Every finding on record at Neighbors Health Center

Based on observation, interview, and record review the facility failed to ensure resident dignity was maintained during personal care for 1 of 2 residents (R53) reviewed for dignity in the sample of 43. The findings include:R53's face sheet printed on 5/7/26 showed diagnoses including but not limited to rheumatoid arthritis, dementia, generalized anxiety disorder, and senile degeneration of brain. R53's facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance required for toilet hygiene, dressing, and transfers. The same assessment showed that R53 is always incontinent of urine and bowel. On 5/5/26 at 9:26 AM, V10 and V11 (Certified Nursing Assistants/CNA) transferred R53 from the wheelchair onto the bed using a mechanical lift. R53's bed was next to the room window. The window looked out to the front parking lot and sidewalk. V10 and V11 removed R53's pants and incontinence brief. Peri care was performed and a fresh brief was put on the resident. R53 was naked from the waist down and exposed to the outside during the entire process. On 5/7/26 at 8:51 AM, V2 (Assistant Director of Nurses) stated resident doors and curtains should be closed during care. Window curtains need to be down during all care for privacy. It is undignified for people outside to be able to see inside. Landscapers, visitors, or anyone walking around outside could see the care being done. V2 said even if a resident is confused and unaware of what is happening, staff still need to put those things in place. The facility's Resident Rights and Dignity policy revision dated 10/24 states: 1. All residents should: a) be treated with dignity in the way in which staff deal with dressings, bathing, feeding, incontinence and all other needs.

Based on observation, interview and record review the facility failed to ensure a urinary drainage bag was off the floor, failed to use a dignity cover, and failed to use personal protective equipment (PPE) during direct catheter care for 1 of 3 residents (R22) reviewed for catheters in the sample of 43. The findings include:R22's face sheet printed on 5/7/26 showed diagnoses including but not limited to right side paralysis following cerebral infarction, heart disease, diabetes mellitus, benign prostatic hyperplasia with urinary tract symptoms, retention of urine, and obstructive/reflux uropathy. R22's facility assessment dated [DATE] showed moderate cognitive impairment and staff assistance required for transfers and personal hygiene. The same assessment showed R22 is always incontinent of bowel. R22's May 2026 order summary report showed an order start dated 11/21/24 for a urinary catheter for urinary retention/obstructive and reflux uropathy. The same report showed an order start dated 4/30/25 for enhanced barrier precautions due to medical device-foley catheter. On 5/5/26 at 11:27 AM, R22 was seated in a wheelchair in the hallway, next to his room door. R22 had a urinary drainage bag under the wheelchair that was touching the floor. A blue dignity sleeve was partially covering the bag and dark urine was visible. R22 stated he had soiled himself and wanted his pants changed. A sign was posted on the door of his room showing enhanced barrier precautions. The sign showed staff must wear gowns and gloves for high contact resident care activities, which included the use of a urinary catheter, changing briefs, and transferring. On 5/5/26 at 11:53 AM, R22 was still sitting outside of his room. The urinary drainage bag was in the same position, uncovered and lying on the floor. At 11:58 AM, V12 (Registered Nurse) hooked the drainage bag up under the chair without wearing gloves. V13 and V14 (Certified Nursing Assistants) assisted V12 to propel R22 down the hall, across the building, and to a neighboring unit. The drainage bag was uncovered during the process. R22 was transferred by V12 and V13 from the wheelchair to the bed using a mechanical lift. V14 exited the room prior to care. V12 and V13 cleansed R22 of the bowel movement, including cleansing of the groin area and catheter tubing. V12 and V13 transferred R22 back to the wheelchair and wheeled R22 down the hall. Staff used gloves but did not wear gowns during the transfer and incontinence care. On 5/7/26 at 8:57 AM, V2 (Assistant Director of Nurses) stated a catheter bag lying on the floor is an infection control issue. It puts a resident at a higher risk of UTIs (urinary tract infections). Germs can get on the bag and into the bladder. Staff should be wearing gloves anytime the bag is handled. It is for the same reason; it lowers the risk of UTIs. The blue dignity sleeves are to be clipped over the drainage bags to cover the urine. It is a dignity thing for a resident. Enhanced barrier precautions (EBPs) are needed to protect the residents from us. Staff should be wearing gowns and gloves during high contact activities if they have a catheter. Incontinence care is a high contact activity, and they should have been wearing gowns. The facility's Urinary Catheter Insertion and Maintenance policy revision dated 07/26 states: 2. Attach drainage bag to frame, below level of resident's bladder-not touching the floor. The facility's Resident Rights and Dignity policy revision dated 10/24 states: 1. All residents should: a) be treated with dignity in the way in which staff deal with dressings, bathing, feeding, incontinence and all other needs. The facility's Enhanced Barrier Precaution policy last revision dated April 2025 states: 2. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities.ii. Indwelling medical device examples include.urinary catheters.

Based on observation, interview and record review the facility failed to follow their policy for food brought in by family or visitors for 1 of 1 resident (R80) reviewed for food safety in the sample of 43. The findings include: On 5/5/26 at 10:05 AM, R80 was seated in a wheelchair in her room. A counter size mini refrigerator was on a stand, next to her bed. The door had a handwritten sign on the front dated 4/1 and it stated do not take anything out of it or throw anything away. The family makes the food for the resident to eat. R80 gave permission for this surveyor to look inside the refrigerator. The small, freezer section was thawed and dripping water over all the items. A plastic storage container with an unidentified liquid was wet and a small baggie of meat was wet. R80 identified the items as soup and lunch meat. There was a baggie of cinnamon bread and a baggie of croissants which were both wet. None of the foods had any dates or labels on them. There was a baggie of grapes and a bottle of syrup on the inside door. Neither item had dates or labels on them. There was a small packet of French dressing on the door which showed an expiration date of 10/9/25. There was a May 2026 temperature log on the side of the refrigerator. The log stated: Temperature parameters: 36-46 degrees. Circle temp and initial daily. The log was blank for 5/2, 5/3 and 5/5.On 5/6/26 at 8:31 AM, the temperature log and food items remained the same. On 5/7/26 at 8:15 AM, the temperature log and food items remained the same. The baggie of grapes had a white, creamy substance on the outside of it. At 9:37 AM, R80 said her sister brings food to her now and again. R80 could not recall how often or how long the food had been in her refrigerator. R80 said she is losing her eyesight and has trouble reading or seeing things clearly. R80 could not identify the white substance on the grapes and said they came from her grandfather. (R80 is [AGE] years old.) On 5/7/26 at 9:45 AM, V10 and V11 (Certified Nursing Assistants) said nursing staff does not monitor resident room refrigerators. The housekeeping staff was responsible for that. V10 and V11 stated R80 is somewhat confused at times and her vision is declining. On 5/7/26 at 9:49 AM, V15 (Housekeeping Supervisor) stated she was not sure who monitors resident room refrigerators, but it should be done daily. They need to stay within the temperature parameters for food quality. On 5/7/26 at 9:53 AM, V1 (Administrator) and V2 (Assistant Director of Nurses) said the housekeepers should be checking the room refrigerator temperatures daily and document them on the log. It ensures the refrigerator is holding temperature appropriately. Food could spoil if the temperature falls out of range. V1 and V2 stated nursing staff should be reviewing the food brought from R80's family and dating it the same day. It should be dated to ensure it is still good and gets disposed of if it is not fresh or unsafe to eat. The facility's Foods Brought by Family/Visitors policy dated 01/16 states: 5.Perishable foods must be destroyed after 3 days. The facility's undated Resident Refrigerator policy states: All refrigerator temperatures will be checked at least once daily and a log maintained. Staff will assist residents in maintaining log if necessary.

Based on observation, interview and record review the facility failed to have enhanced barrier precautions in place for residents with pressure wounds. This applies to three of three residents (R2, R47, R105) reviewed for infection control in the sample of 43.The findings include: 1 On 5/6/26 at 10:50 AM R47 was receiving wound care for her stage 3 pressure injury from V8 (Wound Nurse), V9 (Wound Physician) and V16 (Wound Physician's Assistant). No sign was displayed on R47's door showing she was on enhanced barrier precautions and there was no PPE (personal protective equipment) available near her room. V8, V9 and V16 were not wearing a gown during the treatment. On 5/7/26 at 9:08 AM, V8 said R47 did not need to be on enhanced barrier precautions because her dressing was a band-aid like dressing. V8 said when a new wound is found in the facility, the infection preventionist is notified and she determines if they need isolation or not. On 5/7/26 at 9:33 AM, V2 (Infection Preventionist and Assistant Director of Nursing) said if a resident's wound treatment is using a band-aid like dressing or is not a daily dressing, they do not need to be on enhanced barrier precautions. V2 said R47 does not need to be on enhanced barrier precautions because her wound care is only three times a week and her dressing is a foam island dressing. The facility face sheet for R47 shows she was admitted to the facility with diagnoses to include Type 2 Diabetes Mellitus, dementia and congestive heart failure. The facility assessment dated [DATE] shows R47 to have severe cognitive impairment and requires assistance with her activities of daily living. A nursing note dated 2/11/26 shows R47 has a new stage 3 pressure injury to her left heel. The Physician orders for R47 dated May 2026 does not show any orders for enhanced barrier precautions. An order for R47's left heel shows to apply a calcium alginate sheet cut to fit the wound and cover with a gauze island dressing three times per week. The facility policy with a revision date of 4/2025 for enhanced barrier precautions (EBP) shows EBP refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are applied to residents with any of the following.b. wounds.chronic wounds which include pressure ulcers. An order for EBP will be entered into the clinical record for residents with any of the following: wounds. Door signage: a sign will be placed to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. The EBP signage shows wear gloves and a gown during high contact resident care activities which includes wound care: any skin opening requiring a dressing. 2. On 5/5/26 at 10:58 AM, R105's door did not have an Enhanced Barrier Precautions (EBP) sign posted and there was no isolation bin outside the room. R105 said he had a pressure ulcer on his left heel. R105 pointed to the back of his heel. R105 said they change the dressings daily. On 5/6/26 at 12:26 PM, R105's door did not have an EBP sign posted and there was no isolation bin. V8 (Wound Care Nurse), V9 (Wound Care Physician) and V16 (Wound Physician's Assistant) removed R105's previous dressings, performed an assessment of R105's wounds, and provided treatments to R105's wounds. They were not wearing gowns during R105's wound care. V8 (Wound Care Nurse) said R105 developed a pressure ulcer to his heel from his shoes. R105's Face sheet dated 5/7/26 showed diagnoses to include but not limited to routine healing for fractures of the pubis and right hip; anorexia; insomnia; squamous cell carcinoma; hypothyroidism; muscle wasting and atrophy; dysphagia; and heart failure. R105's Physician Order Sheet dated 5/7/26 showed Right heel wound care with iodosorb gel and cover with gauze island dressing three times a week. This document did not contain an order for EBP related to R105's pressure ulcer. R105's facility assessment dated [DATE] showed he was cognitively intact. R105's Skin Note dated 5/6/26 showed he had a Stage 3 pressure ulcer to his right heel. R105's Care Plan revised 5/3/26 showed he had a Stage 3 pressure ulcer to his right heel. R105's Care Plan did not include EBP as a focus area. On 5/7/26 at 11:09 AM, V20 (Registered Nurse/RN) said R105 does have a pressure ulcer, but he was not on EBP. V20 said if R105 was on EBP he would have an EBP sign on the door, isolation bin outside the room with PPE (personal protective equipment), and it would be documented in his EMR (Electronic Medical Record). V20 said she thought residents with pressure ulcers were usually on EBP. V20 said she worked as an agency before and other facilities had placed residents with pressure ulcers on EBP. V20 stated, I'm not sure here. I think it's up to V2 (Assistant Director of Nursing /Infection Preventionist). V20 said EBP means the staff would wear gown and gloves during high contact activities, including wound care and transfers. On 5/7/26 at 11:45 AM, V8 (Wound Care Nurse) said R105 was not on EBP for pressure ulcers. V8 said she discusses each resident's wounds with V2 and V2 makes the determination if EBP is needed. V8 said she would refer to her. On 5/7/26 at 11:55 AM, V2 (ADON/Infection Preventionist) said R105 did have a pressure ulcer, and he was not on EBP. V2 said she thought EBP wasn't required for resident's that didn't have daily dressing changes or used a bandaid-like dressing. The surveyor showed V2 the regulation text in the State Operations Manual. V2 replied that all residents with pressure and chronic wounds will need to be put on EBP. V2 said the purpose of EBP was to protect the residents from potential infection from the facility staff. V2 said she was sure that she had learned in order to place a resident on EBP the wound care had to be daily. The surveyor asked V2 to provide documentation showing that residents with pressure ulcers did not require EBP. V2 was unable to provide documentation. V2 said residents on EBP should have a physician's order, EBP sign on the door, isolation bin outside the room, and a care plan for EBP. 3. On 05/05/2026 11:27 AM, R2 was sitting up in his wheelchair, adjusting the stockings to his left stump. R2 had a roommate and there was an EBP sign posted on the door and isolation bin outside the room. On 5/6/26 at 12:52 PM, V8 (Wound Care Nurse) said R2 had developed a pressure ulcer to his left stump from his prosthetic. V8 (Wound Care Nurse), V9 (Wound Care Physician) and V16 (Wound Physician's Assistant) removed R2's previous dressings, performed an assessment of R2's wounds, and provided treatments to R2's wounds. They did not wear gowns during R2's wound care. R2's Face sheet dated 5/7/26 showed diagnoses to include but not limited to muscle wasting and atrophy; syncope and collapse; diabetes; COPD (chronic obstructive pulmonary disease); seizures; peripheral vascular disease; and chronic kidney disease. R2's Physician Order Sheet dated 5/7/26 showed he had left shin (stump) wound orders for Mupirocin (antibiotic) ointment after cleansing wound and cover with optifoam dressing daily and as needed. This document did not contain an order for EBP related to R2's pressure ulcer. R2's facility assessment dated [DATE] showed he was cognitively intact. R2's Skin note dated 5/6/26 showed R2 had a Stage 4 pressure injury to his left shin (stump). R2's Care Plan showed he had Stage 3 pressure ulcer to his left shin and a diabetic ulcer to the right dorsal foot. This care plan did not include a focus area for EBP. On 5/7/26 at 11:09 AM, V20 (RN) said the EBP sign on R2's door was for his roommate. V20 said R2 was not on EBP. On 5/7/26 at 11:45 AM, V8 (Wound Care Nurse) said R2 had a diabetic wound to his foot and pressure ulcer to the stump. V8 said R2 wasn't on EBP. V8 said she discusses each resident's wounds with V2 (ADON/Infection Preventionist) and V2 makes the determination if EBP is needed. V8 said she would refer to her. On 5/7/26 at 11:55 AM, V2 (ADON/Infection Preventionist) said R2 did have a pressure ulcer and diabetic wound, but he was not on EBP. V2 said she thought EBP wasn't required for resident's that didn't have daily dressing changes or used a bandaid-like dressing. The surveyor showed V2 the regulation text in the State Operations Manual. V2 replied that all residents with pressure and chronic wounds will need to be put on EBP. V2 said the purpose of EBP was to protect the residents from potential infection from the facility staff. V2 said she was sure that she had learned in order to place a resident on EBP the wound care had to be daily. The surveyor asked V2 to provide documentation showing that residents with pressure ulcers did not require EBP. V2 was unable to provide documentation. V2 said residents on EBP should have a physician's order, EBP sign on the door, isolation bin outside the room, and a care plan for EBP.

