed R1 in a chair in the hallway but forgot the helmet in the shower room. V2 stated went to assist another resident that was calling for help but did place R1 in her chair with her hipster on and proper footwear but did not place her helmet on. V2 stated as she was going into assist the other resident heard a nurse heard staff call for help. V2 state went back into the hallway and saw R1 on the floor and she was bleeding from side of her face. V2 stated the nurses assessed R1 and they helped her get back into the chair and attended to her injury. V2 stated she was written up for leaving R1's helmet off. V2 stated she was just rushing a little too much, trying to help another resident and mistakenly rushed off and forgot to put R1's helmet on. V2 stated had taken care of R1 before and normally get her cleaned put all her safety items on her like the helmet, hipsters and proper footwear on before she leaves her to provide patient care to her other residents. Facility's staff interview dated on 2/17/21 denotes V2 stated Got R1 dressed, put on her hipsters and clothes. Had R1's helmet in the shower room with her as they were exiting the shower room heard someone call for help. Sat R1 in a chair in the hallway and ran to assist with the other resident. Came back R1 was on the floor. V1 (Fall Coordinator) she stated on 2/25/21 at 3:05pm did an investigation after R1 had fell and discovered R1's aide (V2) had washed R1 up that morning and placed her in the hallway in a chair when suddenly a nurse called for assistance and that V2 walked away to help that nurse. V1 stated part of her investigation was to review the facility cameras and noted V2 had placed R1 in her chair with the hipster on but did not put R1's helmet on. V1 stated saw R1 get up from her chair walk a little then turn around stumble then fall onto the floor and hit her head. V1 stated V2 placed R1 in a chair without the helmet on that was supposed to be one of R1's safety measures. V1 stated the V2 was disciplined because she did not make sure one of R1's safety measures were in place before she left her in the hallway sitting. V2's discipline notice dated 2/17/21 denotes poor performance; failure to ensure R1's had on all safety devices. Corrective action employee committing when dressing a resident all safety precautions should be in placed to ensure residents safety. Facility's fall policy denotes Residents at fall risk will be identified for staff awareness. Residents at risk for falls will have Fall Risk identified on the plan of care with interventions implemented to minimize fall risk. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. Facility's use and care of helmet manual denotes headgear can substantially reduce the risk of head injury.

Based upon record review and interview the facility failed to follow care plan interventions and failed to supervise one of four residents (R1) reviewed for falls/injury. These failures resulted in R1 sustaining a prominent frontal scalp hematoma and laceration requiring sutures. Findings include; R1 is a [AGE] year old with [DIAGNOSES REDACTED]. R1's (1/2/20) admission fall risk screen determined a score of 13 (moderate risk). R1's (1/6/20) care plan includes the following; 1.) Resident is at risk for falls related to weakness. Interventions: get to know resident's habits to anticipate needs. Ensure resident is positioned correctly in bed after providing care. Check on resident frequently. 2.) Resident exhibits impaired bed mobility related to generalized weakness and poor functional endurance. Intervention; bed rails up x2 while in bed. R1's (1/22/20) fall with injury (final report) affirms on 1/16/20, resident was observed on the floor near her bed. Resident states she was trying to get into her wheelchair. Resident was admitted to the hospital status [REDACTED]. On 2/11/20 at 1:58pm, surveyor inquired about R1's (1/16/20) fall. V2 (Director of Nursing) stated she had a fall and laceration on her forehead. It was determined that she just rolled from the bed because no one was in the room with her. On [DATE] at 2:20pm, surveyor inquired about R1's (1/16/20) fall. V6 (Registered Nurse) stated she was on the bed sleeping before the fall. When they called me to the scene she said I fall she could not tell what happened. I think she was in the prone position, she faced the floor. Surveyor inquired if R1's side rails were raised V6 responded I cannot remember. On [DATE] at 2:38pm, surveyor inquired about R1's mobility. V8 (Therapy Director) reviewed her (1/15/20) physical therapy treatment notes and stated She was at a contact guard assist level for bed mobility. So she can do it but needs our hands on her. On 2/18/20 at 10:49am, surveyor inquired about the potential harm to R1 if she fell face down. V10 (Nurse Practitioner) stated If they were trying to get up that could be a brain bleed. R1's (1/16/20) head CT includes prominent frontal scalp hematoma. The falls policy (revised 7/14) states; residents at fall risk will be identified for staff awareness. Residents at risk for falls will have Fall Risk identified on the interim plan of care with interventions implemented to minimize fall risk.

