Every finding on record at Nexus at Mascoutah

Based on interview and record review, the Facility failed to prevent accidents for 1 of 3 residents (R2) reviewed for quality of care in the sample of 4. Findings include:Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including quadriplegia. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, used wheelchair, and was dependent for transfer. R2's Physician Order dated 7/22/26 documents (mechanical lift) via two (person) assist only every shift. On 8/21/26 at 7:50 AM, R2 was lying in bed in his room. He stated around 8/6/26 staff tried to pick him up out of his wheelchair in the mechanical lift and forgot to take off the seat belt from his wheelchair. He stated he was squealing like a pig and telling them to put him down, so after two or three seconds they realized what was happening and unlatched the seat belt. R2 stated he got a bruise on his stomach. On 8/21/26 at 8:25 AM, V3, Licensed Practical Nurse (LPN), stated Therapy came to her and reported the Certified Nursing Assistants (CNAs) tried to lift R2 in the mechanical lift with his wheelchair seat belt on resulting in bruising across his stomach. On 8/21/26 at 9:13 AM, V9, Physical Therapy Assistant (PTA), stated she was going in R2's room with V10, Certified Occupational Therapy Assistant (COTA),. R2 stated he wishes they had been there earlier when he needed them. V9 asked R2 to elaborate and he stated the CNAs were putting him to bed from the wheelchair with the seat belt buckled, and the wheelchair was hanging from his body. R2 reported severe abdominal pain and had redness on his left hip area at that time. On 8/21/26 at 9:40 AM, V10, Certified Occupational Therapy Assistant (COTA), stated R2 told her there was a transfer issue where the seat belt was not removed and he was in the air with his power chair. V10 was unsure whether R2 was injured, but he did complain of abdominal pain. V10 stated she and V9 reported this to V2, Director of Nursing (DON), because it is the Facility's policy to report anything that happens and a resident gets hurt. On 8/21/26 at 10:40 AM, V2 stated Therapy notified her of R2's transfer and she completed an incident report. R2's 8/6/26 Incident Report by V2 documents R2 was being transferred via mechanical lift with the seat belt still attached to the chair. On 8/21/26 at 1:24 PM, V2 stated she would expect staff to unlatch wheelchair seat belts before using the mechanical lift, and there should have never been a seat belt on R2's wheelchair in the first place. The facility's Mechanical Lift policy, revised 10/2025, does not address the use of wheelchair seat belts while using the lift.

Based on interview and record review, the Facility failed to ensure residents were free from abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 5. This failure resulted in a staff member directing a resident to clean feces from the toilet after the resident had used it, which constitutes emotional abuse and a failure to maintain the resident's dignity, respect, and psychosocial well-being. This past non-compliance occurred from 6/24/26 to 6/25/26. Findings include:R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was severely cognitively impaired, independent with walking, and required partial assistance with toileting. R1's Care Plan last reviewed 7/7/26 documents R1 requires assistance with daily care and is at risk for abuse and neglect. The Facility's Initial Report sent to the Illinois Department of Public Health (IDPH) on 6/24/26 documents alleged inappropriate interaction involving R1 and V4, Former Housekeeping Supervisor. An investigation was initiated. The Facility's Abuse Investigation Staff Questionnaire by V5, Certified Nursing Assistant (CNA), dated 6/24/26 documents, (V5) reported that she walked down the hallway past the visitor bathroom and overheard (V4) make the statement 'Oh he is going to clean it.' (V5) then told (V4) that she didn't think (R1) should be doing that. Then (V4) said, 'Come on, (R1).' (V4) then walked away. On 8/6/26 at 8:45 AM, V5 stated she was walking by the bathroom when she heard V4 tell R1 he was going to clean the bathroom. The Facility's Abuse Investigation Staff Questionnaire by V6, CNA, dated 6/24/26 documents, (V6) stated that she walked past the visitor bathroom and saw (R1) in the bathroom, saw (V4) standing in the doorway of the bathroom. She stated that she did see (R1) with gloves on but didn't see what he was doing. (V6) stated that (R1) did not appear distressed in any way. (V6) did hear (V4) complaining about having to clean the bathroom. On 8/6/26 at 1:00 PM, V11, CNA, stated she was at the nurse's station when one of the CNA's asked V4 to come clean the bathroom because there was stool all over the floor. V4 came down and told R1 to clean it up. R1 is confused and did not react, but V11 knew that interaction was wrong and had to be reported immediately. On 8/6/26 at 11:37 AM and 8/7/26 at 10:00 AM, V4 was unavailable for interview by phone. The Facility's Final Report sent to IDPH on 6/30/26 documents, On 6/24/26, it was reported to this writer that the Housekeeping Supervisor, (V4), directed resident (R1) to clean feces from the visitor bathroom toilet after the resident had used it. During the investigation, a few staff members reported observing (V4) standing at the doorway of the visitor bathroom while resident (R1) was cleaning the toilet. One staff member stated she overheard (V4) complaining about having to clean the bathroom. Another staff member reported hearing (V4) state, 'Oh, he's going to clean it.' That same staff member stated she told (V4) that she did not think the resident should be doing that; however, (V4) ignored the statement and said, 'Come on (R1).' The investigation determined that this directive was outside the Housekeeping Supervisor's scope of responsibility and that the task was not identified as part of the resident's care plan or approved therapeutic programming. Facility expectations require that resident participation in activities or tasks be voluntary, appropriate to the individual's care plan, and not involve duties that are the responsibility of facility staff. Upon completion of the investigation, the facility acknowledged that the Housekeeping Supervisor exercised poor judgment by assigning the resident this task. Although the investigation did not identify evidence of intent to harm the resident, the action was determined to be inappropriate and inconsistent with facility standards of care. Out of an abundance of caution, the Housekeeping Supervisor was released from her position. On 8/7/26 at 7:50 AM, V13, Nurse Practitioner (NP), stated V4's behavior was inappropriate and is a dignity issue. The Facility needs to treat residents with dignity and respect. On 8/7/26 at 9:36 AM, V1, Administrator, stated she expects the Facility staff to follow its abuse policy. The Facility's Undated Abuse Prevention Program Policy documents, This facility desires to prevent abuse, neglect or misappropriation of property by establishing a resident sensitive and resident secure environment. Prior to the survey date of 8/7/25, the Facility had taken the following steps to correct the non-compliance: 1-On 6/25/26, an Ad Hoc QAPI meeting was held to discuss the incident and implement corrective actions. R1 was evaluated for effects, and V4 was terminated.2-The Facility's Abuse Prevention Program Policy was reviewed and enforced.3-All staff were educated regarding resident rights, dignity, respect, prevention and reporting of abuse, and appropriate interaction and communication with residents.4-Audits were performed on five staff to resident interactions weekly and five resident interviews weekly for four weeks.6-Results of audits to be discussed in upcoming QAPI meetings. The Facility's Plan of Correction was verified with interviews with V1, V10, V11, V14, V15 and V16, review of staff education and audits, and review of QAPI meeting agenda.