Based on interview and record review the facility failed to assess a resident for return from an acute care hospitalization and failed to document specific resident needs that cannot be met by the facility upon a resident's proposed return from an acute care stay for 1 of 1 resident (R1) reviewed for involuntary discharge in the sample of 3. The findings include:R1's Nursing Notes on 3/31/26 show that around 5:00 PM, R1 was found in her room cutting her arm with a pair of cuticle scissors. R1 was sent to the hospital. On 4/8/26 at 12:49 PM, V1 (Administrator) said that she filled out an Involuntary Discharge (IVD) Form for R1 on 3/31/26 and it was delivered to the emergency room on 3/31/26. V1 said that it was provided because of the self-harm and she knew that she would require additional support services that the facility was unable to provide to her. V1 said that they haves a psychiatric Nurse Practitioner that comes to the facility every two weeks. V1 said that she received a call from the hospital on 4/2/26 that R1 was ready to be discharged back to the facility. V1 said that she asked the person if she was aware that R1 was issued an IVD. V1 said that the person then said that she has been cleared medically and by psychiatry to return to the facility. V1 said that she told the person that she was just reviewing the chart and it shows that R1 is still a 1:1, is at moderate suicidal risk and was just started on new medications that need monitoring. V1 said that the person then thanked her and said that they would be back in touch with them. V1 said that later that afternoon, she received a call from V12 (Hospital Psychiatric Nurse Practitioner) and V12 told her that the hospital records must be wrong because R1 has moved to low risk and is on every 15 minute checks. V1 said that V12 asked her if she was abandoning R1 at the hospital and she responded, absolutely not, we want her to get the treatment that she needs, you have all these protocols, how could I accept her back. V1 said that V12 told her that she (V1) is not the expert, she is, and R1 is cleared to return. V1 said that they were unable to accept her back because according to her hospital notes she is still on checks, still doing room sweeps, is still experiencing anxiety, they do not have onsite behavioral health services and they do not have the resources to keep her safe for her own well-being at this point. On 4/9/26 at 8:05 AM, V12 (Hospital Psychiatric Nurse Practitioner) said that she saw R1 in the emergency room when she admitted . V12 said that at that time, R1 said that she had a moment of impulse due to stress from moving to the permanent side of the nursing home. V12 said that when she saw R1, she was tearful, very apologetic and had regretted what she did. V12 said that R1 did not look well and looked like she had not showered. V12 said that when she saw R1 the next day, she was up in her chair and had let the staff give her a shower. V12 said that R1 was in good spirits. V12 said that R1 stabilized and was no longer meeting criteria for admission so she was going to discharge her back to the nursing home. V12 said that they adjusted her hydroxyzine (for anxiety) to every 6 hours as needed (which she was on before) and she had only been using it about once a day. V12 said that R1 was not voicing any self-harm or suicidal thoughts. V12 said that she then heard that the nursing home was not allowing R1 to return so she contacted them. V12 said that the only psychiatric care needs that R1 was in need of was to follow up with a psychiatric professional for medication monitoring and management. V12 said that R1 was still on 15 minute checks at the hospital because that is the protocol for all patients on the unit. V12 said that she would not require that at the nursing home. V12 said that the only reason that R1 was ever on 1:1 supervision was because they do not have call lights and did not know what R1 could and could not do for herself and they did not want R1 to fall. On 4/9/26 at 2:14 PM, V1 (Administrator) said that the IVD was provided based on the status of the resident when she transferred to the hospital on 3/31/26. V1 said that on the day that the hospital wanted R1 to return, V4 (General Nurse Practitioner) agreed that it was not safe for her to return. On 4/9/26 at 2:30 PM, V4 (General Nurse Practitioner) said that she did not recommend the IVD of R1. V4 stated, I am a health care provider, I do not make those decisions, the facility does but she agreed with it. V4 said that the incident happened on a Tuesday and they were calling on Thursday morning that she was ready to be discharged . V4 said that she felt that she was in no way safe to come back so soon. V4 said that she did not feel that R1 would be safe to return to the facility without being on 1:1 or every 15 minute checks. V4 said that when people try and kill themselves, they typically are monitored more than what a nursing home can do. On 4/9/26 at 2:55 PM, V3 (Facility Contracted Psychiatric Nurse Practitioner) said that they do have a psychologist on staff that does provide counseling to residents at the facility on a weekly or biweekly basis. V3 said that she did hear today that the facility is going back and forth on if she is going to be able to return or not return. V3 said that she has not talked to R1 or the hospital staff to be able to tell if she felt that it was safe for her to return to the facility or not. R1's Electronic Medical Record (EMR) does not document that the resident was assessed on her proposed discharge from the hospital 4/2/26. Between 4/1/26 and 4/9/26, there were no assessments of R1 documented. There were no documented notes in R1's EMR regarding her proposed return nor what needs could not be met by the facility. On 4/9/26 at 11:50 AM, V12 (Hospital Psychiatric Nurse Practitioner) said that the facility did not have R1 evaluated by a medical professional prior to providing her an involuntary discharge. V12 said that the facility did not give the patient even the opportunity to get better before giving her a discharge. V12 said that they just decided immediately that they were not going to take her back. V12 said that a lot of facilities come to the hospital and do an assessment of the resident once they have been stabilized to make sure they are able to meet their needs but this facility did not do that. The answer was that they gave her an involuntary discharge, and they were not taking her back. R1's Psychiatry Nurse Practitioner Daily Progress Notes dated 4/1/26 at 10:15 shows, Patient seen today for follow up.Patient is sitting up in a wheelchair. Patient is A&O x 4 (Alert and Oriented). Patient denies SI/HI (Suicidal Ideation/Homicidal Ideation). Patient has been isolating to her room this morning. She is tearful and states she is afraid to be here. She states that she has accepted that her husband cannot care for her and asks to return to the nursing home, where she feels safe.Unit Status/Precaution: SP (Suicide Precautions), low.R1's Progress Notes by V12 dated 4/2/26 at 2:15 PM shows,. facility was unwilling to take patient back to the facility due to regulation that would require 1:1 monitoring for a minimum of 30 days. When asked to provide this exact regulation, she was unable to.It was explained that patient was moved to a low safety level at 9:00 AM.Discussed that patient expressed deep regret and remorse for a moment of impulsivity during an episode of emotional dysregulation.Discussed that patient has shown marked improvement in less than 24 hours from the initial meeting yesterday. [V1] stated the facility could not meet the patient's needs because they do not have mental health services available.They only come once every two weeks. This writer stated patient should not require being seen more than that.discussed patient is cleared for discharge and should be able to return to their facility today.continued to refuse, stating the facility could not meet the patient needs despite this conversation from the current treatment team. R1's Nurse Practitioner Note by V6 (General Nurse Practitioner) dated 3/31/26 show, We are no longer able to meet her needs and welfare as we have no on-site psychiatry and are unable to provide 1:1 supervision for her.R1's Communication Note dated 3/31/26 shows, Bed Hold Policy, Emergency IVD, and Form 5 brought to emergency room to deliver to the resident at the hospital.On 4/9/26 at 8:05 AM, V12 said that R1 is still currently on the behavioral unit at the hospital. R1's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form shows that R1 was emergently transferred or discharged . The reason for the proposed transfer or discharge is: your welfare and needs cannot be met in this facility, as documented in your clinical record by your physician and the safety of individuals in this facility is endangered. The form shows that on the date of transfer or discharge, R1 will be relocated to [Local Hospital]. The form shows that the proposed transfer or discharge is 3/31/26. The form shows, If you request a hearing, it will be held not later than 10 days after your request, and you generally will not be transferred or discharged during that time.The facility's Involuntary Discharge Policy shows, Prior to any involuntary discharge decision, perform a thorough clinical and psychosocial assessment documenting: Current medical/functional status and needs, Specific behaviors/events prompting consideration of discharge, Interventions tried, dates, outcomes, and interdisciplinary team (IDT) input, Evidence that the facility cannot meet the resident's needs or manage the risk despite reasonable accommodations. Provide written notice of involuntary discharge to the resident and their legal representative at least the minimum timeframe required by law (specify state/federal timeframe here; e.g., 30 days when required), except in emergency situations as defined by regulation.

Based on interview and record review, the facility failed to ensure a comfortable temperature range of 71 degrees Fahrenheit to 81 degrees Fahrenheit was maintained for 10 of 11 residents (R1, R3-R11) reviewed for a comfortable environment in the sample of 11.The findings include:On March 23, 2026, there were multiple rooms on the 100 hall of the facility that had multiple blankets on the windowsills of residents' rooms and a blanket over the air conditioning units in the residents' rooms.On March 23, 2026, at 8:55 AM, R1 said her room has been cold. R1 said about a month ago, there were portable heaters in the hallways. R1 said she must have three blankets on her bed to stay warm. R1 said it gets colder at night, and it makes her sad that it cannot be warmer. R1's Minimum Data Set (MDS) dated [DATE], shows she is cognitively intact. R1 has no behaviors of rejecting any care.On March 23, 2026, at 9:08 AM, R5 said it has been cold in the facility for a while. R5 said she has to wear a bunch of blankets when it gets cold. R5 said she feels depressed because she has no heat. R5 said when the residents ask about the heat, the facility says, we are fixing it.On March 23, 2026, at 9:15 AM, R4 said, We haven't had much heat this winter. At one point it was 61 degrees. R4 said 68 degrees would be a comfortable temperature for him. R4 said he sleeps with five blankets on his bed. R4 said at one point the facility had portable heaters in the hallway that were handy, and the heat was coming in but the facility had to get rid of those. R4 said he has to wash up fast because it is so cold in his room. R4 thought the unit was without heat since January 2026. R4's MDS dated [DATE], shows he is cognitively intact. R4 has had no behaviors of rejecting any care.On March 23, 2026, at 9:24 AM, R7 said it was cold for weeks. R7 said it was terrible. R7 said she has five blankets on her bed. R7 said the facility offered for her to change rooms, but R7 said she did not want to move her room.On March 23, 2026, at 9:31 AM, R3 said when the temperature outside is cold, It gets cold in here. R3 said this has been going on for a while, a little over two months. R3 said when it gets down to 30 degrees outside, It's freezing in here. It makes me feel angry, makes me feel like I got left here and they don't want to do anything about it. There's four blankets on my bed, if I need more I have more in my closet. R3 said the facility cannot use portable heaters. R3 said the facility offered to move her. R3 said she slept in another unit one night and slept for ten hours. R3 said she doesn't want to move her room. R3 said she prefers to have her bedroom door closed so she does not hear all the noise, but when it gets too cold, she props it open so it can be warmer. R3 said she had to refuse her shower because it was too cold. R3's Shower Sheet dated February 23, 2026, shows that she refused her shower. R3's MDS dated [DATE], shows she is cognitively intact. R3 has had no behaviors of rejecting any care.On March 23, 2026, at 9:45 AM, R8 said it is cold in her room. R8 said a few days ago, it was really cold outside. R8 said she sleeps with three thick blankets on. R8 said she's disappointed, because she expects to be comfortable.On March 23, 2026, at 10:00 AM, R9 said she is so tired of not having heat. R9 said the unit has gone months with no heat. R9 said the facility told her that they are working on the heat. R9 said she has slept in her coat because it is so cold. R9 sleeps with four blankets on. R9 said she is not comfortable. R9 said she has refused showers, because it is too cold. R9 said she has to undress herself little by little because it's cold. R9 said the facility has taken temperatures in her room, but do not tell her what the temperature is. If the weather is warmer outside, R9 said it is warmer in the facility. R9 said the facility has offered her to move rooms, but R9 said, I don't want to move. All my stuff is in my room. R9's MDS dated [DATE], shows she is cognitively intact. R9 has had no behaviors of rejecting any care.On March 23, 2026, at 10:20 AM, R6 said her room was cold last week. R6 said she let staff know that she was cold, and they said they would talk to maintenance. R6 said she did not see maintenance come in her room. The staff offered her more blankets.On March 23, 2026, at 10:31 AM, V6 (Restorative Certified Nursing Assistant/CNA) said she works the 100 hall about every other week. V6 said it has been cold in that hall. V6 said she did not know why it was so cold. V6 said she knows the facility has had people working on the heating, but it doesn't seem to change. V6 said it has been cold for months. V6 said residents have complained that they were cold and V6 let maintenance know and gave them an extra blanket.On March 23, 2026, at 11:46 AM, V8 (CNA) said the 100 hall is freezing. V8 said it has been cold down there for about the last month now. V8 said that all she has been told is that the maintenance guy is working on it. V8 said staff have not been told why it is so cold in that hall. V8 said residents complain all day long about it being cold in that hall. I make sure to give them extra blankets and ask the nurse when they are going to fix the heat. There are days when I have to work in a hoodie because it is so cold down there. Alot of residents want to stay in bed because it is so cold. Last week, a couple of residents refused showers because it was so cold. [R10] refused her shower last week.On March 23, 2026, at 2:13 PM, R10 said it has been freezing all winter. R10 said her roommate and herself stay in the dining room because it is warmer in there. R10 said she sleeps with 4-5 blankets on. R10 said the facility offered to move her to another room, but R10 said, We would have to move all of our stuff. We shouldn't have to move. It makes me angry and upset. I feel like we are not being heard. It has been all winter; I don't think the facility is being forthright with us. R10 said there are blankets placed by the windows and air conditioning units to prevent the drafts that come in. R10's MDS dated [DATE], shows she is cognitively intact. R10 has had no behaviors of rejecting any care.On March 23, 2026, at 2:27 PM, V11 (Licensed Practical Nurse) said the temperature on the 100 hall fluctuates. V11 said if it is cold outside, then the hall and rooms get really cold. V11 said she did not know what happened. V11 said a lot of residents complain about being cold. V11 said she let maintenance know and gets the residents extra blankets. V11 thought the heating issue has been occurring for about the last three months. On March 24, 2026, at 10:59 AM, V3 (Representative Payee Monitor) said she was in the facility on February 24, 2026. V3 said she was in the facility for about eight hours. V3 said there was a clear temperature difference when she moved from the administrative office area to the residential area. V3 said she wore her winter coat when she was walking through the resident hallways. V3 said it was her understanding that this issue has been happening for a while now. V3 said she saw and spoke to some residents that were in bed with multiple blankets on, some residents were even wearing hoodie coats while lying in bed.On March 24, 2026, at 11:18 AM, V5 (Ombudsman) said residents have been complaining about no heat for most of the winter. V5 said that Resident Council Meeting Minutes for the month of February should have included concerns about the heating issue. V5 said she was present during this meeting, so she knows that the heating concerns were brought up. (These minutes were reviewed onsite and did not include any concerns regarding the residents' concerns about the heat.) V5 said the heat is still not working. Those people are cold.On March 24, 2026, at 12:17 PM, V7 (Maintenance Director) said he received complaints that it was too cold on February 24, 2026, and February 26, 2026. V7 said on February 24, 2026, he was told it was too cold at night, so he came into the facility. V7 said he had to turn the fourth boiler on letting it get to temp and then shut it off. V7 said the fourth boiler was not working earlier on in the day so he had to shut it off. V7 said the boiler had a blockage in it and the boiler was overheating and shutting off. V7 said as of now, the fourth boiler is still down. V7 said the facility has ordered new filters, and as soon as the new filters come in, the entire system will be drained and then refilled with water. V7 said he is hoping when the boilers are drained, that the blockage will come out. V7 said temperatures should be kept at 68-69 degrees in residents' room. V7 said all residents were offered to be moved to another unit and all residents refused. V7 said the last time the facility used portable heaters was about December 2025 when the facility had similar issues. V7 said blankets are placed on residents' windowsills and air conditioners to help with keeping heat in and stop the drafts from coming in.On March 24, 2026, at 1:08 PM, V1 (Administrator) said the facility has done a lot of work to the boiler system. V1 said there were blockages seen in the boiler system. V1 said a new heating and cooling system was ordered but could not be installed yet because the temperatures have been too cold outside and some bricks need to be knocked out. The facility's Room Temperature logs that were provided by V7 show that on February 24, 2026, the lowest temperature on the 100 hall was 65.3 degrees Fahrenheit and the highest temperature was 68.1 degrees Fahrenheit. The baseboard temperature in one of the rooms was 54.6 degrees Fahrenheit. On February 26, 2026, the lowest temperature on the 100 hall was 62.6 degrees Fahrenheit and the highest temperature was 67 degrees Fahrenheit. The facility's Invoice from the heating and cooling company dated February 18, 2026, shows, Still not getting good flow through boiler #4. The facility's invoice from the heating and cooling company dated February 22, 2026, shows, No flow through 400 pad. Flow issues throughout whole building. Invoice dated February 23, 2026, shows, 100 wing is the most concerning wing according to maintenance. I opened up the circuit [NAME] to allow more water flow through that wing. The system is as open as it will get.The facility's Severe Cold Weather Procedures policy not dated, shows, Facility will prepare for periods of severe cold weather as follows: Assure that heating systems are working correctly in residents' rooms.The Illinois Department on Aging Residents' Rights for People in Long Term Care Facilities booklet revised November 2018 shows, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based on observation, interview, and record review the facility failed to provide water to residents in a sanitary manner. This applies to 5 of 8 (R1, R2, R3, R4, R5) in the sample of 11 reviewed for dietary services. The findings include: On 6/30/2025 at 11:43AM, observations of residents being given ice water by V6 (Activity Aide). V6 used a scoop that was sitting on the water cart holding the cooler with water and ice. V6 opened the lid of the cooler to fill R5's and R2's cup with the scoop, placed the wet scoop back down on the cart, and took the cup back into the resident's room. V6 was observed holding R3, R4, and R1's water cup that was removed from the resident's room above the open water and ice cooler while filling the cup. On 6/30/2025 at 12:06AM, V7 (Food Service Director) said the scoop should not be placed back on the cart due to risk cross contamination. V7 said the resident's water cup shouldn't be held above the water cooler because of the risk of cross contamination. The facility provided Ice Dispensing policy revised 5/20/2014 states, the healthcare community stores, prepares, distributes and serves food in a sanitary manner to prevent foodborne illness.