Based on interview and record review, the facility failed to have appropriate fall interventions in place for 1 of 3 residents (R5) reviewed for falls in a total sample of 8. This failure resulted in R5 falling and sustaining an abrasion to the nose, a hematoma to the right forehead, an intracranial bleed and a possible C1 and C2 spinal fracture. Findings include: The Incident Report dated 1/8/18 documents that R5 was observed on the floor next to the bed with a raised area to the forehead and a skin abrasion to the nose. The Nurse's Notes dated 1/9/18 documents that R5 was medicated for pain and given a cold compress. The MD was notified and R5 was transferred to the local hospital for evaluation and treatment. The hospital records dated 1/9/18 documents that R5 sustained an abrasion to the nose, a hematoma to the right forehead, a left intracranial bleed and a possible fracture to the C1 and C2 spinal vertebrae. R5's plan of care dated 11/25/17 documents that R5 has some long term and short term memory deficits, R5 is unable to properly use a call light due to cognitive deficits, and R5 is at risk for falls related to impaired mobility, weakness and impulsive behaviors. A bed alarm was put into place for fall safety and fall prevention. On 2/16/18 at 2:00pm V13 (Nurse) stated I was called to the room by one of the aides. I found the resident on the floor by the bed. We got R5 up and back in the bed. R5 had a bump on the head and a cut on the nose. I cleaned the resident up and put a dressing on it. The resident was one that would try to get up and try to reach items. The family warned us about this because the resident used to work nights so R5 would be up at night a lot. The facility's Fall Policy documents that the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies and facilitate a safe environment.

Based on interview and record review, the facility failed to ensure resident equipment was properly maintained for one of three residents (R3) reviewed for falls. This failure resulted in R3 sustaining fracture of the left hip fracture after falling from a shower chair with a malfunctioning wheel. Findings include: Review of the facility's incident report (final dated 01/20/2017) notes in part: upon investigation, resident had a fall on 1/16/17 from shower chair. Resident was being pushed in the shower chair by staff to the shower room for a shower when resident fell to the floor. MD made aware with new orders to send resident to (local hospital) emergency room for further evaluation. X-rays completed at the hospital with X-ray results showing a left intertrochanteric femoral neck fracture, osteopenia and osteoporosis. Resident admitted to the hospital. The fall investigation was completed and revealed that malfunctioning of a wheel on the shower chair may have contributed to (R3's) fall. E3 (Certified Nursing Assistant, 02/03/2017 at 1:43 PM) said in part, while pushing R3 down hallway in shower chair, R3 fell out of chair onto floor. E2 (Director of Nursing, 02/08/2017 at 10:54 AM) said in part, she reviewed tape related to R3's fall, saw a wheel on R3's shower chair lock or freeze and then resident fell from chair. E4 (Maintenance Director, 02/03/2017 at 2:10 PM) said in part, it was reported to him that a shower chair on (R3's) unit was broken. E4 said the chair was not working properly; the caster was not rolling as smoothly as it should have. Facility's Work Order Request of 01/17/17 notes in part: shower chair not working right.