Based on interview and record review, the facility failed to prevent misappropriation of resident medications in 2 of 7 residents (R1, R2) reviewed for abuse in the sample of 7. This past non-compliance occurred on 6/2/26 with a correction date of 6/2/26. Findings Include:1) R1's Face Sheet, undated, documents R1, in part, has the following diagnosis: Osteomyelitis, Malignant Neoplasm of the Endometrium, Pain in Bilateral Feet, Neuropathy, and OA (Osteoarthritis). R1's MDS (Minimum Data Set), dated 5/27/26, documents R1 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R1 is cognitively intact. R1's Care Plan, dated 5/4/23, documents R1 is at risk for abuse. R1's Progress Note, dated 6/2/26 9:00 PM, documents the following: Resident notified by administrator (she is her own responsible party) of an ongoing investigation regarding a potential medication diversion incident involving facility staff. Resident was informed that a review of medication administration records is being conducted to determine whether any residents may have been affected. Resident was advised that the investigation remains ongoing and that appropriate regulatory agencies and authorities have been notified as required. At the time of notification, no adverse effects related to medication administration were identified. Resident was reassured that measures have been implemented to ensure continued medication, safety and quality of care. Resident was provided the opportunity to ask questions and verbalized understanding of the information provided. R1's Progress Note, dated 6/3/26 at 1:52 PM, documents the following: Family member notified on 6/3/26 of an ongoing investigation regarding a potential medication diversion incident involving facility staff. Family informed that resident may have been affected and that the facility is reviewing medication administration records and investigating the matter. Family advised that no adverse effects have been identified at this time and that appropriate corrective actions and notifications are being made. Family verbalized understanding and was given the opportunity to ask questions. On 7/2/26 at 10:00 AM, R1 was interviewed and was unable to recall any details of the misappropriation of medication. 2) R2's Face Sheet, undated, documents, in part, the following diagnosis: OA, Gout, Chondromalacia of the Right Knee, Patellar Tendinitis of the Left Knee, and Myalgia. R2's MDS, dated [DATE], documents R2 has a BIMS score of 12 indicating R2 has moderate cognitive impairment. R2's Care Plan, dated 3/11/26, documents R2 is at risk for abuse. R2's Progress Note, dated 6/2/2026 9:05 PM Resident notified by administrator (he is his own responsible party) of an ongoing investigation regarding a potential medication diversion incident involving facility staff. Resident was informed that a review of medication administration records is being conducted to determine whether any residents may have been affected. Resident was advised that the investigation remains ongoing and that appropriate regulatory agencies and authorities have been notified as required. At the time of notification, no adverse effects related to medication administration were identified. Resident was reassured that measures have been implemented to ensure continued medication, safety and quality of care. Resident was provided the opportunity to ask questions and verbalized the understanding of the information provided. R2's Progress Note, dated 6/3/26 at 1:54 PM, documents the following: Family member notified on 6/3/26 of an ongoing investigation regarding a potential medication diversion incident involving facility staff. Family informed that resident may have been affected and that the facility is reviewing medication administration records and investigating the matter. Family advised that no adverse effects have been identified at this time and that appropriate corrective actions and notifications are being made. Family verbalized understanding and was given the opportunity to ask questions. On 7/2/26 at 8:20 AM, R2 was interviewed and was unable to recall any details of the misappropriation of medications. The facility Abuse Investigation Final Report on R1 and R2, dated 6/8/26, documents, in part, on 6/2/26 an allegation of abuse and diversion of medications was reported. The summary documents the following: During routine medication review, staff identified evidence that narcotic medication cards had been tampered with. Further examination revealed that narcotic tablets had been removed from the blister pack and replaced with other non-prescribed pills. Upon identification of the concern, the facility immediately secured the affected medications, notified appropriate parties, and initiated a comprehensive investigation. The investigation confirmed that narcotic medication cards belonging to two residents had been tampered with and that the prescribed controlled substances had been removed and replaced with other pills. As a result, the facility substantiated that drug diversion had occurred. Despite extensive interviews and record review, the facility was unable to identify the individual responsible for the diversion. All nurses with access to the medication cart were interviewed. No admissions were obtained, no witnesses observed the diversion, and the investigation did not reveal sufficient evidence to determine which staff member removed the medications. On 7/2/26 at 8:30 AM, V1, Administrator, stated R1 and R2's medication cards, unable to recall the medications, looked like the medication was popped out of the card, a different medication was placed in the card, and tape was placed over the back to seal the medication in. V1 stated they did a thorough investigation and was unable to identify who did it. V1 and V3, ADON (Assistant Director of Nurses), stated neither resident was administered the medication that was tampered with. V3 stated she has been doing the audits and has not had any concerns and there have been no further problems. On 7/2/26 at 10:50 AM, V8, LPN (Licensed Practical Nurse), stated she was doing the narcotic count with V9, LPN, when she noticed that the back of the medication cards belonging to R1 and R2, had been cut open, the 3-4 pills that had been inserted were not the same medications, verified by the number printed on the actual pills, that were supposed to be in there and then the covering had been pushed back over the medications. R8 was unable to recall which medications they were but she believed it was oxycodone on both R1 and R2. V8 stated she spoke with V9 who normally only works the 200-hall, and she was not the nurse that did the narcotic count with the prior shift, so this was the first time she had seen those medications. V8 stated she immediately took the cards of medication, secured them and then reported it to V2, DON (Director of Nurses) On 7/2/26 at 1:15 PM, V2, DON, stated that she had been notified about the discrepancy in the medications with R1 and R2. V2 stated she completed a full narcotic count on all controlled substances. V2 stated both R1 and R2's oxycodone medication cards had some random punch marks where the oxycodone had been removed and another medication, later verified as trazadone was replaced where the oxycodone had been and then the covering had been placed back over where those medications had been located. V2 stated the residents had not been given any of the trazadone that she was aware of. V2 stated she interviewed all of the nursing staff including V10, Agency, LPN, who was the nurse that had worked the 100-hall and had access to the medication cart prior to V8, LPN. V2 stated V10 told her that she had not noticed any of the medications appearing to be opened. The Abuse Prevention Program Facilities Procedures, undated, documents the following, in part, the facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and secure environment. Prior to the survey date, the Facility took the following actions to correct the noncompliance on 6/2/26. Immediate Actions: On 6/2/26, the facility immediately removed all medications identified in the discrepancy from service. The Medical Director and Responsible Parties of both residents were notified. Residents were assessed for any adverse effects with appropriate medical follow up provided. An immediate 100% audit of all narcotic cards were completed by V2 and V3 on 6/2/26. On 6/2/26, the medication carts, medication rooms, and controlled substance records were conducted by V2 and V3 to identify any other residents that may have been affected. Ongoing Monitoring: The following systemic changes were made to ensure the alleged deficient will not recur, prior to the start of their shift, staff will be in-serviced on the abuse prevention policy, the education began on 6/2/26 by V1 and is ongoing. The nursing staff will be in-serviced on controlled substances, drug diversion, narcotic policy, and medication administration prior to the start of their shift. This in-servicing began on 6/2/26 by V2 and is ongoing. To ensure that the alleged deficiency will not recur, the V2 and/or Designee will conduct audits 5 times weekly for 4 weeks of narcotic cards. Any adverse findings will be immediately reported to V1, investigated, and reported to the State Agency as deemed appropriate. Re-education will be provided if deviation is identified. Findings will be reported at the monthly Quality Assurance Performance Improvement meeting.