Based on interview and record review the facility failed to ensure a resident was assessed for a change of condition of 1 of 3 residents (R3) reviewed for change of condition in the sample of 6. The findings include: R3's face sheet documents she was admitted to the facility on [DATE] with a primary diagnosis of pressure ulcer of sacral region, stage 4. She also had diagnosis of unspecified dementia, unspecified severity. The 10/6/24 quarterly resident assessment and care screening shows R3 to have severe cognitive impairment and required supervision/touch assistance for sit to stand and toilet transfers. The same assessment documents her to be occasionally incontinent of urine and frequently incontinent of bowel. On 5/23/25 at 1:40 PM, V10 (Certified Nursing Assistant/CNA) said R3, for the most part, she was confused, and she needed stand by assist. She was always trying to get up out of bed on her own, and she had alarms so we could know when she was moving. V10 said remembers, R3 she was just laying down. We would check on her and poke our heads in to check on her, and she did not get up once, that was unusual. V10 reported this to the nurse and left at the end of her shift. On 5/23/25 at 1:51 PM, V11 (CNA) said R3 was confused, but knew her name. She could let us know if she needed to go to the bathroom. She would be up and down to the bathroom every 4 minutes. She would put her light on and if you were not right there, she would just get up and go. V11 said she came in for 2nd shift, the day R3 was sent out to the hospital. She said during her afternoon shift, R3 did not get up, did not put on her call light, and would not sit up. She said the nurse on the unit was notified of the change. She recalled V5 (Licensed Practical Nurse/LPN) was the nurse on duty, but the only response the nurse had was her vital signs are fine. She said when the night shift nurse came in at 6:00 PM, she reported the changes to her, and R3 was immediately sent out to the hospital. R3's progress notes for 11/24/24 at 6:06 AM show staff reported possible blood in urine this morning. Difficult to tell due to large bowel movement. Will hand off to oncoming nurse. The progress notes show no further assessment or progress notes until 10:38 PM, when R3 was being sent out to the hospital. The vital sign results for 11/24/24 show V5 checked R3's vital signs at 10:28 AM, 2:13 PM, and 5:15 PM. On 5/23/25 at 2:45 PM, V5 (LPN) said she did not recall R3. She said she did not recall being told about possible blood in the urine. She did not recall why she took vital signs three times during her shift. She said she would not document anything if nothing was wrong, sometimes she just monitors residents. On 5/27/25 at 2:50 PM, V16 (Registered Nurse) said, if she received in report there was a resident experiencing a change of condition, off their baseline and having blood in their urine, she would frequently assess the resident, get vitals, and notify V18 (Nurse Practitioner) of any findings. V16 stated she would do a full head to toe assessment, document those assessments and notifications start to finish. V16 stated it would be important to do that to maintain full circle of communication for the care of the resident. If it isn't charted it didn't happen. On 5/27/25 at 3:21 PM, V18 (Nurse Practitioner) said if a resident possibly has blood in their urine, she should be informed about that. She would have checked for fever, vitals, chills, and/or pain. She said R3 had dementia could voice her concerns, maybe not 100 percent reliable but she could tell. She said she probably would have ordered a straight catheter to check the urine, but the nurse should have had some follow up. The nurse should have been documenting outputs if she was eating or drinking. After reviewing the charting and vital signs, she said it appears the nurse was concerned about something as it was not usual to check vital signs multiple times a shift and not have any documentation of an assessment. On 5/27/25 at 1:40 PM, V2 (Director of Nursing) said for any resident with a possible change of condition or concern, V18 should be notified. She recalls R3 to have behaviors of repeatedly getting up. If there was any change with her, she would expect the aides to report to the nurse, and the nurse to follow up an assessment. V2 said she does recall the situation and believes the aides on duty did get their mother (another nurse on duty) to look at R3, if that in fact did occur, there should have been documentation from her in the record. The facility's 2/2025 policy for Change in a Resident's condition or Status documents the objective as: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. 5. The nurse will record in the resident's medical record any changes in the resident's medical condition or status.

Based on interview and record review the facility failed to keep a resident free from physical abuse. This applies to 4 of 6 residents (R1, R2, R3 & R4) reviewed for abuse in the sample of 41. This failure resulted in R1 being sent to the local hospital and diagnosed with a posterior head laceration and initial CTH with acute SDH (computed tomography with acute subdural hematoma) of the left frontal, parietal, and temporal lobes. The findings include: 1. The facility's final report to the state surveying agency regional office dated December 20, 2023, shows, It was immediately reported to Administrator (V1) that R1 sustained a fall with injury while in the memory care dining room. Staff reported that they heard a female resident say that a resident is moving the chair around and to leave it alone, when the one CNA (Certified Nursing Assistant) turned toward the resident she saw R1 and another male resident (R2) both had hold of the chair and due to the momentum of both residents tugging at the chair they both fell. R2 the other male resident landed on top of R1 which caused him to hit his head on the corner of the wall Conclusion: Based on a thorough investigation resident (R1) sustained a laceration to the back of his [head] requiring staples and had a small subarachnoid hematoma requiring no surgical interventions as a result of two dementia residents wanting to move the same chair around the table, they lost their balance and fell together On May 14, 2025, at 1:58 PM, V11 (CNA) stated, she witnessed the incident between R1 and R2 on December 20, 2023. She was in the dining room helping another resident with her back turned towards R1 and R2. R1 was sitting at a table in the dining room. R2 was up walking around. She heard R12 (another female resident) screaming, They are going to fight. They are going to fight. so she turned around to see R1 and R2. R1 was trying to stand up from the table as R2 had a chair and was shoving the chair towards R1. She tried to grab the chair but was not able too. R2 shoved the whole chair into R1 hitting him and causing him to fall back and hit his head on the corner of the wall. R1 hit the wall so hard there was pieces of plaster/dry wall on the floor. He was also bleeding badly. On May 15, 2025, at 8:03 AM, V3 (CNA) stated, R1 and R2 were fighting. R2 hit R1 and caused R1 to fall backward and hit his head hard on the wall. R2 was in an aggressive mood and wanted to still fight R1. R2 would get aggressive with staff but never the other residents. This was the first time he hit a resident that she knew of. R1's local hospital paperwork dated December 31, 2023, shows, History and Physical: .R1 was admitted to local hospital on [DATE] after a fall at his nursing home, he had an argument with another NH (nursing home) resident who pushed him backward against a wall and struck his head. He had a posterior head laceration and initial CTH with acute SDH (computed tomography with acute subdural hematoma) of the left frontal, parietal, and temporal lobes . R1's progress notes dated December 20, 2023, shows, The resident fell in the common area during breakfast and hit the back of his head on the corner of the wall. Bleeding was noted R2's progress notes dated December 20, 2023, shows, Resident fell in the common area during breakfast as a result of pushing a chair. Resident has no injury and was able to stand up by himself . 2. R3's progress notes written by V9 (Licensed Practical Nurse/LPN) dated December 7, 2023, shows, Resident had a disagreement with his roommate that had escalated between them. Decision was made to separate the roommates per both of their requests. On May 15, 2025, at 8:33 AM, V9 (LPN) stated, the incident with R3 and R4 happened in the middle of her shift, December 2023. R3 and R4 got into a fight. R3 and R4 both got up and were arguing. R3 tried to walk over to R4 and fell. R4 started kicking him. She broke them apart and separated them. V8 (CNA) was there also. She moved R3 into another room and called V1 (Administrator). She stated, V1 (Administrator) told her how to document the incident. On May 14, 2025, at 12:57 PM, V8 (CNA) stated, she heard commotion and went to R3 and R4's room. When she walked in R4 was kicking R3 pretty badly. She yelled for V9 (LPN). V9 came down and together they got them separated. R3's progress notes written by V1 (Administrator) dated December 8, 2023, shows, Administrator followed up with resident regarding his disagreement with his roommate. Resident explained that they were having a disagreement about the television being loud and when this resident went to get up to try to turn his roommate's television down, he said, my chair got away from me and I sat on the floor. He states that his roommate then laughed at him because he sat on the floor. Staff heard this resident asking for help and they assisted the resident back into his chair R3's progress notes written by V7 (Nurse Practitioner/NP) dated December 12, 2023, shows, CC (current concern): bruising, recent fall. HPI (history of presenting illness): Patient is reporting that on 12/7 he was pushing his wheelchair and it got away from him. He fell landing on his buttocks. He goes on to report that while he was on the floor, his roommate kicked me. He points to bruises to his right upper arm and elbow and the top of his head. He previously has denied any physical contact was made .Bruising noted to right hip and along right gluteal fold. Tenderness with palpation to right hip and low back. Right upper arm with resolving bruise and bruising noted at right elbow. Tender with palpation. Elbow with full ROM (range of motion). No BLE (bilateral lower extremity) edema. IMPRESSION/PLAN: 1. S/P Fall: x-ray right humerus, elbow, hip, pelvis, and lumbar/sacral spine. 2. Contusions: due to being on Brilinta and ASA increased bruising is expected and appears to be resolving. 3. Head contusion: denies LOC. No h/a. Resolving bruising. On May 14, 2025, at 12:16 PM, V6 (LPN) stated, R3 and R4 never really got along. She wasn't the nurse when they got into a fight in their room however she was the nurse a few days later. It was reported to her that R3 had some bruises on him. She asked him what the bruises were from. R3 told her that he had a fall and when he was on the ground R4 was kicking him. She reported that information to V1 (Administrator) and V7 (NP). R3 was alert and oriented x3. V7 ordered x-rays and when the x-rays came back R3 had a fracture on his lower spine. On May 14, 2025, at 12:28 PM, V7 (NP) stated, these two guys (R3 & R4) were rowdy guys. She was asked to see R3 because he had some bruising, and no one knew where it was from. She assessed R3 and thought his bruises were of a defensive nature. He had bruising on the back of his arms and covering his head. R3 told her his wheelchair got away from him and he fell on the floor. He was on R4's side of the room and R4 started kicking him. His statement was supportive with the bruising she assessed. R3 was not happy she put her documentation in of what she saw on R3. On May 19, 2025, at 12:01 PM, R4 stated, he remembered R3. R3 was threatening to kick his a**. He told him, No you won't. R3 came at him, and he knocked him down and started kicking him. I warned him. R4's electronic medical record does not show, any documented incidents with R3. The facility's final report to the state surveying agency regional office dated August 19, 2024 shows, Administrator received an anonymous call today reporting that some time back in December 2023 the two residents (R3 & R4) had a disagreement in their room and R4 made physical contact with R3. R3 no longer resides in the nursing home, he was discharged as of 6/6/2024. The caller refused to provide any additional information. Local police department was notified, and they provided a case number but because it was an anonymous call and no claim from the victim, they will not be investigating . R4's Minimum Data Set, dated [DATE], shows, he is cognitively intact. The facility's abuse prevention guidance dated October 2022 shows, Policy Statement: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this guidance is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents Definitions: The following definitions are based on federal and state laws, regulations and interpretive guidelines. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5)

Based on observation, interview, and record review the facility failed to ensure mechanical lift equipment was in good working order for 5 of 5 residents (R8, R19, R36, R40, R41) reviewed for mechanical lifts in the sample of 41. The findings include: On [DATE] at 9:55 AM, V22 (Certified Nursing Assistant/CNA) said on [DATE] she was toileting R36 using the sit to stand machine. V22 said she had R36 standing up with her arms above her head attached to the machine with the sling when she attempted to lower R36 to the toilet. V22 said the battery died and the machine wouldn't lower R36. V22 said she got other batteries and none of the batteries she tried were working. V22 said R36 was getting weak and starting to panic, so she tried to use the emergency release on the machine, and it wouldn't release. V22 said she had to put her knees under R36's bottom, and with a gait belt around R36's waist, manually lower R36 to the wheelchair. V22 showed this surveyor a mechanical lift in the resident hallway and pointed out the red emergency release ring was not connected to the shaft and slid up and down with no effect. V22 said this is broken, the emergency release should be connected to the shaft. V22 said they didn't have reliable equipment and staff have let the management know. On [DATE] at 9:37 AM, V38 (CNA) said the batteries for the mechanical lifts don't stay charged. V38 said about 2 weeks ago, during a mechanical lift transfer with R8, the battery died while R8 was in the sling in the air over the bed. V38 said they had to try multiple batteries before they finally were able to get one that worked and complete the transfer. On [DATE] at 9:40 AM, V25 (CNA) said staff is very frustrated over having to run to get new batteries. V25 said you leave one person with resident up in sling and then one person runs to get new battery. V25 said some mechanical lifts have messed up wheels, and some the emergency release doesn't work. V25 said R19 and R41 use sit to stand machine for transfers. On [DATE] at 10:35 AM, V22 (CNA) said R40 is a mechanical lift for transfers. On [DATE] at 9:50 AM, R41 was sitting up in his wheelchair in his room watching TV. R41 said they use a sit to stand machine to help him move from the wheelchair to bed and back. R41 said there have been many times while he was attached and up in the machine that the battery dies, and they must get another to swap out. On [DATE] at 1:08 PM, V1 (Administrator) said V26 did a sweep recently on all the mechanical lifts and we have new batteries on order. V1 said she was not sure if the lifts were safety checked. V1 said staff should not be using equipment if the emergency release is not working. V1 said staff should fill out a work order and place the lift by the maintenance room. On [DATE] at 2:45 PM, V26 (Maintenance Director) said about 2 days ago, he went through and checked out all the mechanical lifts, and they should now be in working order. V26 with this surveyor, found the mechanical lift with the unattached emergency release ring and said the ring should be attached. The facility's undated Maintenance Service Policy shows the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on interview and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 1 of 41 residents (R33) reviewed for dignity in the sample of 41. The findings include: On May 19, 2025, at 1:10 PM, V14 (Licensed Practical Nurse/LPN) stated, her, V9 (LPN) and V12 (Dietary Manager) got into a verbal altercation at the nurses' station. V9 and her work the night shift. They were giving report to the oncoming day shift when V12 (Dietary Manager) overheard them talking about their concerns with the dinner meal the night before. He was calling us wussies and telling us that the menu is planned out by a dietitian. V14 admitted to calling the dietitian a dumb b****. Another staff member (V22 Certified Nursing Assistant/CNA) saw what was happening and told her to stop and leave it alone. She admitted to saying 2 cuss words. R33 was up and sitting by the nurses' station. On May 19, 2025, at 1:43 PM, V22 (CNA) stated, V12 (Dietary Manager), V9 (LPN) and V14 (LPN) were arguing at shift change. V12 was punching in the time clock (which is right by the nurses' station) and overheard V9 and V14 were upset about the dinner the night before and residents were hungry. He got defensive and very aggressive verbally. He was saying the dietitian makes the menu and they follow the menu. V14 did swear and called her a stupid b****. I told V14 to walk away but she was mad. R33 was sitting by the nurses' station. On May 19, 2025, at 2:43 PM, V12 (Dietary Manager) stated, he got to work around 6:00 AM and heard the nurses talking about what was served for dinner the night before. I tried to let them know the menus are approved and sent to us through a dietitian. V14 (LPN) stated, the dietitian was a stupid b****. I was trying to talk with V9 (LPN) and V14 kept intervening our conversation. Even V22 (CNA) told her to stop the conversation was inappropriate. V14 stated, she didn't give a f***. He wasn't sure who exactly was sitting out by the nurses' station at the time of the argument, but it was 1 or 2 residents that were there. On May 20, 2025, at 10:58 AM, V10 (LPN) stated, she witnessed the argument with V9 (LPN), V14 (LPN) and V12 (Dietary Manager). It was awful. V12 (Dietary Manager) was instigating that. R33 was sitting up by the nurses' station. She is always up there. The facility's resident privacy and dignity policy dated October 2021 shows, Objective: This policy is intended to set out the values, principles and policies underpinning the facility approach to privacy and dignity Procedure: 2. Staff should remember the following: g) Never discuss private or personal issues with a resident in public, h) Avoid the use of patronizing or insulting language.