Based on interview and record review the facility failed to provide adequate monitoring for one resident (R1) of three residents reviewed for central catheter monitoring and care in a total sample of 12 residents. This failure resulted in R1's pulling out his hemodialysis catheter exsanguination and death. Findings include, In Minimum Data Sheet ((MDS) dated [DATE] in Section C, R1 has a score of 7 for Brief Interview of Mental Status (BIMS). On "Dialysis Report Form" obtained after the incident with a date [DATE] in the section of comments its documented "(R1) has been trying to remove shoes and trying to stand up from his dialysis chair. Patient needs constant attention." On [DATE] at 1:30pm E1 (Administrator) stated this form was faxed last night from the dialysis center. R1's care plan imitated on [DATE] with an identified behavior of pulling hemodialysis catheter does not address what to do for frequent monitoring. On physician's orders [REDACTED]. No orders in chart that R1 required frequent monitoring for behaviors of pulling out catheters. Last admission to the facility was on [DATE]. On "Nursing Admission & Assessment Sheet" the section of mental/neuro was marked with an asterisk (*) as an area of concern. Nurse's Notes reviewed. On [DATE] at 4:00pm and 8:00pm is documented facility attempting to contact family member to obtain consent for restraint but were unsuccessful to contact. It was requested on several occasions to review documentation of restraint assessment and facility did not provide it. No documentation of any new interventions were put in place for R1 other than frequent monitoring. On 1//,[DATE] at 10:45pm E11 (nurse) documented in R1's nurses' notes, "R1 had returned that evening from dialysis and no report was available from dialysis center. R1's nurses notes with a date of [DATE] at 10:45pm E11 (LPN) documented, "(R1) does not have any accompanying paperwork from dialysis center. At 11:45pm documented, R1 with legs outside of the bed and R1 was redirected. R1's nurses' On [DATE] at 11:00pm R1 was in bed, at 11:45pm R1 was observed attempting to get out of bed. On [DATE] at 12:00am E11 documented R1 asleep, and at 1:00am R1 was found bleeding. On occurrence report dated [DATE] is documented by E9 (Unit Manager) R1 had pulled hemodialysis catheter from right neck and was required to be transferred to local hospital. This report also mentions R1 had pulled out the hemodialysis catheter on [DATE]. The hemodialysis catheter was located on right side of chest not the neck as this report indicated. On [DATE] at 8:30am, E11, (Licensed Practical Nurse - LPN) stated at approximately 1:00am "(E7,Certified Nurse Assistant, CNA) notified me that in R1's room one of the residents had pulled something and there was blood. Both residents in this room had central line catheters and I went to check. When I arrived to the room E7 pointed out it was R1. E11 also stated there was a lot of blood and asked R1 what happened and R1 responded "I know I did it". E11 described R1 as being alert and oriented with frequent confusion. R1 was not aggressive nor combative, and easy to redirect. E11 also stated E10, (Registered Nurse- RN), reported R1 needed frequent monitoring but did not give an explanation of why. " Nurse Supervisor (E6) made me aware during rapid response that the resident had pulled the catheter before". Prior to this incident of [DATE], E11 stated that no one said (R1) had done this before. On [DATE] at 11:15am via telephone E6, Nurse Supervisor, stated "I was in the first floor hallway it was 12:30am -1:00am when I was notified of the rapid response. E6 stated upon arrival to R1's room noticed there was "quite a bit of blood". R1 became unresponsive shortly after E6 arrived in the room. Cardiopulmonary resuscitation (CPR) was initiated. E6 also stated R1 was confused and did not know the consequences of his actions. R1 required frequent monitoring due to exhibiting the same behavior of pulling lines in the past, and family was also aware of it. On [DATE] at 12:45pm E7 Certified Nurse Assistant (CNA) via telephone stated "I was notified during report that R1 required frequent monitoring". E7 was made aware by E11 (LPN) that R1 had been readmitted from the hospital due to R1 had previously pulling out the hemodialysis catheter. On [DATE] at 3:02pm E10 Registered Nurse (RN), stated "I reported verbally to the oncoming nurse about R1 required frequent monitoring. Also endorsed to E11 that R1 pulled out hemodialysis catheter recently. R1 was confused and believed was capable of doing things on his own". On [DATE] at 2:00pm E9 (Unit Manager) stated "close monitoring" consists of monitoring the resident at least every hour. "Usually when a resident required frequent monitoring its because they can't use the call light. R1 required frequent monitoring for behavior issues of pulling out lines". On [DATE] at 12:45pm E7, (Certified Nurse Assistant, CNA) stated "I needed to chart that resident was being monitored". This documentation was reviewed. It is charted the resident had been monitored hourly, although, it's unclear of what the resident was being monitored for. On [DATE] at 12:35pm Z1 (MD) stated the facility was aware that resident had a history of [REDACTED]. Z1 also stated "(R1) had episodes of confusion especially at night and would pull lines out in the hospital setting. They had attempted restraints for security at one point even though the resident was upset. Z1 also mentioned had not been made aware of psychiatry recommendation of [DATE] to have R1 transferred to the Dementia unit due to increased confusion and behaviors. "R1 was a resident that wanted to live". "I don't believe it was a suicidal attempt that resulted in death nor did R1 have suicidal thoughts at time of incident. On [DATE] at 3:00pm, Z2 (psychiatrist) stated "initially R1 was evaluated for behavior issues, but had not evaluated resident after that time". Z2 also stated had not been made aware that R1 had pulled out hemodialysis catheter on [DATE]. R1 was initially admitted on [DATE] to the facility and started to receives hemodialysis in [DATE]. No care plan was created for this until last readmission on [DATE]. It does not address the monitoring of the hemodialysis site.