Based on observation, interview, and record review the facility failed to properly clean an indwelling urinary catheter, failed to complete and document indwelling catheter care as ordered, failed to verify an indwelling urinary catheter flush order, failed to monitor intake and output as ordered, and failed to ensure a resident's indwelling was properly positioned and covered for 3 of 3 residents (R1, R2, R5) reviewed for indwelling urinary catheters in the sample of 11. These failures caused R2 to experience increased pain and sepsis secondary to developing a catheter associated urinary tract infection. Findings Include:1. R2's admission Record document, print date of 8/18/25, documented R2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses including Wernicke's encephalopathy, type 2 diabetes mellitus, chronic gout, insomnia, alcohol abuse, major depressive disorder, polyneuropathy, hypertension, and obstructive and reflux uropathy.R2's MDS, dated [DATE], documented R2 was severely cognitively impaired, dependent on staff for toileting and hygiene needs, and had an indwelling urinary catheter.R2's care plan, initiation date of 6/30/25, documented R2 required use of an indwelling catheter related to obstructive uropathy and was at risk of infection. Care plan interventions include monitor for s/s (signs/symptoms) of UTI (urinary tract infection), notify MD (Medical Doctor) of abnormal findings, staff to monitor patency of catheter, and record output as directed. R2's care plan did not address indwelling catheter care although R2's admission orders, dated 6/30/25, documented indwelling catheter care every shift as needed.R2's TAR (Treatment Administration Record), dated 7/2025, documented an order for indwelling catheter care every shift as needed. This TAR did not document R2's catheter care was completed at all on 7/2/25 nor was it completed on every shift as ordered on 7/11/25, 7/21/25, nor 7/23/25. This TAR documented monitor urine for infection q (every) shift. This TAR did not document this was completed on 7/2/25. This TAR also documented monitor (indwelling urinary catheter) placement q shift. This TAR does not document it was completed every shift on 7/2/25, 7/6/25, 7/10/25, 7/12/25, 7/21/25, nor on 7/23/25.R2's TAR, dated 8/2025, does not document R2's catheter care was completed every shift as ordered on 8/8/25.R2's progress note authored by V12 Nurse Practitioner, dated 7/1/25, documented obstructive and reflux uropathy, unspecified, continue (indwelling catheter) care and management. Monitor I&O (intake and output).R2's catheter output record, dated 7/1/25, did not document any output on 7/1/25, nor did it document R2's urinary output was completed every shift on 7/6/25, 7/8/25, 7/10/25, 7/12/25, 7/13/25, 7/14/25, nor on 7/15/25.R2's output record, print date of 8/20/25, does not document R2's urine output was monitored every shift as ordered on 7/22/25, 7/30/25, 7/31/25, 8/1/25, 8/3/25, 8/5/25, 8/6/25, 8/7/25, nor 8/10/25.R2's fluid intake records for July and August of 2025 are not documented every shift as ordered on 7/1/25, 7/2/25, 7/6/25, 7/8/25, 7/10/25, 7/12/25, 7/13/25, 7/14/25, 7/15/25, 7/18/25, 7/21/25, 7/30/25, 7/31/25, 8/1/25, 8/4/25, 8/5/25, 8/6/25, 8/8/25, and 8/10/25.R2's progress notes, dated 7/3/25, documented at 4 PM while assisting CNA (Certified Nurse Assistant) noted urine in drainage bag to have the appearance of thin beige liquid. (R2's Facily) states she would like this to be expedited. Call placed to NP (Nurse Practitioner) at 4:40 PM, received order to send out to ER (Emergency Room) if family desired. At 4:50 PM, family stated they would like him sent to ER.R2's hospital Discharge summary, dated [DATE], documented R2 was hospitalized with severe sepsis secondary to CAUTI (catheter associated urinary tract infection). Suspect (indwelling urinary catheter) was dislodged or clogged as patient had immediate large volume output with new (indwelling urinary catheter) placement.R2's hospital discharge orders, dated 7/5/25, documented an order to flush R2's indwelling urinary catheter with 30 ML NS (normal saline) BID (two times per day).R2's facility progress note, dated 7/5/25 at 5:55 PM, documented resident returned to the facility by way of (local) EMS (emergency medical service) in company of (R2's Family). Resident is alert and oriented x 1-2, (indwelling urinary) catheter in place draining yellow urine with small amount of sediment noted in the tubing. New orders for amoxicillin 500 mg PO (by mouth) every 12 hours for 7 days and Keflex 500 mg PO 3 times daily for 10 days. Instructions to flush (indwelling urinary) catheter with 30 ml of saline every 12 hours.R2's MAR (Medication Administration Record), dated 7/2025, documented an order, dated 7/5/25, to flush R2's indwelling urinary catheter with 30 CC H20 (water) Q 12 hours. This MAR documented R2's indwelling urinary catheter was flushed with 30 CC H20 Q 12 hours twice a day from 7/7/25 through 7/31/25.On 8/18/25 at 1:55 PM V3 LPN/CPC (Licensed Practical Nurse/Care Plan Coordinator) stated she completed the admission for R2 on 7/5/25, the indwelling catheter flush order didn't specify what it should be flush with. V4 stated she put the order in as water. Surveyor asked V4 what kind of water was used for the flushes and V4 replied tap water. Surveyor requested that order.On 8/18/25 at 2:04 PM V3 came to surveyor and stated I know where that water order came from, it was from the R2's urologist on 8/4/25. V4 presented the order, the order documents catheter flushing every 8 hours. The order does not specify what to flush with.R2's progress note, dated 8/4/25 at 9:27 AM, documented left facility for appointment with urologist. Accompanied by (R2's Family) and CNA (Certified Nurse Assistant).R2's after visit summary from R2's urologist, dated 8/4/25 at 10 AM, documented orders for topical antibiotics around the tip of R2's penis and indwelling urinary catheter flushing every 8 hours.R2's progress note, dated 8/4/25 at 1:18 PM, documented returned to facility at this time. No changes in orders. R2's progress notes do not document the orders to increase R2's indwelling urinary catheter flush to every 8 hours, no documentation of any facility nursing staff calling R2's physicians for clarification of what to flush R2's catheter with, nor does it document a topical antibiotic was ordered for R2's penis pain and infection.On 8/18/25 at 8:06 AM V11, (R2's Family), stated she did inform R2's nurse of R2's new orders from his urologist for topical antibiotics and to increase R2's indwelling urinary catheter to every 8 hours from every 12 hours. V11 stated she provided the facility nurse with a copy of the orders. V11 stated she had a care plan meeting with the facility staff on 8/5/25 to discuss a very long list of issues and she brought up the catheter flush upgrade to every 8 hours as well as the topical antibiotic and R2's reporting of pain at his penis. V11 stated when she visited R2 on 8/8/25 and R2 once again told her the tip of his penis hurt. V11 stated she approached the nurse's station to check on R2's topical antibiotic order and found the facility had never implemented R2's topical antibiotic order.R2's August 2025 MAR documented R2's topical antibiotic bacitracin was not implemented until 8/9/25. This MAR documented flush (indwelling urinary) catheter with 30 cc H20 Q 8 hours for UTI. This was ordered on 8/4/25 by R2's urologist although it was not implemented until 8/5/25 at 4 PM. R2's progress notes do not document any physician notification to clarify what R2's indwelling urinary catheter should be flushed with.R2's Medication Review Report documented R2 had a physician order, dated 7/16/25, for (indwelling urinary catheter) and bag, change monthly and as needed 16 FR (French) with 10 cc balloon.R2's progress note, dated 8/5/25 at 2:22 PM, documented (indwelling urinary) catheter leaking, scant amount of cloudy amber urine in tubing. Bulb deflated, and (indwelling urinary catheter) removed. New #16 FR indwelling catheter inserted with 30 ml normal saline. R2's medical record did not document any orders for a size 16 FR with 30 ml bulb.R2's progress note, dated 8/6/25 at 8:35 AM, documented care plan meeting, met with the whole family and most of the department heads. It continues, we went over his urology appt (appointment) wants his (indwelling catheter) flushed every 8 hours instead of 12.R2's progress note, dated 8/12/25 at 7:15 AM, documented nursing notified provider that resident had a fall early this am where he slid from his bed to the floor. Post fall BP (blood pressure) was 70s/60s. Additionally, labs that resulted overnight revealed WBC (white blood cell) was critical high at 38k (38,000), with elevated procalcitonin level as well. Gave order to send resident to ED (emergency department) d/t suspected septic shock.R2's critical care medicine history and physical note, dated 8/12/25, documented septic shock, etiology likely secondary to PNA (pneumonia) vs CAUTI. (Indwelling catheter) replaced in ED due to leaking around cuff on 8/12. 