Based on interview and record review the failed to ensure an allegation of abuse was reported to the state surveying agency in a timely manner. This applies to 2 of 6 residents (R3 & R4) reviewed for abuse in sample of 41. The findings include: On May 15, 2025, at 8:33 AM, V9 (Licensed Practical Nurse/LPN) stated, R3 & R4 got into a fight in their room, December 2023. R3's progress notes dated December 7, 2023, shows, Resident had a disagreement with his roommate that had escalated between them. Decision was made to separate the roommates per both of their requests. On May 19, 2025, at 12:01 PM, R4 stated, he remembered R3. R3 was threatening to kick his a**. He told him, No you won't. R3 came at him, and he knocked him down and started kicking him. I warned him. The facility did not report the incident to state surveying agency or local police department at the time of the incident. R3's progress notes written by V7 (Nurse Practitioner/NP) dated December 12, 2023, shows, CC (current concern): bruising, recent fall. HPI (history of presenting illness): Patient is reporting that on 12/7 he was pushing his wheelchair and it got away from him. He fell landing on his buttocks. He goes on to report that while he was on the floor, his roommate kicked me. He points to bruises to his right upper arm and elbow and the top of his head. He previously has denied any physical contact was made The facility did not report the incident following allegations made to V7 (NP) on December 12, 2023. The facility's final report to the state surveying agency regional office dated August 19, 2024 (8 months after the initial incident) shows, Administrator received an anonymous call today reporting that some time back in December 2023 the two residents (R3 & R4) had a disagreement in their room and R4 made physical contact with R3. R3 no longer resides in the nursing home, he was discharged as of 6/6/2024. The caller refused to provide any additional information. Local police department was notified, and they provided a case number but because it was an anonymous call and no claim from the victim, they will not be investigating . On May 14, 2025, at 11:27 AM, V1 (Administrator) stated, corporate received an anonymous phone call through their compliance hotline stating that two gentlemen back in December 2023 (R3 and R4). At the time of the initial incident, it was instantly determined that both gentlemen had no contact so she never reported the incident. When the anonymous call came in, then she reported it. She stated, she had a soft file but never provided anything other than the original report sent into the state surveying agency on August 19, 2024 (8 months after initial incident). The facility's abuse prevention guidance dated October 2022 shows, Policy Statement: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this guidance is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents Procedures: V. Internal Reporting Requirements and Identification of Allegations: .Supervisors shall immediately inform the administrator or person designated to act 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. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours

Based on interview and record review the facility failed to assess and treat a resident after the resident hit their head when their wheelchair flipped backwards. This applies to 1 of 3 residents (R34) reviewed for quality of care in the sample of 41. The findings include: On May 20, 2025, at 11:17 AM, V34 (R34's daughter) stated, R34 had appointment at his orthopedic office. The facility transported R34 to the appointment and she met him there. She noticed a scrape on the crown of his head. R34 told her that the guy flipped him over on the way to the appointment. He stopped too fast and flipped him backwards and his head got scraped. She called the facility and asked what was going on. They said they got over booked and the maintenance man (V19) had to drive him to the appointment. The facility was going to have a nurse that previously worked in the neurology department at the hospital look at him. They checked him out and he was fine just had a scrape on the top of his head that was all she knew. On May 20, 2025, at 11:57 AM, R34 stated, he remembers the guy flipping him backwards in the van on the way to his appointment. I'm fine. On May 20, 2025, at 11:33 AM, V19 (former Maintenance Director) stated, he transported R34 to his appointment on April 15, 2025. He made sure he was strapped down and buckled in. He was at a stop light and when he went to go forward, R34's wheelchair fell backwards. He pulled over right away and picked him up. R34 told him he was fine. He has done a million of these transports and has never had any issues. This was the first time. He continued taking R34 to his appointment and waited for him until he was done. He did not call the facility and let them know because R34 said he was fine, and he was at the doctor's office. I didn't know, I'm just the maintenance guy just trying to get him to his appointment. On May 20, 2025, at 11:07 AM, V33 (Registered Nurse/RN) stated, R34 had an appointment and V19 (former Maintenance Director) took him to his appointment. Someone (she couldn't remember who) approached her and asked if she had heard what happened to R34 on the way to his appointment. Supposedly, R34's daughter (V34) called and was irate because she wasn't informed that her dad had an incident on the transport van. He flew backwards and hit his head. A little while later, V2 acting Director of Nursing/Assistant Director of Nursing (DON/ADON) was pushing R34 down the hall. She got R34 situated in the room and told V33 (RN) that she assessed him, and he was ok. She didn't need to worry about charting but to start doing neuro checks on him every hour. She stated, she got busy because she had 8 nursing students and did not do any neuro checks. She only did hourly charting (which was not in R34's electronic medical record). The incident happened on April 15, 2025. She did not call anyone and inform them of R34's incident. On May 20, 2025, at 12:13 PM, V2 (acting DON/ADON) stated, her understanding was that V34 (R34's daughter) called and said, R34 fell in the transport van on the way to his appointment. She was asked to check out R34 when he got back from his appointment. Once he returned, she took him to his room and assessed him. She used to work as an ICU (Intensive Care Unit) RN with a specialty in neurology trauma. She thought R34 was fine. She did not chart what she assessed, neuro checks or notified any physician about R34 falling backwards and hitting his head. She told V33 (RN) to do hourly neurology checks on him. She stated, doing neurology checks on someone after they hit their head would help determine if something is wrong. The facility's policy is to do neuro checks and document the incident. She also confirmed she is a Registered Nurse and not a Nurse Practitioner (NP) or Physician. On May 20, 2025, at 11:58 AM, V7 (NP) stated, she was not notified of R34's incident in the transport van. V2 (acting DON/ADON) checked him and said he was fine. R34's electronic medical record does not show any incidents have happened related to a fall in the transport van on the way to a follow up appointment with his orthopedic physician. There is no documentation related to R34's incident (progress notes, neuro checks, incident report, notification of physician). The facility's fall prevention and management dated December 2023 shows, Purpose: .Additionally, the program addresses a safe process to follow for supporting a resident who has experienced a fall event Documentation: In the medical record, document the vent, outcome, and initial and ongoing observations, and update fall risk assessment and care plan. Documentation includes notification of licensed independent practitioner and resident's representative. The facility's medical emergencies policy (no date) shows, 5. If head injury has occurred and resident is unable to communicate their physical status, notify physician for orders for immediate transport to the emergency room for further evaluation. If resident has the ability to communicate and assessment finds no abnormalities in neurological status and there are no visible signs of significant injury, monitor vital signs and neuro checks at least every four (4) hours for twenty- hour [four]24 hours, or until stable, or as otherwise ordered by physician.

Based on observation, interview, and record review the facility failed to ensure residents were transferred in safe manner with properly working equipment for 3 of 41 residents (R8, R36, R40) reviewed for safety in the sample of 41. The findings include: 1. On [DATE] at 9:55 AM, V22 (Certified Nursing Assistant/CNA) said on [DATE] she was toileting R36 using the sit to stand machine. V22 said she had R36 standing up with her arms above her head attached to the machine with the sling when she attempted to lower R36 to the toilet. V22 said the battery died and the machine wouldn't lower R36. V22 said she got other batteries and none of the batteries she tried were working. V22 said R36 was getting weak and starting to panic, so she tried to use the emergency release on the machine, and it wouldn't release. V22 said she had to put her knees under R36's bottom, and with a gait belt around R36's waist, manually lower R36 to the wheelchair. V22 showed this surveyor a mechanical lift in the resident hallway and pointed out the red emergency release ring was not connected to the shaft and slid up and down with no effect. V22 said this is broken, the emergency release should be connected to the shaft. V22 said they didn't have reliable equipment and staff have let the management know. V22 did not put a broken sign on the machine or remove the machine from the hallway. On [DATE] at 9:37 AM, V38 (CNA) said R36 is a mechanical lift. V38 said R36 has bad arthritis and pain in her knees and has dementia and doesn't know how to use the sit to stand machine. On [DATE] at 10:55 AM, V37 and V38 (CNAs) transferred R36 from her wheelchair to the bed. V38 said, while transferring R36, the emergency release doesn't work on this machine, they had just tried to use it on R8 (R36's roommate). V38 attempted to use the emergency release on the lift to show this surveyor and the release did not release. V37 and V38 continued transferring R36 to bed, provided incontinence care and then transferred R36 back to her wheelchair. V37 and V38 then transferred R8 from her bed to her wheelchair with the same mechanical lift machine. On [DATE] at 11:45 AM, V15 (Restorative Nurse) said she was notified that staff was doing a sit to stand transfer on R36 and the equipment malfunctioned. V15 said she told staff to always use a mechanical lift for R36. V15 said R36 is supposed to be a mechanical lift, but the girls were doing a trial with R36 on a sit to stand machine. V15 said she did not do an assessment on R36 to change R36's transfer status from a mechanical lift to a sit to stand. V15 said R36's cognition has been on the decline, and she is not appropriate for the sit to stand based on that. R36's Care Plan dated [DATE] shows R36 is at risk for activities of daily living decline related to generalized weakness and transfers via mechanical lift. Resident has inability to transfer self. Resident is a mechanical lift. Resident has impaired cognitive function/dementia or impaired thought processes i.e , memory/recall; orientation; decision making; delusional though content; etc., related to Alzheimer's, Dementia. 2. On [DATE] at 10:35 AM, V22 and V39 (CNAs) transferred R40 from the bed to his wheelchair using the same mechanical lift with the unattached emergency release lever. On [DATE] at 1:08 PM, V1 (Administrator) said V26 (Maintenance Director) did a sweep recently on all the mechanical lifts and we have new batteries on order. V1 said she was not sure if the lifts were safety checked. V1 said staff should not be using equipment if the emergency release is not working. V1 said staff should fill out a work order and place the lift by the maintenance room. On [DATE] at 2:45 PM, V26 (Maintenance Director) said about 2 days ago, he went through and checked out all the mechanical lifts, and they should now be in working order. V26 with this surveyor, found the mechanical lift with the unattached emergency release ring and said the ring should be attached. The facility's undated Maintenance Service Policy shows the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review the facility failed to ensure residents records were up to date and accurate. This applies to 3 of 12 residents (R34, R35 & R36) reviewed for resident records in the sample of 41. The findings include: 1. On [DATE] at 11:17 AM, V34 (R34's daughter) stated, R34 was on his way to an appointment in the transport van and flipped backwards in his wheelchair and hit his head. On [DATE] at 11:33 AM, V19 (Former Maintenance Director) stated, R34 did flip backwards in the transport van on the way to an appointment. On [DATE] at 11:57 AM, R34 stated, he remembered the guy flipping him backwards in the van on the way to his appointment. R34's electronic medical record (EMR) does not show any documentation nor provide any documentation regarding R34's incident in the transport van. On [DATE] at 12:57 PM, V1 (Administrator) stated, the nurses should be documenting any incidents with a progress note and all assessments should be in medical record. The facility's fall prevention and management dated [DATE] shows, Documentation: In the medical record, document the vent, outcome, and initial and ongoing observations, and update fall risk assessment and care plan. Documentation includes notification of licensed independent practitioner and resident's representative. 2. On [DATE] at 9:22 AM, V36 (Licensed Practical Nurse/LPN) said R35 walked out the 500-hall dining room door and was outside of the building on the sidewalk. V36 said staff heard the alarm sound and went outside. V36 said staff were able to bring R35 back into the building and R35 did not have any injuries. V36 could not remember the date of the event, but said it was about one year ago. V36 said she notified V1 (Administrator) about what happened, and V1 told her to hold off on charting while they were trying to figure it out. V36 said V1 did not say why she was not supposed to chart, but this was something that should be charted. V36 said she did notify V40 (R35's Power of Attorney) about the event and V40 declined to move R35 to the memory care unit at that time. V36 said R35 was able to walk with a walker and did look for exits to go home. On [DATE] at 1:08 PM, V1 (Administrator) said she did not recall any event where R35 got out of the building. V1 said that would be something that would need to be charted in the progress notes. On [DATE] at 1:35 PM, R35 was sitting in her room with V40. V40 said R35 does like to wander around the facility. V40 said the facility did call her about a time when her mom got out of the building. On [DATE] at 11:10 AM, V16 (Social Service Director) said she was not aware of an incident with R35 going out of the building. V16 said that was something that should be charted and then investigated to make sure appropriate interventions are put in place for resident's safety. The facility was unable to provide any documentation regarding R35 exiting the building. The facility's Missing Residents Policy dated 5/17 shows Facility must report and investigate all reports of missing residents. It is the responsibility of all personnel to report any resident not authorized to leave the facility attempting to leave the premise or suspected of being missing to the charge nurse immediately. Upon return of the resident to the facility, the charge nurse should: complete and incident report and make appropriate notations in the resident's medical records. 3. On [DATE] at 9:55 AM, V22 (Certified Nursing Assistant/CNA) said on [DATE] she was toileting R36 using the sit to stand machine. V22 said she had R36 standing up with her arms above her head attached to the machine with the sling when she attempted to lower R36 to the toilet. V22 said the battery died and the machine wouldn't lower R36. V22 said she got other batteries and none of the batteries she tried were working. V22 said R36 was getting weak and starting to panic, so she tried to use the emergency release on the machine, and it wouldn't release. V22 said she had to put her knees under R36's bottom, and with a gait belt around R36's waist, manually lower R36 to the wheelchair. V22 said she told the nurse on duty. On [DATE] at 11:34 AM, V10 (LPN) said she was the nurse on duty on [DATE] when the sit to stand machine malfunctioned with R36. V10 said she told V16 (Social Service Director) who was the manager on duty about the incident. V10 was not sure if she charted anything. On [DATE] at 11:39 AM, V16 said she spoke with V10 and V22 that day about the incident and let V1 (Administrator) and V2 (Assistant Director of Nursing) know about it. V16 said she didn't chart anything about the incident. R36's medical records do not contain any documentation of an incident with R36 on [DATE] with a sit to stand machine. On [DATE] at 1:08 PM V1 (Administrator) said V16 did notify her of the incident with R36 and the sit to stand machine and there should have been a progress note made about the incident. The facility's undated Charting and Documentation Policy shows The purpose of charting and documentation is to provide: A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's cares. Assistance in the development of a Plan of Care for each resident.

Based on observation, interview, and record review the facility failed to securely store medications. This applies to 1 of 6 medication carts reviewed for medication storage. The findings include: On 9/5/24 at 10:45 AM, V3 (Assistant Director of Nursing) was assisting this surveyor during medication storage review. V3 said she had to find the nurse on the hall to get the keys to the cart and walked away from the surveyor. When V3 returned to the medication cart she opened the narcotic count binder that was laying on the right side of the cart and the nurse's keys were laying just under the binder cover. V3 removed the keys from the binder and proceeded to open the medication cart. On 9/5/24 at 10:50 AM, V3 said the keys to the medication cart and medication rooms should be on the nurse and not laying on the medication cart. V3 said she did not know why the nurse would have left the keys on the cart. On 9/05/24 at 11:33 AM, V2 (Director of Nursing) said the keys to the medication cart should be with the nurse at all times. V2 said it is important to keep the medications secure and to make sure none of the residents get into the medication cart as they could possibly ingest medications. V2 said it is important to maintain secure medication storage to ensure both patient safety and medication control. The facility's policy and procedure with revision date of 8/2023 showed, Storage of Medications; Objective: Drugs and biologicals shall be stored in a safe, secure, and orderly manner .