Based on record review and interview, the facility failed to follow their policy and procedure for assessing residents at risk for pressure ulcers and failed to implement a pressure ulcer intervention to prevent an avoidable facility acquired pressure ulcer for one resident (R30). Findings include: R30 has a [DIAGNOSES REDACTED]. 5/27/2011 at 10:10 am, interviewed E33, Wound Care Supervisor, who stated that he "first learned of the wound on April 9, 2011" after a referral was made by the 11-7 shift nurse. On Per Wound and Skin notes date 4/9/2011, the wound was first identified on 4/9/2011 after the blister ruptured and a referral was received. R 30 has a history of Diabetes and Venous Insuffiencey. Wound and Skin notes dated 4/9/2011 indicates the wound was measured at 5.0 x 7.0 cm with light serous sanguinous drainage noted. On 5/12/2011, R30 was transferred to a local hospital for evaluation of the left heel. On 5/13/2011 a medical procedure of debridement was performed on the R30's left heel.

Based on interviews and record reviews, the facility failed to provide appropriate supervision, monitoring or use of safety device to prevent one resident (R3) from falling. R3 is in a sample of 5 residents, who were identified at risk for falling. This failure resulted in R3 having an avoidable fall and sustaining a right hip fracture. This failure also has the potential to effect other residents identified in the facility at risk for falls. Findings include: Review of R3's Admission Face Sheet document that R3 is a [AGE] year old female with the following Diagnosis: [REDACTED]. Review R3's Fall Risk Assessment Tool, dated 7/29/2010, documented that R3 was at risk for falls. Review of the facility Incident Reports documented the following: "August 11, 2011... 7 AM... The Resident (R3) up in the wheelchair. Attempted to ambulate. Was heard by staff when she fell to the floor. Head to toe (assessment) done, noted raised area to temporal (area of head), found lying on the floor on the right side of the body. Noted resident holding right hip... Incident Type: Fall." R3's Nursing Note, dated 8/26/2010, documented that R3 returned to the facility from the hospital after being diagnosed and treated for [REDACTED]. Review of R3's care plan prior to her fall of 8/11/2010 documented that she was at risk for falls. The plan of care documented the use of low bed with bed alarm to prevent R3 from falling. The director of physical therapy (E9) was interview on 5/18/2010 at 12:48 PM. E9 reported that R3 was initially evaluated in the physical therapy department on 7/29/2010. E9 told surveyor that R3 could not walk by herself, and was unaware that it was unsafe for her to walk. E9 described R3 as frequently "popping up" and trying to walk independently, which made her unsafe. E13, the MDS (Minimum Data Set) Coordinator was interviewed on 1/18/2010 at 12:43 PM. E13 said she completed R3's initial assessment on 8/06/2010. E13 described R3 as having short term memory problems, moderated impaired decision making and unable to ambulate. E13 reviewed R3's care plan for August of 2010 and reported the only safety measure documented in the care plan was bed alarm. The restorative nurse (E8) was interviewed on 5/18/2011 at 12:06 PM. E8 was not the facility's restorative nurse in August of 2010. But E8 reviewed R3's restorative care noted and described R3's care. After reviewing R3's plan of care, E8 said she only saw use of bed alarm in R3's care. The certified nurse aide/CNA (E12), that care for R3 on 8/11/2010, was interviewed on 5/18/2011 at 3:06 PM. E12 told surveyor that she another CNA dressed R3 that morning and put her in a wheel chair. E12 stated: "I'm not sure she (R3) had a chair alarm. If R3 had one, we would have heard it. I just remember me and the other CNA were walking pass the room. R3 was falling to the floor." E7, nurse, was interviewed on 5/18/2011 at 11:45 AM. E7 told surveyor that August of 2010, R3 was very confused, unable to walk and