2L urine output returned.2. R1's admission Record, print date of 8/18/25, documented R1 has diagnoses including rheumatoid arthritis, malnutrition, chronic fatigue, heart failure, altered mental status, neuromuscular dysfunction of bladder, cognitive communication deficit, hypertension, and acquired absence of right shoulder. R1's MDS (Minimum Data Set), dated 7/11/25, documented R1 is moderately cognitively impaired.R1's care plan, undated, documented R1 has an (indwelling urinary catheter) related to neurogenic bladder and is at risk of infection. Interventions include keep drain bag covered to promote privacy. R1's care plan does not address catheter care.R1's physician orders, dated 7/24/25, documented monitor for foley catheter position and placement every shift, intake and output every shift, and catheter care every shift. R1's August 2025 TAR (Treatment Administration Record) did not document R1's indwelling urinary catheter care was completed on the day shift on 8/15/25, evening shift on 8/7/25, 8/8/25, nor 8/15/25, nor on the night shift on 8/8/25.R1's August 2025 TAR documented monitor for (indwelling urinary catheter) position and placement q (every) shift. This TAR does not document this as completed on the day shift of 8/15/25, evening shift on 8/7/25, 8/8/25, nor on 8/15/25, nor on the night shift of 8/8/25. R1's urinary output record, print date of 8/20/25, does not document R1's urine output was documented every shift on 8/7/25, 8/8/25, 8/10/25, 8/12/25, 8/13/25, 8/15/25, nor on 8/17/25. On 8/20/25 at 12:27 PM V1 Administrator provided intake stated she could not find any intake records for R1 for July nor August 2025.On 8/18/25 at 8:38 AM R1 was observed in bed with her breakfast in front of her. R1's indwelling urinary catheter bag was uncovered and lying directly on the floor under the bed. V3 Care Plan Coordinator/LPN (Licensed Practical Nurse) walked in and stated to R1 where is your catheter bag? V3 then picked the catheter bag up off the floor, placed the bag in the bag cover, and attached it to R1's bed. 3. R5's admission Record document, print date of 8/18/25, documented R5 has diagnoses including multiple myeloma, ataxia following nontraumatic intracranial hemorrhage, polyneuropathy, glaucoma, hypertension, benign prostatic hyperplasia, and obstructive and reflux uropathy. R5's MDS, dated [DATE], documented R5 is moderately cognitively impaired although at time of interviews R5 was alert and oriented. R5's care plan, undated, documented R5 is at risk for complications related to receiving chemotherapy, R5 requires use of an indwelling catheter related to obstructive uropathy and is at risk of infection, and R5 requires enhanced barrier precautions (EBP) related to indwelling medical device. R5's care plan interventions include staff to wear gown and gloves when performing ADL's (activities of daily living) including when providing hygiene care. R5's physician orders, print date of 8/18/25, documented orders for enhanced barrier precautions for indwelling medical device urinary catheter, indwelling catheter care every shift as needed, and I & O (intake and output) q shift. On 8/18/25 at 8:40 AM surveyor asked R5 how often the nurses and CNAs clean around his catheter. R5 replied not very often, I can't remember the last time they cleaned it.On 8/18/25 at 11:02 AM V6 CNA and V9 CNA were observed as they provided indwelling urinary catheter care for R5. V6 and V9 had the clean supplies set up on a bedside table covered with a clean towel although the clean gloves were off to the side of the towel and directly on the bedside table. R5's door to his room is clearly marked with enhanced precautions signs and PPE (personal protective equipment) including gowns was readily available on the isolation door supply caddy. Neither V6 nor V9 donned gowns at any time during this observation. V9 cleansed R5's penis, scrotum, and inner thighs but did not cleanse R5's indwelling catheter tubing. V6 and V9 rolled R5 onto his right side without repositioning the catheter bag or tubing causing the urine to back flow in the tubing. R5's 8/25 TAR documented (indwelling urinary) catheter care every shift as need although it was not documented as completed every shift on 8/7/25, 8/8/25, nor 8/15/25. R5's catheter output record, print date of 8/20/25, did not document R5's urine output was monitored every shift on 7/22/25, 7/23/25, 7/27/25, 7/28/25, 7/29/25, 8/2/25, 8/3/25, 8/4/25, 8/5/25, 8/7/25, 8/8/25, 8/10/25, 8/12/25, 8/13/25, 8/15/25, 8/16/25, nor 8/17/25. R5's fluid intake records for July and August of 2025 do not document R5's intake was recorded every shift as ordered on 7/17/25, 7/19/25, 7/23/25, 7/26/25, 7/27/25, 7/31/25, 8/1/25, 8/2/25, 8/3/25, 8/6/25, 8/7/25, 8/10/25, 8/12/25, nor 8/15/25.On 8/20/25 at 11:07 AM V2, DON, and V15, ADON were interviewed. V2 stated she would expect the CNAs to don (put on) gowns and cleanse the indwelling catheter tubing while providing catheter care. V15 stated she expects the CNAs to reposition the urinary catheter tubing and bag during turning and repositioning to prevent the urine from back flowing. V2 stated she and the other nurses did not view R2's urologist's instructions on 8/4/25 as physician orders therefore they were not clarified nor implemented. V15 stated she did not view them as orders either. V15 stated she would expect the CNAs and nurses to complete and document catheter care and I&Os as ordered.The facility's (Indwelling) Catheter Care policy, dated 4/2019, documented Policy: Daily and PRN catheter care will be done to promote comfort and cleanliness. Equipment: The following equipment and supplies will be necessary when giving catheter care: 1. Basin with warm water and soap/or pre-moistened disposable cloths. 2. Personal protective equipment (i.e. gowns, gloves, etc.) as necessary. 3. Towel and washcloth. 4. Protective bed pad. Procedure: 1. Wash your hands before beginning the procedure. 2. Assemble all equipment and supplies that will be necessary to perform the procedure. 3. Knock before entering the room. 4. Arrange the supplies so they can be easily reached. 5. Identify yourself. Explain procedure to resident. It continues, 11. Cleanse area of catheter insertion site, using soap and water or pre-moistened wipes. 12. Wash catheter itself by holding on to catheter at insertion site, wash with one stroke downward, using same procedure for rinsing. The facility's Intake and Output policy, dated 6/2015, documented General: Intake and/or output are monitored accurately to ensure adequate fluid balance for residents. Responsible Party: all nursing staff. Guideline: 1. All staff can record the intake or output in the resident record. 2. Intake is recorded for residents with the following: a. Fluid restriction, b. IV therapy, c. Tube feedings, d. Order. 3. Output is recorded for residents with the following: a. (indwelling) catheter, b. Suprapubic catheters c. Order.

Based on record review and interview, the facility failed to verify and implement a consultant physician's instructions, failed to follow hospital discharge orders for normal saline indwelling urinary catheter flushes, and failed to document a resident's response to antibiotics for 1 of 3 residents (R2) reviewed for quality of care in the sample of 11.Findings include:R2's admission Record document, print date of 8/18/25, documented R2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses including Wernicke's encephalopathy, type 2 diabetes mellitus, chronic gout, insomnia, alcohol abuse, major depressive disorder, polyneuropathy, hypertension, and obstructive and reflux uropathy.R2's MDS (Minimum Data Set), dated 7/14/25, documented R2 was severely cognitively impaired, dependent on staff for toileting and hygiene needs, and had an indwelling urinary catheter.R2's care plan, initiation date of 6/30/25, documented R2 required use of an indwelling catheter related to obstructive uropathy and was at risk of infection. Care plan interventions include monitor for s/s (signs/symptoms) of UTI (urinary tract infection), notify MD (Medical Doctor) of abnormal findings, staff to monitor patency of catheter, and record output as directed. R2's care plan did not address indwelling catheter care although R2's admission