Based on interview and record review, the facility failed to ensure accurate weights were obtained and recorded for 5 of 5 residents (R13, R47, R86, R95, R98) reviewed for nutrition in the sample of 20. The findings include: 1) R98's electronic face sheet printed on 9/5/24 showed R98 has diagnoses including but not limited to necrotizing fasciitis, cerebral infarction, diarrhea, cutaneous abscess of groin, and chronic pain. R98's weight log showed, 7/27/24 197.4lbs 7/28/24 175.6lbs (21.8lb weight loss in 1 day). 8/2/24 195.4lbs 8/3/24 188.4lbs (7lb weight loss in 1 day). 8/6/24 192.8lbs 8/8/24 182.8lbs (10lb weight loss in 2 days). R98's nursing progress notes for July-August 2024 showed no documentation that R98 was reweighed or that a physician was notified of any significant weight loss. On 9/5/24 at 10:46AM, V2 (Director of Nursing/DON) stated, When a significant weight change is identified, staff should get a reweigh on the resident to ensure the weight is accurate. As a nurse, I would say the standard of care would be 5 or more pounds in a day would constitute a reweigh. It could be that staff didn't subtract equipment, but they should be identifying the weight loss when they are entering it into the system. The facility's policy titled, Weight Management dated 03/22 showed, Objective: 1. It is the policy of this facility to monitor the nutritional status of all residents, including all significant or trending patterns of weight change to maintain acceptable parameters of nutritional status .4. All significant, unplanned, or trending weight changes must be investigated by the facility .5. In the case of a significant or trending weight change the following steps will be taken: 1. Determine the possible cause . 2) R47's electronic face sheet printed on 9/5/24 showed R47 has diagnoses including but not limited to hypertensive heart disease, major depressive disorder, peripheral vascular disease, atherosclerosis, pulmonary embolism, emphysema, anxiety disorder, and type 2 diabetes. R47's weight log showed, 6/19/24 228.4lbs 6/20/24 255lbs (26.6lb weight gain in 1 day). 6/21/24 254.1lbs 6/22/24 224.4lbs (29.7lb weight loss in 1 day). 8/5/24 238lbs 8/6/24 244lbs (6lb weight gain in 1 day). R47's nursing progress notes for June-August 2024 showed no documentation that R47 was reweighed or that a physician was notified of any significant weight changes. 3) R86's electronic face sheet printed on 9/5/24 showed R86 has diagnoses including but not limited to severe protein-calorie nutrition, and dementia with behaviors. R86's weight log showed, 7/17/24 99lbs 7/18/24 93.6lbs (5.4lb weight loss in 1 day). 7/21/24 98.8lbs 7/22/24 93.4lbs (5.4lbs weight loss in 1 day). 8/30/24 101.6lbs 9/1/24 94.6lbs (7lb weight loss in 1 day). R86's nursing progress notes for July-September 2024 showed no documentation that R86 was reweighed or that a physician was notified of a significant weight change. 38488 4. R13's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, Cardiomyopathy, peripheral vascular disease, Chronic Congestive Heart Failure, and hypertensive heart disease. R13's September 2024 Physician Order Sheet showed an order started 7/6/23, daily weight. R13's July 2024 daily weights showed 7/1/24 she weighed 186 lbs. and on 7/2/24 she weighed 174.6 lbs. This shows an 11.4 lbs. weight loss in 1 day. R13's next weight 7/3/24 showed she weighed 185.6 lbs. which would be an 11 lbs. weight gain in 1 day. R13's 7/14/24 weight was 186.2 lbs. and on 7/15/24 she weighed 181.8 lbs. (4.4 lbs. weight loss in 1 day). R13's 7/16/24 weight was 183.6 lbs. and R13's 7/17/24 weight was 187 lbs. (3.4 lbs. weight gain in 1 day). R13's complete medical record was reviewed and showed no reweighs were completed. R13's August 2024 daily weights showed 8/6/24 she weighed 187.0 lbs. and 8/7/24 she weighed 197.2 lbs. This shows a 10.2 lbs. weight gain in 1 day. R13's complete medical record showed was reviewed and no reweighs were completed. On 9/05/24 at 9:52 AM, V3 (Assistant Director of Nursing/ADON) said notification to a physician of weight changes would depend on if the resident has an order for parameters to notify. V3 said some residents will have parameters on their order for daily weights. V3 said she would guess most of the residents that are daily weights have parameters noted on their orders for notification. V3 said if there is a large discrepancy when they get the resident's weight, she would expect the nurses to get a reweigh and anytime there is doubt in the accuracy of the weight they should reweigh. V3 reviewed R13's weights and said she would expect a reweigh with the changes in R13's weights that were noted. V3 said a 10 lbs. discrepancy would be inaccurate because there is no way someone could gain or lost 10 lbs. in one day. 36186 5. The face sheet for R95 shows she was admitted to the facility with diagnoses to include obesity, depression, hypothyroidism, anxiety, and bipolar disorder. The facility assessment dated [DATE] shows R95 to be cognitively intact and requires moderate assistance from staff for her activities of daily living. The weights for R95 shows on 7/20/24 she weighed 191.8 pounds (lbs.) and on 7/23/24 her weight was 202.8 lbs. On 7/28/24 R95's weight was 200.8 lbs. and on 7/29/24 her weight was down to 190.8 lbs. No notification to the Physician of the changes to R95's weight could be found, and no re-weigh was documented. The weights for R95 on 8/12/24 showed her to weigh 191.8 lbs. and the next day she weighed 181.4 lbs. No notification of the weight changes was documented as being reported to the Physician and no re-weigh was obtained.

Based on observation, interview, and record review, the facility failed to perform glove changes and hand hygiene during incontinence care for 1 resident (R61). The facility also failed to transport linens in a manner to prevent cross contamination on 1 of 5 units. These failures apply to 14 of 14 residents reviewed for infection control in the sample of 20. The findings include: 1. The facility roster dated [DATE] showed 13 residents residing on the unit where V5 (Certified Nursing Assistant/CNA) was working on [DATE]. On [DATE] at 8:50AM, V5 provided incontinence care to R63. R63's bed pad was saturated with urine when V5 picked up R63's soiled linen, held it against her body, and transported it down the hallway to the soiled linen container. V5 did not bag R63's soiled linen. V5 returned to R63's room, completed her cares, then left R63's room and went to the dining room to assist with the remainder of the breakfast meal. V5 did not change her clothing and stated she knows she should have put the soiled linens in a bag to transport it down the hall, but she was nervous. V5 stated she takes care of all the 13 residents on R63's unit throughout the day. V5 stated she does not have a change of clothes and intends to wear her soiled clothing for the remainder of the day. On [DATE] at 10:46AM, V2 (Director of Nursing) stated, It is our policy that the aides bring a soiled linen cart to the doorway of each resident's room when they are providing care, so they do not have to transport the soiled linens down the hall. If they are unable to bring the cart to the doorway, then they need to bag the soiled linens and transport them to the soiled linen cart that way. The way (V5) transported the linens is an infection control concern as the linen (V5) was carrying was soiled with urine. On [DATE] at 10:59AM, V4 (Infection Preventionist) stated, When staff are transporting soiled linens, they should be carried away from body and straight into the soiled linen bin. It is important to carry the linens away from their body for infection control purposes as they don't want to transfer anything to another resident. The facility's policy titled, Laundry Handling revised ,d+[DATE] showed, Objective: Soiled linen contaminated with blood or other potentially infectious materials will be handled as little as possible and with a minimum of agitation .3. Contaminated laundry will be placed and transported in bags or containers . 34891 2. R61's undated face sheet showed diagnoses including but not limited to cerebral infarction, heart disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and urinary tract infection. R61's facility assessment dated [DATE] showed moderate cognitive impairment and the use of a urinary catheter. The assessment showed substantial/maximal staff assistance required for toileting and personal hygiene. The same assessment showed R61 is always incontinent of bowel. On [DATE] at 9:08 AM, V8 and V9 (CNAs) entered R61's room and donned PPE (personal protective equipment) to perform incontinence care. The CNAs put on gowns and gloves (as required for the enhanced barrier precaution). R61 was rolled to his side and was heavily incontinent of bowel. V8 steadied the resident while V9 cleansed the bowel movement off his lower back, buttocks, and inner thighs. V9 continued wearing the contaminated gloves and handed R61's catheter bag to V8. V9 opened the bedside table drawer and removed a tube of medicated skin cream. R61 was rolled onto his back while V9 cleansed the bowel movement off his groin area, catheter tubing, and leg strap. V9 continued wearing the soiled gloves while V8 exited the room for more incontinence supplies. V9 wore the same gloves while changing the bed pad under R61, using the bed remote, and leaning on the bed side rails. V9 finally changed her gloves and stated she does it between dirty and clean items. V9 said she waits until she is completely done with incontinence care before changing her gloves. V9 said she puts on clean gloves just before she helps R61 to get dressed. On [DATE] at 12:32 PM, V2 (Director of Nurses) stated gloves should be changed between dirty and clean areas. Soiled gloves should be removed, hands washed, and new gloves put on before touching anything. It is important for infection control. Germs, feces, and urine will transfer to clean areas if contaminated gloves are worn. Gloves need to be changed several times during incontinence care. It is incorrect to wait until the end to change them. The facility's undated Gloves policy states: 2. When gloves are indicated they shall be used only once and discarded into the appropriate receptacle.

Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) assistance to 2 of 3 residents (R63,R86) reviewed for activities of daily living in the sample of 20. The findings include: 1) R63's electronic face sheet printed on 9/5/24 showed R63 has diagnoses including but not limited to Alzheimer's disease, major depressive disorder, dementia with psychotic disturbance, and type 2 diabetes. R63's facility assessment dated [DATE] showed R63 has moderate cognitive impairment. R63's Restorative assessment dated [DATE] showed R63 requires maximum assistance for oral hygiene and personal hygiene. R63's care plan dated 3/9/23 showed, (R63) is at risk for ADL decline related to muscle weakness, dementia, and anxiety .dependent on staff for personal hygiene. On 9/4/24 at 8:50AM, V5 (Certified Nursing Assistant/CNA) provided morning care for R63. V5 provided incontinence care, dressing assistance, and brushed R63's hair. V5 did not provide or offer to brush R63's teeth or provide any oral care. R63 had facial hair on her chin, above her top lip, and around the sides of her mouth. V5 did not provide or offer any shaving assistance to R63. V5 stated residents receive oral care each morning and every night before bed. V5 stated residents receive shaving assistance (male and female) on shower days. V5 stated she is unsure why she did not provide oral care or shaving assistance to R63. On 9/4/24 at 10:05AM, Surveyor asked R63 if she preferred to have facial hair or if she was used to having it shaved. R63 then felt her face and stated, Oh my goodness! I need this taken care of. I do not like facial hair. The facility's undated policy titled, Activities of Daily Living (ADLs) showed, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADL's .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . 2) R86's electronic face sheet printed on 9/5/24 showed R86 has diagnoses including but not limited to severe protein-calorie nutrition, and dementia with behaviors. R86's facility assessment dated [DATE] showed R86 has moderate cognitive impairment and is incontinent of bladder. R86's care plan dated 9/3/24 showed, Resident experiences incontinent episodes of bowel and bladder provide incontinent care after each incontinent episode. On 9/3/24 at 12:15PM, V6 (CNA) provided toileting assistance to R86. V6 removed R86's incontinence brief and stated it was wet with urine and had feces on it. V6 then applied a new incontinence brief to R86 and pulled her pants up without providing incontinence care. V6 stated she is a new aide and that R86 usually just wipes herself with toilet paper, so she didn't think she needed to wash her. On 9/5/24 at 10:46AM, V2 (Director of Nursing) stated, When a resident is incontinent, they should receive incontinence care for infection prevention, dignity, and cleanliness. It's standard of practice and all aides know this and are trained to do this. Morning care for all residents includes incontinence care (if they are incontinent), dressing, grooming (including coming hair, washing their face, and offering to help them brush their teeth), and anything else that the resident would ask for. All residents with facial hair, regardless of if they are male or female should be shaved on shower days and as needed if the resident is okay with it. The facility's policy titled, Incontinence Care dated 5/2017 showed, Objective: To keep the skin clean, dry, free of irritation and odor . The facility's undated policy titled, Perineal Care showed, Objective: 1. To cleanse the perineum. 2. To prevent infection and odors .

Based on observation, interview, and record review the facility failed to ensure an indwelling urinary drainage bag remained below the bladder level for 1 of 2 residents (R61) reviewed for catheters in the sample of 20. The findings include: R61's undated face sheet showed diagnoses including but not limited to cerebral infarction, heart disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and urinary tract infection. R61's facility assessment dated [DATE] showed moderate cognitive impairment and the use of a urinary catheter. The same assessment showed total staff assistance required for transfers. R61's September 2024 physician order report showed the use of an indwelling catheter for urinary retention start dated 8/8/24. R61's August 2024 medication administration history report showed the use of cephalexin and levofloxacin (antibiotics) were given to treat a urinary tract infection (UTI). On 9/3/24 at 9:53 AM, R61 was lying in bed and was alert. R61's catheter bag was in the bed laying on top of his thighs, near the groin area. Yellow urine was visible in the tubing and bag. R61 stated he was waiting for the aide to return and transfer him from the bed to his wheelchair. At 10:06 AM, V2 (Director of Nurses/DON) and V7 (Certified Nursing Assistant) entered the room and transferred R61 using a mechanical lift. During the transfer V2 stated she would hold the bag to be sure it stays below his bladder. On 9/4/24 at 12:32 PM, V2 (DON) stated R61 needed antibiotics a few weeks ago due to a urinary tract infection. His catheter bag needs to be below his bladder to prevent the back flow of urine. The backflow can cause UTIs. The catheter bag should not be laying in his lap or in bed with him. The bag should be placed on the bed rail until care is provided. R61's care plan showed a focus area related to the use of an indwelling catheter. Interventions included: position bag below the level of the bladder. The facility's undated Closed Urinary Drainage policy states under the procedure section: 3. Attach drainage bag to bed frame, below level of resident's bladder, not touching the floor, to allow flow with gravity and avoid back flow of urine.

Based on observation, interview, and record review the facility failed to monitor blood glucose for a diabetic resident for 1(R1) of 3 reviewed for diabetic care in the sample of 9. Due to this failure, R1's blood glucose level decreased to an abnormally low level of to 20 mg (milligrams)/dL (deciliter) and required being sent to the emergency room . The findings include: On 1/25/23 at 12:20 PM, R1 was sitting up in his wheelchair in therapy. R1 stated, They were evidently not checking my sugars because my sugar dropped too low, and I ended up at the hospital. I didn't know I was in the ambulance. I came to at the hospital. R1's Face sheet shows R1 was admitted on [DATE] with diagnosis of Type 2 diabetes mellitus. R1's Hospital Discharge After Visit Summary dated 1/17/23 shows, Check your blood sugars often. R1's Progress Note dated 1/21/23 at 8:15 AM, shows, Resident noted to be non-responsive when this nurse went to administer morning medications. Resident not responding to name being called or sternal rub. Eyes open with fixed stare. Extremities rigid Resident is full code. Call placed to 911. Fire department arrived to facility. Blood sugar 20 [mg/dL]. Emergency Medical Services started intraosseous [vascular access] to left shin to administer D5. Blood sugar rechecked and up to 90 [mg/dL] prior to leaving facility. On 1/25/23 at 10:00 AM, V5 (Registered Nurse) said, When a resident is admitted from the hospital you look at the hospital discharge summary for orders. If a resident is diabetic there should be orders for blood sugar monitoring and if not, then you should clarify with the Nurse Practitioner (NP). On 1/25/23 at 10:10 AM, V3 (Assistant Director of Nursing) said R1 was admitted from the hospital where they were checking his blood sugars before meals and at bedtime. V3 stated, The orders didn't carry over here. Somehow it didn't happen here. R1 had a hypoglycemic event which was able to be corrected and is now back at the facility. R1 now has blood sugar monitoring ordered before meals and at bedtime. On 1/25/23 at 11:15 AM, V2 (Director of Nursing) said she initially admitted R1 and did not clarify any orders for R1's blood glucose monitoring. V2 said R1's blood sugars were not being checked prior to R1 going out to the hospital for low blood sugar. V2 said the discharge orders check blood sugar often should have been clarified with the NP. R1's Medication Administration Record for blood glucose monitoring dated 1/7/23 to 1/25/23 shows R1's blood glucose was not documented until 1/21/23 at 5:00 PM (when R1 returned from the hospital). The facility's Management of Diabetes Mellitus Policy dated June 2022 shows blood sugar checks as ordered by physician.