at risk for fall. E7 said that the report she received about R3 was that she (R3) had fallen at the hospital before admission to the facility, broken her wrist and she observed R3 wearing a cast. E7 stated she was the nurse who completed the incident for for R3's fall on 8/11/2010. E7 said R3 was on a chair alarm. She (E7) was at the nursing station and heard the chair alarm. However, E7 did not report responding to the chair alarm until a certified nurses aide told her R3 had fallen to the floor. During the Daily Status Meeting with E2 (assistant administrator) and E3 (director of nursing) on 5/18/2011, surveyor expressed concerns that R3 was not provided with comprehensive and appropriate nursing interventions and use of safety devices to ensure she did not fall. Up to date of exit, E1 nor E2 provided a plan of care that would ensure that R3 did not have a fall and sustain a fracture hip.

Based on medical record, interview and change in resident condition, the facility failed to: 1. conduct comprehensive assessments or reassessment and care planning or provide appropriate services related complaining of pain body areas. 2. provided and notified the physician resident needed for a stronger pain medication. 3. notified the physician in change of condition for a resident (R5) one of twenty-three in samples who was having several abdominal pain. 4. documented the effecively of the Tylenol 325 mg 2 tab administered. 5. follow their pain managaement These failure resulted in R5 to be transfer to the hospital unresponsive and non responsive to tactile stimuli. R5 was admitted Intensive Care Unit with [DIAGNOSES REDACTED]. This had the potential to effective all 244 residents who has potential to have pain and change of condition. Finding Includes: The nurses noted denoted R5 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Date Sets dated [DATE] denoted Section B. (4). Cognitive/Decision making score 1 (Modified Independence- some difficult in new situation only. The Nurses notes denoted: [DATE] 12:00am Resident complaining of pain and body aches was given medications. Monitored for 30 minutes and discomfort was releived. Will continue to monitor resident. [DATE] 4:00am Resident awake due to pain. She seen to be in some distress but vital sign were normal Respiration 18, Blood pressure ,[DATE] Pulse 73 and Temperature 98.3%. Was given whenever necessary meidcation (PRN). PRN medications again but relief did not come. Contacting the medical doctor with request for stronger pain medications. [DATE] 12:30pm Resident observed in wheelcgair alert and oriented with some forgetful. Able to verbalize needs. Complaining constipation could not remember when last bowel movement was. Resident observed complaining generalize pain. Resident could not verbalized pain score. Resident groaning and facial grimacing observed. Two regular strength Tylenol given at this time. Appetite was poor for breakfast and lunch. Maximum assisstance needed with activity of daily living. 2 liter of oxygen infusing per nasal canula. Will continue to monitor. [DATE] 1:00pm Certified Nurse Aide (CNA) of resident stated that resident has a moderate size bowel movement. Resident stated that she didn't know that one was made. [DATE] 2:10pm Resident observed sleeping in bed at this time. [DATE] 3:00pm Received resident in bed with oxygen at 2 liter per nasal cannula. Alert and responsive. [DATE] 4:15pm resident complaining of abdominal pain. Abdominal soft and non distended. Call medical doctor. Awaiting return call. Spoke with granddaughter who request that this writer speak with medical doctor to get stronger pain medications. Blood Pressure (B/P) ,[DATE], Pulse (P)60, Resoration (RR) 22, Temperature (T) 97.2 and Saturation Pulse Oximetry (SPO2) 97%. will continue to monitor. ,[DATE] 4:50pm Resident Z4 (doctor) returned call and was notified of resident complaint. Order to send to Z3 hospital for evaluation. ,[DATE] 5:40pm Resident noted to be unresponsive BP ,[DATE], P54,and