orders, dated 6/30/25, documented indwelling catheter care every shift as needed.R2's progress notes, dated 7/3/25, documented at 4 PM while assisting CNA (Certified Nurse Assistant) noted urine in drainage bag to have the appearance of thin beige liquid. (Family of R2) states she would like this to be expedited. Call placed to NP (Nurse Practitioner) at 4:40 PM, received order to send out to ER (Emergency Room) if family desired. At 4:50 PM, family stated they would like him sent to ER.R2's hospital Discharge summary, dated [DATE], documented R2 was hospitalized with severe sepsis secondary to CAUTI (catheter associated urinary tract infection). Suspect (indwelling urinary catheter) was dislodged or clogged as patient had immediate large volume output with new (indwelling urinary catheter) placement.R2's hospital discharge orders, dated 7/5/25, documented an order to flush R2's indwelling urinary catheter with 30 ML NS (normal saline) BID (two times per day).R2's facility progress note, dated 7/5/25 at 5:55 PM, documented resident returned to the facility by way of (local) EMS (emergency medical service) in company of (R2's Family). Resident is alert and oriented x 1-2, (indwelling urinary) catheter in place draining yellow urine with small amount of sediment noted in the tubing. New orders for amoxicillin 500 mg PO (by mouth) every 12 hours for 7 days and Keflex 500 mg PO 3 times daily for 10 days. Instructions to flush (indwelling urinary) catheter with 30 ml of saline every 12 hours. R2's MAR (Medication Administration Record), dated 7/2025, documented an order, dated 7/5/25, to flush R2's indwelling urinary catheter with 30 CC H20 Q 12 hours (water every 12 hours). This MAR documented R2's indwelling urinary catheter was flushed with 30 CC H20 Q 12 hours twice a day from 7/7/25 through 7/31/25. On 8/18/25 at 1:55 PM V3 LPN/CPC (Licensed Practical Nurse/Care Plan Coordinator) stated she completed the admission for R2 on 7/5/25, the indwelling catheter flush order didn't specify what it should be flushed with. V4 stated she put the order in as water. Surveyor asked V4 what kind of water was used for the flushes and V4 replied tap water. Surveyor requested that order.On 8/18/25 at 2:04 PM V3 came to surveyor and stated I know where that water order came from, it was from R2's urologist on 8/4/25. V4 presented the order, the order documents catheter flushing every 8 hours. The order does not specify what to flush with.R2's progress note, dated 8/4/25 at 9:27 AM, documented left facility for appointment with urologist. Accompanied by (R2's Family) and CNA (Certified Nurse Assistant).R2's after visit summary from R2's urologist, dated 8/4/25 at 10 AM, documented instructions for topical antibiotics around the tip of R2's penis and indwelling urinary catheter flushing every 8 hours.R2's progress note, dated 8/4/25 at 1:18 PM, documented returned to facility at this time. No changes in orders. R2's progress notes do not document the instructions to increase R2's indwelling urinary catheter flush to every 8 hours, no documentation of any facility nursing staff calling R2's physicians for clarification of what to flush R2's catheter with, nor does it document a topical antibiotic was ordered for R2's penis pain and infection.On 8/18/25 at 8:06 AM V11, (R2's Family), stated she did inform R2's nurse of R2's new orders from his urologist for topical antibiotics and to increase R2's indwelling urinary catheter to every 8 hours from every 12 hours. V11 stated she provided the facility nurse with a copy of the orders. V11 stated she had a care plan meeting with the facility staff on 8/5/25 to discuss a very long list of issues and she brought up the catheter flush upgrade to every 8 hours as well as the topical antibiotic and R2's reporting of pain at his penis. V11 stated when she visited R2 on 8/8/25 and R2 once again told her the tip of his penis hurt. V11 stated she approached the nurse's station to check on R2's topical antibiotic order and found the facility had never implemented R2's topical antibiotic order. R2's August 2025 MAR documented R2's topical antibiotic bacitracin was not implemented until 8/9/25. This MAR documented flush (indwelling urinary) catheter with 30 cc H20 Q 8 hours for UTI. This MAR does not document sterile water. This MAR does not document R2's indwelling catheter was flushed as ordered on 8/8/25 at 4 PM as it was not signed off as completed. R2's progress notes do not document any physician notification to clarify what R2's indwelling urinary catheter should be flushed with.R2's MAR nor his progress notes document his response to the topical antibiotic.R2's Medication Review Report documented R2 had a physician order, dated 7/16/25, for (indwelling urinary catheter) and bag, change monthly and as needed 16 FR (French) with 10 cc balloon.R2's progress note, dated 8/5/25 at 2:22 PM, documented (indwelling urinary) catheter leaking, scant amount of cloudy amber urine in tubing. Bulb deflated, and (indwelling urinary catheter) removed. New #16 FR indwelling catheter inserted with 30 ml normal saline. R2's medical record did not document any orders for a size 16 FR with 30 ml bulb.R2's progress note, dated 8/6/25 at 8:35 AM, documented care plan meeting, met with the whole family and most of the department heads. It continues, we went over his urology appt (appointment) wants his (indwelling catheter) flushed every 8 hours instead of 12.R2's progress note, dated 8/12/25 at 7:15 AM, documented nursing notified provider that resident had a fall early this am where he slid from his bed to the floor. Post fall BP (blood pressure) was 70s/60s. Additionally, labs that resulted overnight revealed WBC (white blood cell) was critical high at 38k (38,000), with elevated procalcitonin level as well. Gave order to send resident to ED (emergency department) d/t suspected septic shock. R2's critical care medicine history and physical note, dated 8/12/25, documented septic shock, etiology likely secondary to PNA (pneumonia) vs CAUTI. (Indwelling catheter) replaced in ED due to leaking around cuff on 8/12. 2L urine output returned.On 8/20/25 at 11:07 AM V2, DON (Director of Nursing), stated she and the other nurses did not view R2's urologist's instructions on 8/4/25 as physician orders therefore they were not clarified nor implemented.On 8/20/25 at 12:43 PM V16 Nurse Practitioner was interviewed in person with V17 R2's facility physician on speaker phone. V16 and V17 both stated if an indwelling urinary catheter is ordered to be flushed with water it should be sterile water. Surveyor asked V17 if the facility should have clarified R2's instructions given by R2's urologist V14, dated 8/4/25, to increase R2's catheter flushes to every 8 hours and to apply topical antibiotic. V17 replied it is always good to clarify.On 8/20/25 at 2:23 PM V1 Administrator provided surveyor with the facility's Physician Orders policy and stated the facility does not have a policy on consultant physicians.The facility's Physician Orders policy, dated 6/2015, documented General: Drugs will be administered only upon a clean, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders will be received only by licensed nurses or pharmacists and confirmed in writing by the physician. Responsible Party: Nursing. Policy: Elements of the Medication Order:1. Medication orders specify the following: a. Name of medication, b. Strength of medication, c. Dosage, d. Time or frequency of administration, e. Route of administration, f. Quantity or duration, g. Diagnosis or indication for, h. Medication allergy, I. Any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis is verified with the attending physician. It continues, Documentation of the Medication Order: 1. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet in (EMR) and the MAR and TAR. 2. The following steps are initiated to complete documentation: a. Clarify the order, b. Enter the orders with administration schedule in (EMR) and transmit to pharmacy.The facility's Catheter Irrigation: Indwelling policy, dated 6/2015, documented General: Catheter irrigation is done to ensure tube patency and remove clots or sediment from the catheter or bladder. Responsible Party: RN, LPN. Procedure: 1. Obtain order from physician/nurse practitioner as to the type of solution and frequency of irrigation. 2. Wash hands. 3. Explain procedure to the resident. 4. Provide privacy. 5. Open irrigation set by grasping end flap and peeling back. 6. Place irrigation set in convenient position. Maintain sterility of drainage system. Use only sterile solution or water for irrigation. Type of solution should be specified in the order.