Based on observation, interview, and record review the facility failed to supervise a resident with a history of falls; failed to ensure a safe environment for a resident with a history of falls; failed to safely transfer a resident; and failed to supervise a resident with difficulty swallowing for four of six residents (R9, R6, R207, R66) in the sample of 20. This failure resulted in R9 sustaining a right distal femur fracture. The findings include: On 10/01/19 at 02:40 PM, V25 (R26's spouse) reported that someone was on the floor down the hall. V27 (Licensed Practical Nurse - LPN) and V29 (Registered Nurse/MDS) went down the hall to R9's room. R9 was lying her right side, on the floor in her room. R9 was positioned in front of her wheelchair and a recliner. R9 smelled of urine. R9 was saying, Ow, ow, ow, (holding right mid thigh area). At 2:48 PM V27 (LPN) asked R9 if she had pain. R9 pointed to the outside of her right leg, just above her knee. At 2:50 PM, V2 (Director of Nursing) took R9's vital signs. At 3:00 PM, R9 was transported to the local emergency room by the ambulance crew. R9's Facesheet printed 10/03/19 showed [DIAGNOSES REDACTED]. R9's Physician order [REDACTED]. Q4 hours x 2, then Q shift x 3. R9's Fall Risk assessment dated [DATE] showed she was at High Risk for falls. R9's facility assessment dated [DATE] showed R9 had severe cognitive impairment; required extensive assistance of one staff member for bed mobility, transfers, and toilet use; required limited assistance of one staff member to walk in room; and was always incontinent of urine. R9's Progress Note showed she fell in her room on 12/12/18, 3/13/19, 5/27/19, and 10/1/19. The 10/1/19 2:40 PM Progress Note showed, Patient found half sitting/lying on her right hip in her room by a resident's family member. Patient was yelling with movement of the right leg. Patient's head and upper shoulder were against her recliner chair in her room. Two nurses assisted patient to a supine position on the floor to better evaluate patient's injuries. Patient unable to be placed fully on her back as she stated her right leg hurts. Patient was yelling out and stating the right legs hurts her. She pointed to her right knee. However when this writer touched her right hip area to reposition, she yelled out in pain. Patient states, she tried to hang up a hanger that was hers into her closet. Another nurse called 911 and let the family member know of the fall and transfer to the hospital for further evaluation. (Nurse Practitioner) was also notified of fall and transfer to hospital . The undated Fall Log provided to us by the V1 (Administrator) on 10/02/19 showed R9 had falls on 12/12/18, 03/13/19, 05/27/19, and 10/01/19. R9's Fall Care Plan edited 10/2/19 showed, Resident at risk for falling related to anxiety, paranoia, and dementia. One of R9s interventions was, Observe frequently and place in a supervised area when out of bed and Assist of 1 for transfers. R9's emergency room record dated 10/1/19 showed, Reports to the emergency department via ambulance from (the facility) for evaluation of right leg pain after an un-witnessed fall . R9's Right Femur 2-View X-ray dated 10/1/19 showed, [MEDICAL CONDITION] femur in obliques projections with complete displacement with overriding of the proximal fragment foreshortening. Minimal angulation. Right arthroplasty (hip replacement) and knee arthroplasty (knee replacement) with hardware intact. R9's Orthopedic Surgery Consult dated 10/02/19 showed, .The patient had a fall and sustained a displaced right inner-prosthetic femur fracture . On 10/02/19 at 03:30 PM, V29 (R26's spouse) said she was leaving on Tuesday (10/1/19) and happened to glance in a room. V29 stated, I saw her on the floor in front of her recliner, so I went directly to the nurse and told her. On 10/03/19 at 08:50 AM, V1 (Administrator) said R9 is not back from the hospital yet, she suffered a femur fracture from her fall on Tuesday (10/1/19). On 10/03/19 at 09:32 AM, V2 (DON) said her investigation into R9's fall is still in progress. V2 stated, (R9) likes her room tidy and in order; if she sees something out of place, then she will try to fix it. V2 said at this time it sounds like there was a plastic hanger in a place R9 didn't want it. V2 said R9 did sustain a right femur fracture from the fall on 10/1/19 and is still in the hospital. On 10/03/19 at 11:15 AM, V30 (R9's POA) said my aunt fell at the nursing home and now she is at Swedish American Hospital. V30 stated, I think they said she broke her hip on the right side. V30 said R9 had falls in the bathroom and in her room in the past, but it wasn't very serious. V30 said R9 tried to get up all the time by herself, but she needs help. V30 stated, They (the facility) put an alarm on her for a while and that seemed to help. V30 stated, After the last fall they said they would watch her very closely. V30 said they are supposed to keep her under supervision. V30 stated, I'm not sure what happened this time. On 10/03/19 at 12:26 PM, V31 (LPN) said a resident's family member told me that R9 had fallen. V31 said she immediately went to R9's room with V33 (Registered Nurse/MDS). V31 said R9 was half sitting/half lying on her right side with her back, upper torso up against her recliner. V31 said R9 was facing away from the door and toward the window. V31 said R9 had a hanger lying on her when she was lying on the floor. V31 stated, (R9) was telling me she was trying to get the hanger put up and she couldn't do it. V31 said R9 was crying and saying her right leg hurt. V31 said she knew R9 had fallen in the past, but wasn't aware if she had any fall precautions in place. V31 said R9 is supposed to have help with standing up and doing things. On 10/03/19 at 12:35 PM, V32 (CNA) said I had already left for the day before R9 fell . V32 stated, She was acting normal the whole day, I had toileted her throughout the day with no problems. V32 said R9 is a one assist with a gait belt. V32 said R9 is usually only in her room when she needs to go to the bathroom, but there are times when she is in her room that she fiddles with the drawers. On 10/03/19 at 12:45 PM, V33 (RN/MDS) said she was at the nurse's station on Tuesday (10/1/19) afternoon, when a visitor walking up the hall said,There's someone on the floor in 210.V33 said she went to the room with V31 (LPN) immediately. V33 said R9 was lying on the floor on her right side, in front of her wheelchair, in front of the window/closet area. V33 said R9 was crying and probably saying, it hurts. On 10/03/19 at 01:16 PM, a message was left for V34 (Orthopedic Surgeon). The call was not returned. The facility's Fall Reduction Program (rev 04/19) showed 1. It is the policy of this facility to have a Fall Reduction Program that promotes the safety of residents in the facility. The program's intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each resident's individual risks, and the implementation of appropriate interventions, supervision, and/or assistive devices deemed appropriate. Standards: 4. Assigned nursing personnel are responsible for ensuring that the ongoing precaution(s) are put in place and consistently maintained per the individual's plan of care. On 10/01/19 at 12:40 PM, R6 was self-propelling her wheelchair down the hall from the dining room. R6 stated, My knees get tired, you think you can get someone to push me to my room. On 10/02/19 at 08:24 AM, R6 was self-propelling her wheelchair in her room. At 10/02/19 at 08:33 AM, R6 self-transferred into her high back chair. R6 turned her wheelchair so it was facing forward and placed her feet on the seat of the unlocked wheelchair. R6 covered her lap and legs with a blanket and closed her eyes. On 10/02/19 at 03:25 PM, R6 was sitting in her high back chair in her room with her feet propped up on the seat of her unlocked wheelchair. On 10/03/19 at 07:59 AM, R6 was sitting up in her high back chair with her feet resting on the seat of her unlocked wheelchair. R6 stated, I like to sit like this, this is my comfortable position; I don't have a recliner so this works. This surveyor asked R6 if she thought a recliner would be better. R6 replied, A recliner would be nice, but that's not what I have. I just make use of what I have. R6's Facesheet printed 10/3/19 showed [DIAGNOSES REDACTED]. R6's facility assessment dated [DATE] showed had severe cognitive impairment and required extensive assistance of one staff member for bed mobility, transfers,and toilet use. The facility's Fall Log provided by V1 (Administrator) on 10/02/19 showed falls on 12/25/19, 01/15/19, 02/18/19, 04/09/19, 05/30/19 (5 falls in last 10 months). R6's Care Plan created 7/30/19 showed, The resident presents with a functional deficit in ambulation, which appears to be related to the [DIAGNOSES REDACTED]. R6's Fall Care Plan edited 6/21/19 showed, Resident has history of falling related to impaired mobility, weakness, left sided [MEDICAL CONDITION], and [MEDICAL CONDITION]. The interventions include: Assist of 1 for transfers and ambulation; Give resident verbal reminders not to ambulate/transfer without assistance; and provide resident an environment free of clutter. On 10/03/19 at 09:16 AM, V9 (LPN) said R6 always sits like that, she likes to keep her legs up. R6 was sleeping in her high back chair with her feet resting on the seat of her unlocked wheelchair. V9 stated, R6 needs assistance, but she is sometimes non-compliant with that. On 10/03/19 at 09:53 AM this surveyor demonstrated to V2 (DON) how R6 sits with her feet on the seat of the unlocked wheelchair. V2 stated, I don't think that's a good idea. She could slide right out of that chair and fall. V2 continued to state, And the wheelchair could move on her if she's putting it there herself and it's not locked. V2 said R6 probably needs a recliner. V2 stated, Resident self-transferring is another problem we have here. R207's computerized face sheet showed [DIAGNOSES REDACTED]. R207's facility assessment dated [DATE] showed R207 is moderately cognitively impaired and requires staff assistance with transfers, toileting, bed mobility, dressing and hygiene. R207's Fall Risk assessment dated [DATE] showed a high risk for falls. R207's care plan showed a problem area start dated 9/29/19 stating: resident has a surgical wound to right hip R/T (related to) falling. R207's care plan showed a problem area start dated 9/10/19 stating: resident at risk for falling R/T weakness. On 10/1/19 at 1:24 PM, V16 (CNA-Certified Nurse Aide) wheeled R207 to the bathroom and transferred him from his wheelchair to the toilet. R207 stood up to transfer and was unsteady and wobbling on this feet. R207 had difficulty balancing and pivoting around to sit down on the toilet. V16 held onto to R207's arms to assist him. R207 pulled his pants down and a large adhesive bandage was visible on his right outer hip. V16 stated R207 had recent hip surgery and was still weak on that side. R207 used the toilet and was assisted back into the wheelchair, again unsteady on his feet. V16 did not use a gait belt to transfer R207 on or off of the toilet. On 10/2/19 at 1:36 PM, V17 (CNA) stated R207 is unsteady on his feet and needs a gait belt on during all transfers. V17 said the gait belt is necessary to safely hold onto R207 around the waist rather than pulling on his arms which could cause pain or damage. On 10/3/19 at 10:08 AM, V2 (interim Director of Nurses) stated gait belts are needed at all transfers for residents that are weak or unsteady on their feet. V2 said gait belts are necessary to stabilize residents and prevent falls. V2 said falls can occur during transfers if staff do not have a gait belt on residents' waists to hold on to. V2 said all residents with a high fall risk or history of falls should be transferred with a gait belt. V2 said R207 had recent hip surgery and most likely is still not strong on that side. The facility's Transfer-Using a Gait Belt policy dated 5/17 states under the objective section: 1. To relocate from a chair(to) bed, chair (to) toilet, chair (to) chair with gait belt. The policy states under the responsibility section: 1. Nursing assistants will routinely have a gait belt immediately available to them during resident transfer. On 10/1/19 at 12:45 PM, R66 was sitting in his wheelchair at a dining room table for lunch. V13 (Occupational Therapist - OT) was standing by R66 and said to V14 (Certified Nursing Assistant - CNA) that she was good to go and was only looking in for a minute. V14 walked away. R66 was sitting at the table by himself, picked up an entire piece of chicken, tilted his head down to meet his hand and was trying to chew a piece off. At 12:54 PM, R66 received some assistance with eating. On 10/2/19 at 9:00 AM, R66 was served his breakfast. R66 was trying to lift a bowl of hot cereal to his mouth to feed himself and was unable. At 9:08 AM, V11 (CNA) went to R66's table and opened straws and put them in his drinks. On 10/03/19 at 8:26 AM, V3 (Registered Nurse - RN/Clinical Support Supervisor/Assistant Director of Nursing) stated, R66 has to be fed. He does not have the use of his hands. Someone has to be with him at all times at meals because he has to be fed; if he tries to do it himself he could give himself too big of a bite and choke. R66's care plan should show dining room interventions. R66's Care Plan dated 9/18/19 did not have a plan in place for feeding or dining assistance. On 10/03/19 at 9:49 AM, R66 stated, Today I had pancakes and sausage and I can't cut them. They left them in front of me. They came back asked if I needed the pancakes and sausage cut. Someone cut it and left again. I wasn't able to pick it up and eat it. I couldn't hook the fork into the meat or pancake and get it to my mouth. They know I can't. Someone saw that I couldn't do it myself so he sat down and put the stuff on the fork and laid it on the plate for me to pick it up. When he saw that I couldn't feed myself he started to help me. The food was cold. I get regular liquids. I get served food and no one is at table and I have to wait for help; they are feeding other people that need help. I try to feed myself what I can until they can help me. They think I can do more than I can. I won't eat cold food. I eat 1/3 of what I used to eat; since this disability I don't eat as much as I used to. On 10/03/19 at 11:37 AM, V26 (Speech Therapist - ST) stated, R66 as of this week he has made some good gains with his left arm range of motion. If I place certain things positioning wise he can reach and grab. He tends to have difficulty grabbing. It depends on his pincher grasp at that moment. He can bring the fork to his mouth if we stab it ahead of time for him. R66 can't bring his arm to his mouth; he leans forward. A spoon doesn't work to well for him he dumps it. I tell him that's a good thing because he tends to be impulsive. Its pacing him; smaller portions. When I initially did his evaluation he needed one to one for pocketing to the left side and needed a liquid wash and he needed cueing. R66 wanted to be fed fast. R66 still needs the supervision. I wouldn't feel 100 percent about leaving him alone, he needs supervision. My biggest concern is his impulsiveness when eating. He loves talking with food in his mouth. He likes to drink big sips. I don't like the straws because fluid comes up to quickly and if you suck real hard it can go down the wrong pipe. Yesterday was the first day I saw them using a sippy cup. Sometimes they have him a little to reclined at the table and I tell the CNA's that he needs to be upright. I am just concerned with choking. The Dietary Note dated 9/13/19 for R66 showed, Registered Dietician consult. [AGE] year old male presents upon admission with potential for altered nutrition status related to a past medical history of [REDACTED]. Diet recently upgraded. General diet, regular texture, thin consistency appropriate to meet estimated nutrient needs Special instructions: regular diet with 1:1 supervision, small bites and small sips. After 1-2 bites give liquids to wash clear. The Speech Therapist notes for R66 showed: On 9/16/19 he presented with reduced chewing and difficulty with the consistency of the food that day that resulted in a choking episode. On 9/17/19 R66 required pacing to reduce the risk of coughing/choking and overall risk of aspiration. On 9/20/19 R66 had a choking episode on thin liquids. On 9/22/19 there were some safety issues with the CNA who was providing feeding assist to R66 who was in a slightly reclined position. Speech therapy educated on the best position for feeding is as upright as possible; 90 degrees. On 9/27/19 R66 stated he didn't think it was necessary to take smaller bites. On 9/30/19 R66 had incomplete clearance of foods; he is on regular foods and given small bites. On 10/1/19 R66 requests larger bites and if not careful he will take large sips from straw of liquids leading to increased coughing. On 10/2/19 R66 was given feedback on increasing the use of his left arm/hand to use for feeding while pacing as he attempts to eat faster that he should increasing the risk of choking/coughing. The Speech Therapist note dated 10/4/19 for R66 showed, Long term goals: The patient will safely consume regular consistency while facilitating 1:1 feeding assist to decrease signs and symptoms of aspiration or penetration risk to independent. Patient continues to require skilled speech therapy services to focus on treatment of [REDACTED]. Prognosis for further progress: good due to significant decrease in aspiration. Swallow response time improving; however, R66 tends to be impulsive if not verbally and physically cued to take smaller bites and slow down.