R17. Supervisor notified, 911 called out. resident non-responsive to tactile stimuli. [DATE]pm Skin cool clammy to touch. (11 here to see the resident unable to obtain BP of SOP. respiration between ,[DATE]. Daughter called out and notified of change in condition and that resident is being sent to Z1 hospital. [DATE] 6:00pm Resident taken to Z1 hospital via 911. [DATE] 9:10pm Called Z1 hospital to check on status of resident. Resident admitted to intensive Cardiac Care Unit with [DIAGNOSES REDACTED]. Z4 notified that resident was taken to Z1 hospital. The Z1 hospital noted dated [DATE] for R5 denoted: [DATE] 1820 present to emergency room form nursing home. Cool to touch, Rapid, shallow respiration, patient was intubate placement. Vital signs BP ,[DATE], P128, RR43 and T 97.3 axillary. [DATE] 1925 Nasal Gastro tube inserted into left nares, draining brown drainage. Indwelleing catheter in place draining cloudy urine. ,[DATE]/ Her hemoglobin was 6. Plan is give her blood transfusion and also if she improve we will get a Gastro Intestinal Consultation. [DATE] Patient expired at 10:52 am, patient was unresponsive. Patient [DIAGNOSES REDACTED]. The Z1 hospital Laboratory report dated [DATE] denoted White blood count 2.8 low (5XXX,[DATE].0), Red blood count 2.51 low (3XXX,[DATE].98), Hemoglobin 6.0 P (12XXX,[DATE].0) Hemocrite 18.2 low (32XXX,[DATE].0) and Platelet 62 low (,[DATE] thousand). E5, nurse, on [DATE] at 2:44 pm in conference room stated, "Around lunch she was complaining of generalized pain of arms and legs. she was complaining of constipation. The Certified Nurse Aide said she had a nice size bowel movement that morning before lunch. I gave her Tyleno and lie her down in the bed. She was going to sleep when my shift end." E10 (Nurse) on [DATE] at 3:05 pm per telephone stated, "i work the 11:00 pm - 7:00 am shift. she was complaining of severe pain. I gave her tyleno PRN as needed. I gave pain medications. she went back to bed. She said about 3:30 pm complaining of aching pain her body and abdominal. I gave more tylenol. Continue monitor her. Pain was releive about ,[DATE] minutes. We put her back to bed. She was resting comfortable when I left. CNA took a set of vital sign. She was sitting up in wheelchair." E7 (Nurse) on [DATE] at 4:05 pm in conference room stated," She was complaining of pain. She said her abdomen was hurting. I got report from morning nurse. She report to me. When I made round she was not complianing of pain. I got a called about 4:00 pm form granddaughter. The granddaughter stated, " Her mother was there to See R5. she thought her speak was slurred. So, I told her whole on a minute. I went into room. So, I assessed the patient. I spoke to her. Her speak was not slurred. she was alert. She sais her stomach was hurting. I told grandmother was not talking slurred. she was complaining of stomach pain. Granddaughter asked me to call doctor to get something strong pain medication. Then I went took vital sign. They were "OK". I call the physician. He told me to sent to Z1. It was on [DATE]. CNA asked to come in room. That when I noticed she was unresponsive. I call 911. She was sent out to the hospital. The Pain management Policy dated ,[DATE] denoted: 1. To assess and treat resident with pain. 2. To prevent complication related to pain. 3. To provide pyschosocial, medical and nursing support for all residents with acute or chronic pain. 4. To provide a systematic approach to pain assessment and management which enable the nurse to give the comprehensive support and appropriate treatment for [REDACTED]. 5. Accurately assess pain. 8. Increase the comfort and reduce depression and anxiety as much as possible. 11. Prevent and minimize anticipated pain whenever possible. 12. Use pain medication judicously to balance the residnts desired level of pain relief with the avaoidance of unacceptable adverse and consquences. The facility did not present any documentation that residnet was treated for [REDACTED].