Based on observation, interview, and record review the facility failed to follow the facilities policy and don proper PPE (personal protective equipment) while providing care for 2 of 3 (R1, R5) residents reviewed for indwelling urinary catheter in the sample of 11. 1.R1's admission Record, print date of 8/18/25, documented R1 has diagnoses including rheumatoid arthritis, malnutrition, chronic fatigue, heart failure, altered mental status, neuromuscular dysfunction of bladder, cognitive communication deficit, hypertension, and acquired absence of right shoulder. R1's MDS (Minimum Data Set), dated 7/11/25, documented R1 is moderately cognitively impaired.R1's care plan, undated, documented R1 has an (indwelling urinary catheter) related to neurogenic bladder and is at risk of infection. R1's care plan also documented R1 requires enhanced barrier precautions with interventions including staff to wear gown and gloves when performing ADL'S (activities of daily living). On 8/18/25 at 8:38 AM R1 was observed in bed with her breakfast in front of her. R1's indwelling urinary catheter bag was uncovered and lying directly on the floor under the bed. V3, Care Plan Coordinator/LPN (Licensed Practical Nurse) walked in and stated to R1 where is your catheter bag? V3 then picked the catheter bag up off the floor, placed the bag in the bag cover, and attached it to R1's bed. V3 did not don gloves nor a gown prior to touching R1's catheter bag, catheter tubing, and R1's bed. R1's door was clearly marked with a sign noting enhanced barrier precautions and PPE (personal protective equipment) was readily available on R1's door caddy. 2.R5's admission Record document, print date of 8/18/25, documented R5 has diagnoses including multiple myeloma, ataxia following nontraumatic intracranial hemorrhage, polyneuropathy, glaucoma, hypertension, benign prostatic hyperplasia, and obstructive and reflux uropathy. R5's MDS, dated [DATE], documented R5 is moderately cognitively impaired although at time of interviews R5 was alert and oriented. R5's care plan, undated, documented R5 is at risk for complications related to receiving chemotherapy, R5 requires use of an indwelling catheter related to obstructive uropathy and is at risk of infection, and R5 requires enhanced barrier precautions (EBP) related to indwelling medical device. R5's care plan interventions include staff to wear gown and gloves when performing ADL's (activities of daily living) including when providing hygiene care. R5's physician orders, print date of 8/18/25, documented orders for enhanced barrier precautions for indwelling medical device urinary catheter.On 8/18/25 at 11:02 AM V6 CNA (Certified Nurse Assistant) and V9 CNA were observed as they provided indwelling urinary catheter care for R5. V6 and V9 had the clean supplies set up on a bedside table covered with a clean towel although the clean gloves were off to the side of the towel and directly on the bedside table. R5's door to his room is clearly marked with enhanced precautions signs and PPE (personal protective equipment) including gowns was readily available on the isolation door supply caddy. Neither V6 nor V9 donned gowns at any time during this observation. On 8/20/25 at 3:14 PM V1 Administrator stated she expects all facility staff to wear a gown and gloves when caring for residents on enhanced barrier precautions.The facility's Enhanced Barrier Precautions (EBP) policy, dated 10/6/22, documented Policy: Our facility employs the use of Enhanced Barrier Precautions to reduce transmission of MDROs (multi-drug resistant organisms) to staff hands and clothing that employs targeted gown and glove use during high-contact resident care activities. EBP are indicated for residents with any of the following: open wounds regardless of MRDO status, an indwelling medical device regardless of MDRO status, or colonization with a targeted MDRO. Process: Staff utilize gown and gloves for high-contact resident care activities when residents require EBPL high contact activities may include: dressing, bathing, transferring, providing hygiene changing linens, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tub, tracheostomy/ventilator, and would care.

Based on observation, interview, and record review, the facility failed to ensure clean linen carts were kept covered and protected from contaminates. This failure has to potential to affect all 51 residents who reside at the facility. Findings include:On 07/21/25 at 10:15 AM, in the shower room/bathroom on the 100-hallway, the clean linen cart was sitting next to the commode in the shower room and the clean linen cart did not have the front cover pulled down to cover all the clean linen and thus the clean linen was exposed to different contaminates. In the shower room there was also dirty linen barrels as well as the clean linen.On 07/22/25 at 10:40 AM, in the women's shower room on the 200-hallway, the clean linen cart was sitting up against the wall with the cover thrown up over the top of the cart and all the linen on the cart was exposed. There were two barrels containing dirty linen on wheels sitting about three feet away from the clean linen.On 07/22/25 at 10:45 AM, in the men's shower room on the 200-hallway there was a clean linen cart sitting up against the wall with the cover flipped up on the top of the cart exposing all the clean linen to different kinds of contaminates. On 07/23/25 at 10:17 AM, R4 state the linen cart that is kept in the shower room always has the cover up on it.On 07/23/25 at 10:40 AM, R6 stated the clean linen cart in the shower room is always left open and she hasn't ever seen it covered.On 07/23/25 at 12:45 PM, V5, Certified Nursing Assistant (CNA) said the cover has to be down on the clean linen cart at all times.On 07/23/25 at 12:30 PM, V1, Administrator stated when it comes to the clean linen carts, she expects for the staff to make sure the front is covered and pulled down and it has to be at least a door width away from the dirty linen containers per what the policy says.The facility's policy Handling Clean Linen, last updated July 2019, documented Policy: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Definitions: Hygienically clean means rendered free of vegetative pathogens through disinfection during the laundering process. Linen including sheets, blankets, pillows, towels, washcloths, and similar items from departments such as nursing, dietary, rehabilitative services, beauty shops, and environmental services. Contaminated Linen is linen that has been soiled with blood or other potentially infectious materials. It further documented Policy Explanation and Compliance Guidelines: 2. Linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands. It also documented 5. Guidelines for the storage of clean linen include, but are not limited to, the following: a. Clean linen shall be delivered to resident care units on covered linen carts with covers down. Nothing shall be kept on top of linen carts. Only rolls of bags used for linen transport may be kept on the carts, in the designated pockets only. b. Clean linen shall be kept separate from soiled linen. When clean linen carts are in use (i.e. in the hallway), keep at least one door length away from soiled linen collection containers.The facility's census sheet, dated 7/21/25, documented there were 51 residents in the facility.

Based on interview and record review the facility failed to address residents needs by answering call lights in a timely manner for 4 of 5 residents (R1, R3, R4, and R6) reviewed for call lights in a sample of 9. Findings include:1. R1's Face Sheet, with original admission date of 01/15/18, documented R1 has diagnoses of but not limited to multiple sclerosis, schizoaffective disorder, and bipolar disorder. R1's Minimum Data Set (MDS), dated [DATE], documented R1 is moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 10 out of 15, she is dependent on staff for most of her activities of daily living (ADL), and she is always incontinent of bowel and bladder.On 07/22/25 at 9:55 AM, R1 said it can sometimes take the Certified Nursing Assistants (CNA) a little while to answer her call light.2. R3's Face Sheet, admission date of 06/20/25, documented R3 has diagnoses of but not limited to congenital subaortic stenosis, type II diabetes mellitus, schizophrenia, and hypertension (HTN). R3's MDS, dated [DATE], documented R3 is cognitively intact with a BIMS of 13 out of 15 and she requires assistance with her ADLs.On 07/21/25 at 10:00 AM, R3 said she had an incident that happened last Monday (07/14/25) where she was up in her wheelchair (w/c) at 2:00 PM and she put her call light on to get help going to the bathroom. R3 said no one came in to help her until 4:00 PM. She said later that same night at about 9:00 PM she put her call light on to use the bedpan and no one came until 10:00 PM. She said she has had two accidents due to having to wait on someone to answer her call light. R3 said her very first night here and then again about two or three weeks ago she had an accident, and it makes her uncomfortable. She said is worried she is going to get sores and stuff if she is wet. R3 said her first night here she had to wait five and a half hours for any kind of help to use the bathroom. 3. R4's Face Sheet, print date of 07/23/25, documented R4 has diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), sepsis, type II diabetes mellitus, and chronic atrial fibrillation. R4's MDS, dated [DATE], documented R4 is cognitively intact with a BIMS of 15 out of 15, requires assistance with some of her ADLs and is occasionally incontinent of bladder and frequently incontinent of bowel. On 07/23/25 at 10:17 AM, R4 said it can take the CNAs (Certified Nurses Assistants) sometimes a couple of hours to answer the call light. Sometimes when she has her call light on, they will peak in the room and then just walk away. R4 said she has had accidents having to wait on someone to answer the call light. She said it ticks her off when that happens and there are times her roommate must yell for help before they come to check and see what she needs.4. R6's Face Sheet, print date of 07/23/25, documented R6 has diagnoses of but not limited to COPD, HTN, emphysema, and atrial fibrillation. R6's MDS, dated [DATE], documented R6 is cognitively intact with a BIMS of 14 out of 15 and requires assistance with some of her ADLs. On 07/23/25 at 10:40 AM, R6 said it can be slow when it comes to answering the call lights. She said sometimes it can be as long as an hour to an hour and a half before they come. She said the second and night shift seem to be the worst.The facility's Resident Council Meeting Minutes, dated 05/01/25, documented Resident Council Nursing Concerns: Call lights not being answered in a timely manner.The facility's Resident Council Meeting Minutes, dated 06/05/25, documented Resident Council Unresolved Concerns: Call lights not being answered in a timely manner.The facility's Resident Council Meeting Minutes, dated 07/03/25, documented Resident Council Nursing Concerns: Call lights not being answered in a timely manner.The facility's call light response audit tool, dated 07/19/25, documented a call light on the 100 hallway was on at 8:56 AM and it was turned off at 9:15 AM. There was a 19-minute response time.On 07/22/25 at 10:30 AM, V4, Certified Nursing Assistant (CNA) said it is hard for her to get her tasks done and call lights answered timely.On 07/22/25 at 10:35 AM, V5, CNA said doesn't feels like she has time to get all her daily tasks done and she doesn't feel like she is able to answer the resident's call lights in a timely manner.On 07/23/25 at 12:30 PM, V1, Administrator said when it comes to the call lights the Assistant Director of Nursing, V8, has been doing a call light audit on the second and night shift and the response time has been 5 minutes or less recently.On 07/23/25 at 3:20 PM, V1 said call lights should be answered as soon as possible, within at least 5 minutes would be ideal.The facility's Call Light Response, revision date of 09/2024, documented GENERAL: To provide the staff with guidance on responding to resident's request and needs. It also documented Protocol: 6. Answer the patient or resident's call as soon as possible.