Based on observation, interview and record review, the facility failed to implement pain relief interventions for a resident when scheduled pain medications were depleted, resulting in a resident experiencing pain, [MEDICAL CONDITION] and crying. This applies to one resident (R19) in the supplemental sample. The findings include: On October 25, 2017 at 11:05 AM, R19 was in a wheelchair in her room. R19 was alert and oriented and began crying when talking about the pain experienced this past weekend when the facility ran out of her pain medication. R19's September 12, 2017 MDS (Minimum Data Set) shows a BIMS (Brief Interview for Mental Status) score of 15 which indicates a cognitively intact resident. MDS dated [DATE] reports a [DIAGNOSES REDACTED]. On October 25, 2017 at 11:05 AM, R19 said they ran out of my [MEDICATION NAME] for the second time in a couple of months. It was a nightmare. I was up all night. My pain was a 10 and everything hurt even my teeth. I was depressed. At 12:50 PM, E2 DON (Director of Nursing) said if pain medications are not given as ordered pain control could be an issue. If controlled medication is not signed out on the disposition form it was not given. On October 26, 2017 at 10:45 AM, E2 said it is her expectation that prescribed medication is available to residents and reordered in a timely manner so it does not run out. The physician should be notified if a medication is not available to see if any alternative medications could be given in the interim. The facility's Pain Management Policy dated May 2017 shows the facility will develop an effective individualized pain management care plan for residents. R19's pain care plan started March 4, 2013 shows medications will be administered. This care plan has not had a new intervention since December 13, 2013. The facility's Medication Administration Policy dated May 2017, shows all medications must be administered to the resident in the manner and method prescribed by the physician. In the event that a medication cannot be given, the reason must be documented in the Nurses Medication Notes on the MAR indicated [REDACTED] The facility was unable to provide any documentation to show R19's physician was notified in August or October 2017 when R19's [MEDICATION NAME] supply ran out. R19's prescription order dated June 7, 2017 documents to administer [MEDICATION NAME] concentrate 10 milligrams (0.5 milliliters) four times daily (6 AM, 12 PM, 5 PM, and10 PM). In addition, R19's prescription order dated May 20, 2016 shows an order for [REDACTED]. R19's controlled drug disposition forms for [MEDICATION NAME] concentrate dated August 2017 documents no dose was given on August 5, 2017 at 10PM. None of the four ordered doses (8 doses total for both days) were given on August 6 or 7, 2017. And on August 8, 2017, the 6 AM dose was not given. R19's August 2017 controlled drug disposition forms shows a total of 10 [MEDICATION NAME] doses not administered to R19 on August 5-7, 2017. R19's controlled drug disposition forms for [MEDICATION NAME] concentrate dated October 2017 show no dose was given at 10 PM on October 20, 2017. None of the ordered four doses were given on October 21, 2017. And on October 22, 2017 the 6 AM, 12 PM, and 5 PM doses were not given. R19's October 2017 MAR indicated [REDACTED]. The same MAR indicated [REDACTED].

Based on observation, interview and record review the facility failed to identify a causative agent for a rash spreading throughout the facility and failed to implement contact precautions to prevent the spread of infection. This applies to 24 of 36 residents (R1-R3, R5, R7-R8, R10, R11-R21, R24-R29) reviewed for infection control. This failure contributed to residents experiencing, pain, discomfort and bleeding. The findings include: On 10/20/14 at 3:25 PM, E3 (ADON) said, in August we treated the entire house for scabies. There were 2 confirmed cases of scabies. The Nurse Practitioner has been working with the Dermatologist. Two different Doctors did scrapings and skin biopsy 's ( in August). One of the residents was discharged and the other resident is still here. That 's when we made the decision to treat the whole facility. Visitors and Families were still allowed to visit. Last week we identified 20-22 residents who had something (skin rash). The Nurse Practitioner said it 's atypical (the rash) not what you typically see with scabies. We did not put the residents on contact isolation. Staff should be wearing gloves and washing thier hands. The Rash-Type Infection Control Report of October 2014 showed 24 residents R1-R3, R5,R7,R8,R10,R11-R21, and R24-R29 were treated with [MEDICATION NAME] cream (scabicide). On 10/20 /14 at 1:30 PM, R1 's rash was on her upper back, lower stomach, neck, and right thigh. The rash appeared red, round and pimple-like. R1 stated, " My neck is itching. " R1's Skin Assessment Sheets for October shows the rash started on 10/6/14. On 10/20/14 at 10:50 AM, R3 was scratching her upper body. At 11:00 AM, R3 stated, " It itches like crazy. " On 10/21/14 at 10:10 AM, R3 was scratching her upper body. R3 stated, " It 's driving me crazy." At 11:15 AM, R3 had several red small round pimple like rash areas on her chest, stomach, and upper back. E4 (Registered Nurse-RN) lifted R3 's shirt with no gloves on. E4 stated, "To me it looks a lot better." R3's Skin Assessment Sheets shows the rash appeared on 9/25/14. On 10/20/14 at 1:45 PM, R7 had a red dotted rash throughout her chest and a scab on the top of her head. R7 stated, "My chest is itching." The Skin Assessment Sheets for September 2014 showed R7 's rash started on 9/12/14, the document's written note stated, " Resident very itchy, red marks skin looks different." On 10/21/14 at 11:30 AM, R8 had a red pimple like rash on her neck, back, and upper body. E8 and E15 (both CNA's) said, "R8 has had her rash for a while. R8 scratches a lot around her neck and stomach. "The Skin Assessment Sheet for R8 showed the rash started on 9/12/14. On 10/21/14 at 11:40 AM, R5's red pimple like rash was on top of his head, chest, back, and neck. R5 stated, "It is very itchy. I will scratch it and it goes away then it bleeds. " E8 and E15 (both CNA's) stated, "When we get here in the morning R5 's sheets are bloody from him scratching. "The Skin Assessment Sheet for R5 showed the rash appeared on 9/18/14. The September 2014 MAR shows, on 9/26/14 R2 was treated with [MEDICATION NAME] cream. R1 is R2's roommate. R1 did not receive the treatment that day. R1 and R2 were both treated on 10/13/14. On 10/20/14 at 9:30 AM, E10 (Registered Nurse) said, the residents who were treated with [MEDICATION NAME] were not put on contact isolation ...If they have a roommate their roommate should be treated at the same time." On 10/20/14 at 9:30 AM, E7 (CNA) stated,"I had scabies on my breast area." On 10/20/14 at 11:05 AM, E21 (Registered Nurse) stated, "I've been coming here since April and they have had this rash. They have not isolated anyone ...They are not doing something right." On 10/20/14 at 1:10 PM, E5 (Licensed Practical Nurse) said, staff did use gloves while providing care to residents with the rash. Staff did not wear gowns. The residents with the" rash" did not get put on contact isolation. On 10/20/14 at 2:50 PM, E23 (CNA) stated,"I treated myself with [MEDICATION NAME] (scabicide) last month and last week. No precautions were put in place. No directions were given to staff on what to do wear (gloves or gowns). We were told it was just a rash." On 10/21/14 at 10:35 AM, E6 and E16 (both CNA's) said, staff are to were gloves when entering the room with residents who have the "rash." Staff have not been wearing gowns while providing care. The residents have not been on contact isolation. E16 (CNA) stated, " I treated myself 7 times" with [MEDICATION NAME] (scabicide.) On 10/21/14 at 1:35 PM, E17 (Housekeeping Manager) said, we deep cleaned all the rooms top to bottom. All laundry was cleaned and bagged up. My staff wore gloves during cleaning, but did not wear gowns. On 10/21/14 at 2:00 PM, Z1 (Medical Director) stated, "Nothing is going on ...Every time someone gets a rash, staff goes nuts. It's all Psych, it's in their heads. No it 's not scabies. We follow the CDC guidelines. Residents should be on contact isolation." On 10/22/14 at 1:15 PM E3 (Assistant Director of Nursing-ADON), stated,"I don' t have any idea where this rash is coming from. We treated the entire house back in August 2014. We did not put residents on contact isolation." On 10/21/14 at 9:00 AM, Z4 stated, "My dad had surgery and had to go the nursing home. So about 1 month before his discharge (May 2014) he was to be released he was complaining of severe itching. The LPN said it was dry skin, so I bought some Aloe Vera lotion. It didn't help so the day he was discharged he was still complaining of itching. We have caregivers at home who come for a few hours a day they both got it (scabies). They went to a Dermatologist who confirmed the diagnosis. I got it, I went to the VA hospital. They gave me [MEDICATION NAME] (scabicide). I put it on my body all over and still a month later it returned again. We have been battling it ...my sister has it too. My father has it on his chest, torso and arms. At night it's especially bad. He screams and hollers in pain, and scratches like crazy. The rash looks like red pimples, bumps with white centers. He's miserable ...I don ' t want this for anyone. I am trying to prevent it from spreading to others, kids and visitors. This is very contagious. They need good training over there. They need to put the residents in isolation." The facility's undated Scabies Policy states, "Standard Precautions and Contact Precautions ...gloves and gown when giving direct care or indirect contact with linens,clothing, and other materials during infestation time. While the resident is on Contact Precautions, the housekeeping staff will wear gloves and a gown while handling the bed linens and clothing...the roommate of an infected resident [MEDICATION NAME] scabicide treatment is recommended ...If two or more residents in different rooms on the same floor are diagnosed with [REDACTED]..Floor staff will wear gowns or other protective clothing ... According to the CDC guidelines for the treatment of [REDACTED]., use Contact Precautions for all patients or residents for 24 hours after treatment ... "

Based on observation, record review, and interview the facility failed to keep a resident from being physically abusive toward a resident and failed to remove staff from direct care after an incident with (R5). This failure resulted in R11 being abused by the same staff person and R14 having the potential to be abused. This applies to 3 of 5 residents (R5, R11, R14) reviewed for abuse in the sample of 15. The findings include: R5's November, 2013 physician's orders [REDACTED]. R5's Minimum Data Set (MDS) assessment of 9/24/13 documents that R5 requires extensive assistance of two or more persons for transfer, and dressing. R5 was unable to complete the cognitive summary assessment. The Occurrence Report dated 11/17/13 documents that it was reported to E1 (Administrator) that E5 (Certified Nursing Assistant) was rough with R5 when providing care. The police were notified. On 11/19/13 at 9:30 AM, E7 (Human Resources) said that she had been the house supervisor the past Sunday (11/17). She said that Z2 (Agency Nurse) reported to her that E5 (CNA) pushed R5 against the wall striking his knees. (Rolling R5 in his bed) E7 said that she called E1 (Administrator) and E2 (Director of Nursing) and was told to send E5 (CNA) home. E7 said that while she was calling E1 and E2, E5 was in the room of R14. R14's Minimum Data Set (MDS) assessment of 7/31/13 shows that she was unable to complete the cognitive summary test, and requires extensive assistance with activities of daily living. E7 said that she had heard that R11's family had reported that E5 was also rough with R11. E7 said " I don't like it, I think some of the rooms are small, and sometimes she (E5) is a little rough." E7 said that Z2 (Agency Nurse)) had asked E5 (CNA) to stop taking care of R5 and go assist R11 because the family wanted him to lay down. R11 was having trouble breathing. E7 said she went to R11's family and told them that she had sent E5 (CNA) home. E7 said in her opinion E5 was physically abusive to R11. E7 said that R5 does not speak, but E19 the nurse heard R5 say "ouch" when E5 pushed him and struck his knee. On 11/19/13 at 10:55 AM Z2 (Registered Nurse/Agency) said that she was not aware that E5 (CNA) had been approached by another nurse to go and help R11. She said that R11 was short of breath and his family was asking for help. The family asked how much longer would E5 be. I asked E5 if she could stop taking care of R5 and go help R11. She (E5) said " Is that patient more important than the one I am taking care of ?" Z2 said I asked her again if she could just stop for a minute and go help R11. E5 (CNA) pulled the dresser draw out hard and it fell on the floor. I asked E5 if that was necessary. I saw R5 come back quickly in his bed, like bouncing back from the wall. I saw E5's hands coming down. She pushed R5 hard into the wall. I checked out R5 he had a red area on his knee. I made a written report to E7 (supervisor that day). On 11/19/13 at 10:00 AM, E6 (CNA) said she went down the 200 hall when she came into work on Sunday. (11/17) She said she started around 6:00 AM. She said that at 7:00 AM she had gone to the 100 wing to help put R11 to bed. I went to help out because I heard the family was asking to have R11 put to bed. I knocked on the door of R11's room and saw that R11 was already bed. Z1 told me the girl who put R11 to bed was very rough with him. She told me that when E5 put the stand lift up to him , and didn't give him an opportunity to hold on, she pushed him in the lift and hit the back of his legs on the bed frame. Z1 said E5 then walked out without saying a word. E6 said I asked if R11 was ok and Z1 said yes. Z1 said she did not appreciate the way E5 was treating R11. E6 said she reported the incident to the nurses who were in the employee lounge giving report. She said that E19 (Licensed Practical Nurse) E20 (Registered Nurse), Z2 (Agency Nurse), and E21 (nurse) were in the room. 30 minutes had passed since I reported it to them around 7:00 AM, and E5 was still on the floor. I called E1 (Administrator) and told her what happened and she said that E7 had to send E5 home. E5 was also in the room of R14. I know an officer came in to look at R5's knee. He had an abrasion, red marks, looked like a scrape. On 11/19/13 at 11:00 PM E1 (Administrator) said that on Sunday, she had gotten a call from E7. I told her to call the police and send a report to IDPH. The police came in and talked to the nursing staff and took a picture of R5's knee. The police came back and asked to have E5 return to the facility so he could speak to her. R11's family also reported that E5 had been rough with R11. I wish someone else would have gone to help R11. E5 should have been removed from the floor immediately and not had an opportunity to go care for other residents. (R11, R14) R11 should not have been subject to that. E5(CNA) has been counseled by E2 (Director of Nursing) before, for "mouthing off to the nurses." On 11/19/13 at 10:15 AM E2 said that she received several calls on Sunday morning. E5 called her and said she was being sent home. She told me she was being sent home, because the nurses were hounding her to leave R5 and take care of another patient. She said she was getting upset and said " Is that patient more important than this one?" The nurses told me they explained to E5 that R11 was having shortness of breath. They wanted him put to bed and elevate the head of the bed. She (E5) said that that was not explained to her. She did say she pulled out a drawer and it fell on the floor in R5's room. E5 said Z1 (agency nurse) asked "Is that really necessary?" Z1 told me she heard R5 say "ouch" and she saw out of the corner of her eye, R5 rolling back toward E5. She (Z1) said R5 had a red mark on his knee. Another nurse heard R5 say "ouch" out in the hallway. E2 said R5 is not really verbal, but he knows pain. Nurses told me that they assisted R11 to lay down, not E5. E6 then told me that the family said E5 was rough with him when she put him into the bed. No one saw this it was just reported by the family to E6. On 11/18/13 at 1:10 PM, Z1 said that on Sunday, a CNA was rough with her dad. She said the CNA came in and was "jerking" her dad around. She started lifting him in the stand lift before he could even hold on. She was in a bad mood. She did not even say a word to him. I was told later that she got sent home. On 11/18/13 at 1:20 PM, R11 said that she (E5) "was smart with me, she was rude, it was like you'll do it my way or you can go down the road." A Police Report dated 11/17/13 documents the following: R5 was observed and had a 1.5 inch by 2.5 inch mark/bruise on his right knee. I took two photos of the mark. I then had E7 call E5 back to the facility so I could talk to her. When E5 (CNA) arrived I could tell she was agitated. She spoke loudly and advised me to follow her into the office. We went into the office to talk. E7 was there during our whole conversation. I asked E5 what happened. E5 said that on more than one occasion that morning her co-workers had asked her to stop dressing R5 and help another resident. E5 repeatedly told them she was already busy. E5 said that Z1 had eventually "pushed her button" and caused her to "go off" because they kept asking her to stop helping R5 and go help another resident. E5 advised that she then rolled R5 over on the bed and he hit his knee. I asked her if she thought she maybe was a little too aggressive when she did it because she was upset. E5 said "No, I was f...ing pi..sed." E5 was arrested for battery.