Based on observation, interview, and record review, the facility failed to provide resident care in a timely manner to promote resident's dignity for 3 of 5 residents (R1, R2, and R5) reviewed for dignity in a sample of 5. This failure resulted in R2 having feelings of frustration due to soiling herself and being left on a bedpan for 29 minutes and reporting pain related to this. Findings include: 1. R2's Face sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, congenital subaortic stenosis, type two diabetes mellitus, and acquired absence of bilateral legs below the knee. R2's Minimum Data Set (MDS) dated [DATE], documented she was cognitively intact and dependent on staff for toileting hygiene assistance. R2's Care Plan dated 6/27/25 documented she was at risk for skin complications related to immobility. R2's Care Plan dated 6/20/25 documented she has an alteration in comfort advanced disease process, chronic physical or psychological disability circulatory, musculoskeletal, neurological, skin/tissue impairment trauma. R2's Care Plan dated 6/20/25 also documented she required assist with daily care needs related to morbid obesity, bilateral lower extremity amputee. On 7/7/25 at 9:00 AM, R2 stated she has to wait anywhere from 30 minutes to an hour and 20 minutes for her call light to be answered at times. R2 stated it makes her feel frustrated because she ends up sometimes soiling herself instead of using the bed pan because it took the staff too long to respond. R2 stated she should be treated with respect and care. R2 stated she should feel safe and trust that the staff will take care of her appropriately. On 7/7/25 at 11:05 AM, R2 put her call light on to use the bed pan and at 11:06 AM V6, Certified Nurse's Aide, (CNA) responded and placed R2 on a bed pan. At 11:10 AM, R2 pressed her call light and notified V6 she was done using the bed pan. V6 stated she would be back after helping assist with a mechanical lift. On 7/7/25 at 11:25 AM, R2 stated, How long has it been? I thought she would be right back. R2 stated the bed pan was causing her a lot of discomfort and pain. R2 stated she wants to make sure none of the other residents who can't speak up for themselves have to go through this. R2 stated her pain level was a 9 out of 10 on a pain scale being a sharp/shooting pain caused from the bed pan that was not there prior to being placed on it. On 7/7/25 at 11:35 AM, V6 came back to R2's room with incontinence supplies. V6 had V5 (CNA's) assisted with incontinence care. When R2's bed pan was removed, a noticeable reddened outline on R2's skin from where the bed pan sat was observed. On 7/7/25 at 1:11 PM, V6, stated she had to help assist another CNA with a resident needing a mechanical lift because two people are required for that and couldn't get back to R2 until after that was done. V6 stated she tries to get residents off bed pans as soon as possible because she's sure it can cause discomfort and pain. 2. R1's Face sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, type two diabetes mellitus, chronic bronchitis, and type two diabetes mellitus with diabetic neuropathy. R1's MDS dated [DATE] documented she was cognitively intact and dependent on staff for toileting hygiene assistance. On 7/7/25 at 9:10 AM, R1 stated sometimes it takes staff 30 minutes to respond and that makes her feel like they don't care about her and that she is just an option. 3. R5's Face sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, chronic obstructive pulmonary disease, hypotension, and acute respiratory failure. R5's MDS dated [DATE] documented she is moderately cognitively impaired and dependent on staff for toileting hygiene assistance. 7/7/25 at 10:50 AM, R5 stated call lights can take a long time to get answered typically 15-20 minutes. R5 stated she wouldn't put her dog or cat in this place. On 7/7/25 at 1:10 PM, V5, CNA, stated she would expect a resident to be removed from a bed pan within 5-10 minutes after being done with it. V5 stated a bed pan can cause pain and discomfort if left in place for too long. On 7/7/25 at 11:12 PM, V4, CNA, stated she tries to get residents off bed pans as soon as possible and they can be uncomfortable to be on. V4 stated she thinks there is enough staff employed to respond to residents timely except for when there are call offs, today we have a lot. On 7/7/25 at 3:40 PM, V1, Administrator, stated she would expect residents to be removed from a bed pan in the least amount of time possible, and she is sure being left on one for an extended amount of time would cause pain or discomfort. V1 stated she expects staff to respond to residents within 5 minutes if possible. Resident Council Meeting Minutes dated 4/3/25, 5/1/25, and 6/5/25 all documented nursing concerns of call lights not being answered in a timely manner. The facility's Pain Management policy revised on 1/2025, documented it is to facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The facility's Resident Rights policy revised on 10/2024 documented, It is the facility's policy to identify and provide reasonable accommodation for resident needs and preferences except when it would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence.

Based on observation, interview and record review the facility failed to prevent an employee from misappropriating narcotic pain medication for 2 of 3 residents (R2, R3) reviewed for misappropriation of property in a sample of 3. Findings include: 1. R2's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnosis of pain and GERD. R2's Undated Care Plan, documents chronic pain related to GERD and chronic knee pain. R2's Physician's Order Sheet (POS) dated 4/2025 and 5/2025 documents a physician's order, start date of 7/14/2024, hydrocodone-acetaminophen 5-325 milligrams (mg) give 2 tablets by mouth every 4 hours as needed for pain. R2's Minimum Data Set (MDS) dated [DATE] documents resident is cognitively impaired and has occasional pain. R2's Controlled Drug Received Record/Disposition Form, received from the pharmacy on 7/26/2024 documents V4, Licensed Practical Nurse, LPN, signed off she administered hydrocodone 5-325 mg to R2 on 4/17/2025, 4/22/2025, 4/27/2025, 4/28/2025, 5/1/1025 2 doses, 5/2/2025, 5/3/2025, 5/5/2025 and 5/6/2025 that equals 20 pills administered. R2's Controlled Drug Received Record/Disposition Form, received from the pharmacy on 4/23/2025 documents V4 signed off she administered hydrocodone 5-325 mg to R2 on 5/1/2025, 5/6/2025 2 doses, 5/7/2025, 5/9/2025, 5/10/2025 3 doses, 5/11/2025 3 doses, and 5/12/2025 2 doses that equals 26 pills administered. R2's MAR dated 4/2025 documents V4 signed off hydrocodone 5-325 mg was administered to R2 on 4/22/2025 or 4/28/2025 which equals 4 pills administered. V4 signed off 6 pills administered on R2's narcotic count sheet for 4/2025. R2's MAR dated 5/2025 documents V4 signed off hydrocodone 5-325 mg was administered on 5/9/2025, 5/11/2025, 5/15/2025, 5/20/2025 and 5/31/2025 which equals 10 pills administered. V4 signed off 26 pills on 5/2025 on R2's narcotic sheet. 2. R3's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnosis of osteoarthritis and cholecystitis. On 6/8/2025 at 12:03 PM V1, Administrator, stated R3 has general abdominal pain related to his cholecystitis that they were not able operate on. He also reports heel pain at times. R3's Undated Care plan, documents alteration in comfort advanced disease process, chronic physical or psychological disability circulatory, Musculoskeletal, neurological, skin/tissue impairment. R3's POS, dated 4/7/2025 and 5/2025 documents a physician's order started 4/7/2025 hydrocodone-acetaminophen 5-325 mg give 1 tablet by mouth every 6 hours as need for pain. R3's MDS dated [DATE] documents resident is alert and has occasional pain. R3's Controlled Drug Received Record/Disposition Form, received from the pharmacy on 4/16/2025 documents V4 signed off she administered hydrocodone 5-325 mg to R3 on 4/22/2025, 4/26/2025 2 doses, 4/27/2025, 4/28/2025, 5/1/2025 2 doses, 5/2/2025, 5/3/2025, 5/5/2025, 5/6/2025 3 doses, 5/9/2025, 5/10/2025 3 doses, 5/11/2025 and 5/12/2025 3 doses that equals 21 pills administered. R3's MAR dated 4/2025 documents V4 signed off hydrocodone 5-325 mg was administered to R3 only on 4/22/2025 and 4/27/2025 which equals 2 doses administered, not 5 doses like the narcotic count sheet documents she