Based on observation, interview and record review the facility failed to identify and treat pressure ulcers to resident's heels prior to the wounds becoming Unstageable. The facility failed to identify a pressure ulcer to a resident's coccyx prior to a Stage II. The facility failed to inspect the skin under a splint device and failed to identify specific risk factors and develop a prevention plan for R15. The facility failed to prevent pressure ulcers to the right calf and ankle under a splint device and failed to consistently off-load pressure to R15's heels. The facility failed to follow their wound management policy by not conducting quarterly skin risk assessments for R15. These failures resulted in R14 developing an unstageable pressure ulcer to the left heel on 5/28/11. R18 developed an unstageable pressure ulcer to the left heel on 7/22/11. R15 developed pressure ulcers under the splint device on 8/10/11 and an unstageable pressure ulcer to the left lateral heel on 11/9/11. This applies to 4 of 7 residents (R14, R15, R17, R18) reviewed for pressure ulcers in a sample of 19. The findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set of 5/22/11 shows that R14 requires total assist of 2 staff for bed mobility. The Nurse's Notes of 5/10/11 states, "(Nurse) in the ER reported that (R14) has a [MEDICAL CONDITION] tibia/fibula." (R14 was involved in a motor vehicle accident while out of the facility with her husband and had been thrown out of her wheelchair., causing the injury.) R14 returned to the facility on [DATE] with a soft cast in place. The Nurse's Notes dated 5/27/11 states, "Bowel movement seeped down into splint and dressing. This writer entered (R14's) room to change dressing. After removal of splint and old dressing noted 18 x 18 cm dark brownish discoloration to left upper posterior thigh of unknown origin. Also noted a 4.0 x 2.5 x UTD (unable to determine)cm dark purple discoloration to left heel. Unstageable due to suspected deep tissue injury.....Resident is on complete bed rest at this time." R14's Braden Scale for predicting pressure sore risk dated 5/23/11 shows that R14 scored a 12. (High Risk) R14's care plan with a start date of 1/27/11 states, "Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences." The undated facility policy entitled Pressure Ulcer Risk Assessment Policy and Procedure states, "Based on the results of the Pressure Ulcer Risk Assessment, all residents AT HIGH RISK for pressure ulcer development will receive a documented daily visual inspection of their skin by the RN/LPN or CNA delivering care. All other residents will have a documented weekly review of skin condition utilizing the CNA Skin Attention Form.." 2. R15's November, 2011 physician's orders [REDACTED]. R15's Minimum Data Set (MDS) assessment of 9/14/11 shows that R15's cognitive summary score is 05. ( 00 - 07 = Severe Impairment) R15 is totally dependent on one person for bed mobility. R15 is dependent on two or more persons for transfer .R15 has functional limitation in range of motion of both lower extremities. R15 is incontinent of urine and bowel. The same assessment shows that R15 has a fracture. R15's Braden Scale Assessment of 4/1/11 documents a score of 12. (12 or less = high risk) (Last documented skin risk assessment) R15's Nursing Notes for 8/7/11 documents that R15's knee was extremely swollen and painful, with an area of redness to the medial aspect of the right knee. An occurrence report dated 8/8/11 documents that R15 had an x-ray of the right knee which showed a moderately displaced [MEDICAL CONDITION] femur. The same report shows that R15 returned to the facility from the hospital with a leg brace on. R15's Nursing Notes for 8/10/11 at 10:00 AM documents that R15 had a 1 cm x 1 cm (centimeter) red area on the posterior ankle that was under a right leg brace. The same note documents that R15's right leg brace did not fit properly because it was too big. R15's Nursing Notes for 8/17/11 at 8:00 PM, documents that R15 had an open area on the left lateral ankle. R15's Nursing Notes for 8/19/11 documents that R15 has 2 open areas on the right lower calf. One open area is described as 1 cm with a 6.5 cm open center. (This note describes the center wound opening as larger than the total wound surface) The other area is described as 0.10 cm x 6.10 cm area of redness with a 0.4 cm x 0.4 cm open area. On 9/28/11 at 9:00 PM the notes show : splint removed due to observed sores on posterior ankle and pedal [MEDICAL CONDITION] on the top of the right foot. The splint had slid down till around the ankle and while up foot hanging over edge of splint caused rubbing to the posterior calf and impeded circulation. Dents running on the proximal to distal on the posterior leg matches the metal stays on the splint. On 10/19/11 at 6:00 AM R15's Nursing notes shows that R15 has a 2.0 cc x 2.0 cm red area on her mid back. On 11/9/11 Nursing Notes at 5:00 AM documents that R15 has unstageable necrosis (devitalized tissue) to the left lateral heel. R15's current care plan for pressure ulcer dated 9/21/11 through 12/19/11 does not identify the use of a splint device or approaches for monitoring the skin under the splint. The care plan does not document off loading pressure to R15's heels. On 11/16/11 at 7:55 AM, R15 was observed in a high back wheel chair with her feet resting on the foot rests, wearing quilted type boots to her feet. (Heels were not off-loaded.) According to the facility Wound Management Policy; At risk residents will be reassessed at least quarterly and additionally in the event that there is a significant change in physical condition. The policy does not include inspection of skin under splint/brace devices. 3. The Nurses Notes dated 7/14/11 for R18 showed, "R18 admitted to facility.... Right groin has new incision site with 4 staples, well approximated without signs and symptoms of infection noted at this time. Left groin has small bruise noted. Right inner knee area has 9 staples on new incision without signs and symptoms of infection noted; well approximated. Top of right foot at ankle area, R18 has new incision area with 6 sutures noted. Site well approximated also without signs and symptoms of infection noted at this time. Right great toe amputated with open wound dressing changed to area so [DEVICE] was started earlier. 3rd toe - right, has open area to tip of toe, right side. Area cleansed with new dressing applied. Slight yellow drainage noted to toe wound. Buttocks and coccyx area slightly red." The physician progress notes [REDACTED]. He had a traumatic amputation of his great toe for gangrene. He currently has a [DEVICE]. During his hospitalization he had a right popliteal to dorsalis pedis bypass to hopefully resolve some of the circulatory problems to his foot. R18's Nurses Notes dated 7/22/11 showed, "Physical Therapist brought to this nurses attention that resident had a small amount of drainage on sheet under his left heel. Upon further examination, noted 2cm by 2cm open area to left heel. Border of wound is irregular in shape and has a grayish/white center. Heel protectors initiated. Attempted to call nurse practitioner to report unstageable pressure ulcer to left heel." The physician's orders [REDACTED]. Left heel - [MEDICATION NAME] twice a day." The Wound Care Center Note for R18 dated 8/4/11 showed, "Use/wear when in bed: Pressure relief boot when in bed." On 11/16/11 at 10:55am, E10 (Wound Care Nurse) stated, "I am here for 8 hours per week to do treatments. I rely on everyone to make sure interventions are in place and effective." The facility's Skin Assessment Policy showed, "Upon admission to the facility the following will be assessed: Risk for developing pressure ulcers using valid assessment of pressure ulcer risk. General skin condition. History of ulcers and skin condition. Current ulcers.; On admission, a head to toe assessment of the resident's skin will be completed by a licensed nurse along with the admission nursing history. Residents' who are determined "At High Risk" for the development of pressure ulcers will have a head-to-toe skin assessment done by a licensed nurse or CNA (Certified Nursing Assistant) daily and documented on the Daily Skin Assessment record or the Treatment Administration Record (TAR).; All residents, regardless of risk, will have a documented weekly review of skin condition utilizing the CNA Skin Attention Form. The Skin Assessment Sheet dated 7/21/11 for R18 showed, "No new issues. See treatment record." The Pressure Sore Risk Score for R18 on 7/15/11 was documented on the form as a 19. A total score of 12 or less represents high risk. The Care Plan dated 7/14/11 for R18 showed, "Right groin has 4 staples; Left groin has bruises; Right upper calf (just below knee area) has 9 staples.; Right top of foot by ankle area has 6 sutures. Right great toe amputated with [DEVICE] dressing.; Right third toe has open wound with puss.; Coccyx and buttock slightly red.; Approach: 7/22/11 - [MEDICATION NAME] to left heel twice a day.; 7/23/11 - Wound treatment to wound bed on left heel. Apply [MEDICATION NAME] around wound bed. Cover with dry dressing twice a day. Bactrim DS, 1 by mouth every 12 hours for ten days - wound infection." 4. On 11/16/11 at 10:45am, R17's gel cushion was observed to be flattened out. E10 (Wound Care Nurse) was present and confirmed the observation. R17's Nurses Notes dated 7/8/11 showed, "Noted abrasion to R17's coccyx measures 2.0 by 1.0 by 0.05cm with [MEDICATION NAME] tissue noted. Scant serous drainage noted. Gel cushion in wheelchair." The Weekly Pressure Ulcer Report dated 7/17/11 for R17 showed, "Date Acquired: 7/8/11.; Facility acquired. Ulcer site: Coccyx.; Stage III.; Minimum Data Set (MDS) Stage: III.; Size: 4.0 x 1.5 x 0.1cm; &5% devitalized & 25% granulation.; Serous exudate.; Slight odor." The Weekly Pressure Ulcer Report for R17 showed on 7/24/11 the coccyx wound was "unstageable." R17 continues to have the pressure ulcer to her coccyx and the Weekly Pressure Ulcer Report dated 11/13/11 showed, "Date acquired: 7/8/11.; Facility acquired.; Ulcer site: Coccyx.; Healing unstageable.; MDS Stage: Unstageable.; Size 0.6 x 0.2 by 0.2cm.; 100% granulation tissue." On 11/16/11 at 10:55am, E10 (Wound Care Nurse) stated, "I am here for 8 hours per week to do treatments. I rely on everyone to make sure interventions are in place and effective." The facility's Management of Wounds Policy showed, "Pressure Ulcers - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Pressure ulcers are staged to determine the extent of tissue damage. treatment of [REDACTED].; Managing tissue load: It is the policy of this facility to manage tissue load and improve tissue tolerance to pressure, friction, and shearing forces. This will be accomplished through the use of appropriate positioning practices, positioning devices, and support services." R17's Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/12/11 showed short term memory impairment, long term memory impairment and cognitive impairment.; Extensive assistance required for bed mobility, transfer, dressing, toilet use, personal hygiene and bathing.

Based on interview and record review the facility failed to supervise a resident with cognitive impairment, during mealtime on 11/11/2010. R1 spilled a cup of hot coffee onto her abdomen and upper legs, causing 2nd degree, Deep Partial Thickness burns. This failure resulted in R1 being transferred to a burn unit for care and debridement of the burns. This is for 1 (R1) of 1 resident's reviewed with 2nd degree, Deep Partial Thickness burns to the abdomen and bilateral thighs. The example includes: R1's Physician order [REDACTED]. R1's medications include scheduled subcutaneous insulin injections 3 times daily and extra doses of insulin based on blood glucose levels 4 times daily. A physician progress notes [REDACTED]. R1's Minimum Data Set (MDS) of 10/19/2010 shows that the resident has short and long term memory deficits and requires supervision. The MDS documents that R1 requires extensive assistance in eating. Nurses notes of 11/11/2010 at 12:25 PM, shows that R1 spilled a cup of hot coffee on her abdomen and lap. The 9:00 PM entry documents that there are blisters with redness over the resident's bilateral upper legs and abdomen. On 11/14/2010 at 11: 00 AM, the Nurses Notes document that the wounds to R1's upper thighs are larger in size. The left upper thigh wound is documented to be approximately 10 centimeters X 4.5 centimeters with increased bright green slough. The notes document that the resident has multiple large blisters noted with surrounding areas of redness. The resident was transferred to a hospital burn unit per physician orders [REDACTED]. A hospital History and Physical (H&P) dated 11/14/2010, documents the resident's assessment as "Liquid burn. Second degree burn to abdomen and bilateral thigh 5-6 % TBS (Total Body Surface). The H&P shows that the resident was admitted to the burn unit for debridement and burn management. The H&P states, "Today the nursing home called the patient's doctor and was directed to be evaluated here. The patient is a brittle diabetic with Dementia secondarily from Alzheimer Disease." An inpatient progress note dated 11/20/2010 shows that R1 was treated with Unasyn (antibiotic) because the wounds were cellulitic (infection of the tissue). The Progress Note shows that all 3 burn areas were debrided. The wounds are documented to be Deep Partial Thickness Burns to the abdomen and bilateral thighs. Partial Thickness Burn - Care Guide (www.drugs.com) states that partial thickness burns are caused from scalding which are burns from hot water, steam, or liquids, such as boiling water, coffee, or tea. The online Merck Manual (www.merckmanuals.com) states, "Surgery is indicated for burns that are not expected to heal within 2 weeks, which includes most deep partial-thickness and all full -thickness burns...". Emergencies: Burns: From Treatment to Prevention (www.the doctorwillseeyounow.com) states that a moderate burn should be managed on an inpatient basis and includes patients with Diabetes and elderly patients with a 5-10% TBS burn. On 11/23/2010 at 8:15 AM, E2 (Director of Nursing) said that R1 requires assistance and supervision with feeding. E2 said that she frequently falls asleep during the meal and has to be woke up and encouraged to eat. E2 said that on 11/11/2010, the resident had requested coffee and E4 (Certified Nursing Assistant) went to the kitchen window to get the coffee. E2 said that the coffee was put poured directly from the coffee maker into the resident's plastic coffee cup. E2 said that the cup did not have a lid on it. E2 said that the temperature of the coffee that day was 170 degrees Farenheit (F). On 11/23/2010 at 10:50 AM, Z1 (Coffee machine representative) and E3 (Food Service Supervisor) were interviewed. Z1 said, "The brew extraction temperature is 185-205 degrees F." E3 said, "The coffee machine temperature cannot be adjusted, but does have a night brew function, which lowers the temperature of the coffee somewhat. Since R1 getting burned, we have put the coffee machine on night brew." The coffee machine's manufacturers book shows that the coffee maker has a digital temperature adjustment. It states, "...you have the option to set the brewing temperature precisely where you want it. The low temperature brew lock-out feature ensures adequate water temperature." The Nutrition Care Systems Resources - Nutrition and Food Sanitation Consulting (www.nutritioncaresystems.com) states, "While many people like their coffee or other beverage in the 170-200 degree range, this can present a risk to facility residents who are cognitively impaired, have weakness, or are fatigued, have difficulty with motor skills, or just require assistance to eat and drink. These residents need to be monitored closely by staff at meals-perhaps including this risk in the resident's individual care plan, and possibly conducting a staff training program on how to safely serve hot beverages or soups. Many facilities have adopted a policy of beverages leaving the kitchen between 130-135 degrees...". The Hot Water Burn & Scalding Graph (Copyright 2004-2005) shows that hot liquid will cause 2nd and 3rd degree burns in less than 0.5 seconds at 170 degrees. The Serve Hot Foods Hot (www.RDOffice.net) documents that coffee, hot tea, soup, and hot chocolate are typically served at a hotter temperature than what is considered safe. The article states, "Research suggests people prefer coffee served at 136 degrees F...". The article states that to prevent food burns to individuals with mental impairment, hot beverages should be allowed to cool before giving it to the residents. It also suggests serving hot beverages with a lid and pouring hot beverages into a ceramic mug or cup to dissipate heat. The Coffee Cooling Problem(http://demonstrations.wolfram.com/TheCoffeeCoolingProblem/) states, "Freshly brewed coffee, immediately after being poured into a cup, has an approximate temperature of 185 degrees F. The coffee becomes safe to drink after it cools to 143 degrees F." On 11/23/2010 at 10:50 AM, E2 said that the facility does not do safety assessments to determine if residents can handle hot liquids. E2 said, "We consider all residents to be at risk." Prior to the 11/11/2010 incident, R1 did not have a careplan showing her need to be assisted with hot beverages. R1's 10/22/2010 Nutrition Care Plan does not list approaches to assist the resident with eating. The care plan just shows that the resident needs to be encouraged with her food and fluid intake. On 11/23/2010 at 10:30 AM, E3 (Dietary Manager) said that the facility does not have a policy on hot liquids. The Mosby's Testbook for Nursing Assistants, 6th Edition (page 161) states, "Burns are a leading cause of death. Children and older persons are at great risk...spilling hot liquids...are common causes." The Safety Measure to Prevent Burns (Box 10-4, page 161) states, "Assist with eating and drinking as needed. Spilled hot foods and fluids can cause burns."