administered to R3. R3's Controlled Drug Received Record/Disposition Form, received from the pharmacy on 5/12/2025 documents V4 signed off she administered hydrocodone 5-325 mg to R3 on 5/19/2025, 5/20/2025 2 doses that equals 2 pills administered. R3's MAR dated 5/2025 documents V4 signed off hydrocodone 5-325 mg was administered to R3 only on 5/3/2025, 5/5/2025, 5/13/2025 and 5/15/2025 which equals 4 pills administered, not 16 pills like the narcotic count sheet documents she administered to R3. On 6/3/2025 at 5:00 PM V1, Administrator stated she was first alerted by V2, Director of Nursing, DON about suspicious documentation on R2's hydrocodone 5-325 mg narcotic count sheet on 5/21/2025. V1 stated she, V2 and V3, Assistant Director of Nursing, ADON went over all narcotic count sheets at that time and noted that V4, LPN was assigned to R2 and R3 on a regular basis and was signing off on the narcotic count sheets both hydrocodone 5-325 mg tablets were being administered to both residents PRN (as needed) as soon as the medications were available. V1 stated neither R2 nor R3 have a history of taking hydrocodone on a regular basis and they are both prescribed PRN. V1 stated both R2 and R3 aren't interviewable and she believes that is why V4 targeted their hydrocodone because they couldn't speak for themselves. V1 stated V4 didn't sign the hydrocodone off on either R2's or R3's MAR, just on the narcotic sheets. V1 stated she called V4 into the facility to be interviewed. V1 stated V2 and V3 and the police were called. V1 stated V4 confessed to the police that she took R2's and R3's hydrocodone 5-325 mg tablets and had taken 66 pills total. V1 stated V4 was hired as an LPN to the facility and worked night shift 6:00 PM to 6:00 AM and worked full time since her hire date of 4/2/2025. The first time V4 signed off hydrocodone on R2's narcotic count sheet was 4/17/2025 and it was brought to her attention on 5/21/2025. V4 told her that she got the hydrocodone medication from the medication cart, signed it off on the resident's narcotic count sheet then went to the resident's room and placed the pill in her pocket to take it later. V1 stated there was no video evidence of V4 taking the narcotic pain medication by mouth or putting it in her pocket because she allegedly did that in resident rooms, where there are no surveillance cameras. V1 stated the facility has done several audits of the narcotics since this has been brought to her attention and no further issues with narcotics were discovered. V1 stated V4 was terminated the same day the investigation was initiated on 5/21/2025 so she no longer has access to the resident's narcotic pain medication at the facility. On 6/3/2025 at 5:20 PM V3, Assistant Director of Nurses (ADON) stated V5, Registered Nurse, RN, stated she was aware of suspicious documentation on R2's and R3's hydrocodone 5-325 mg PRN narcotic count sheets on 5/21/2025 and she worked with V1 and V2 to get the investigation started. V3 stated she and V2 interviewed V4 at the facility and she initially stated it was a mistake and that she read the resident's hydrocodone physician order wrong, she thought it was scheduled, not PRN then she changed her story to it was just a mistake then she spoke 1:1 to the local police officer at the facility and she confessed to stealing R2's and R3's hydrocodone 5-325 mg pills and it was 66 pills she stole in total. V3 stated V4 told her she was in pain and the hydrocodone helped her get through the day. V4 told her she walked into the resident's room as if she was going to administer the hydrocodone medication then she put it in her pocket. V3 didn't know if V4 took the hydrocodone pain medication while working or not. V3 stated she worked with V4 on night shift a few times and never noted her to be under the influence or off in any way. On 6/3/2025 at 5:45 PM V2, Director of Nurses (DON) stated she and V3 were notified by V5 of suspicious documentation on (R2's) narcotic count sheet on 5/21/2025. V2 stated her and V3 did a complete audit on all resident's narcotic count sheet and noted suspicious documentation on R3's narcotic count sheet as well. Neither R2 nor R3 took the hydrocodone PRN medication often but according to the narcotic count sheet something had occurred because V4 documented both residents were taking the narcotic pain medication multiple times a shift when V4 worked. V2 stated it was odd and she knew something was really wrong when she checked R2's and R3's MARs, V4 didn't document on the resident's MAR that the medication was administered. V2 stated no resident's narcotic count sheets count was off at anytime. V2 stated it was only because V5 brought it to her attention that the facility caught onto what V4 was doing which was stealing R2's and R3's hydrocodone PRN narcotic pain medication. V2 stated she and V3 interviewed V4 the same day and she initially denied taking any residents hydrocodone narcotic pain medication, then the police got here, and she spoke to the police officer 1:1 and admitted to stealing 66 pills of R2's and R3's hydrocodone 5-325 mg PRN pills. On 6/3/2025 at 6:05 PM V5, RN stated she works days from 6:00 AM to 6:00 PM. V5 stated was the nurse to initially find the suspicious documentation on R2's narcotic count sheet on 5/21/2025. V5 stated as soon as V2 got to the facility she gave her R2's narcotic count sheet and said something is suspicious here and V2 told her she'd look into it. V5 stated she knew something wasn't right because R2 rarely takes Tylenol and never requests a narcotic pain medication from her and when she saw R2's hydrocodone 5-325 mg PRN pill count went from 20 pills for the longest time down to 6 pills she knew there was an issue. V5 stated V4 probably took the narcotic pain medication from R2 and R3 because neither one of these residents are interviewable and they couldn't speak up and tell on her for taking their medications. On 6/3/2025 at 7:05 PM V4, LPN stated she started working at the facility as an LPN on 4/2/2025 and she has chronic bilateral hip pain which she used to get pain injections for, but she no longer has health insurance so when she started working at the facility, she was tempted to take R2's and R3's hydrocodone 5-325 mg PRN narcotic pain medication because she was hurting really bad. V4 stated she documented the hydrocodone was administered on the narcotic count sheet but not on the resident's MAR and that's how she got caught. On 5/21/2025 she was sleeping and V2 called her to come in and speak to about a concern. V4 stated when she got to the facility, she spoke to V2 and V3 about the documentation on R2's and R3's hydrocodone narcotic count sheets and initially V4 stated she denied taking the resident's hydrocodone pills but then she spoke to the police officer at the facility, and she finally admitted to it. V4 stated she took approximately 11 to 14 hydrocodone 5-325 mg PRN pills from R2 and R3 hydrocodone 5-325 mg PRN pills from R3. V4 stated she didn't take anywhere close to 66 hydrocodone 5-325 mg pills from the residents. V4 stated she knew what she did was wrong, but she was in such pain she felt she didn't have another choice. V4 stated she didn't take the resident's hydrocodone pills at the facility she entered the resident's room as if she was going to administer the medication then she put the pill in her pocket and took it so she could sleep when she got home from work. Employee Disciplinary Form dated 5/21/2025 documents V4, LPN start date at the facility was 4/2/2025 and last day worked 5/19/2025. Employee action/discipline: discharge and felony/theft. Describe what happened: two residents were found to have narcotics signed out on the narc sheets but not on the MAR. Residents were given urine drug screens which were negative for any opioids despite documentation on the narc sheets that she gave the residents Norco the morning of 5/20/2025 at approximately 5:30 AM and 6:00 AM. Video was reviewed and did not show V4 entering one of the resident rooms at all during that timeframe. V4 was given a urine drug screen that was positive for opioids. V4 admitted to Administrator and local police officer to taking the medication. Report filed with local police department. Report made to IDPH as well. On 6/3/2025 at 9:00 PM V7, Local Detective, stated V4 admitted to stealing hydrocodone from the facility in April and May 2025 and stated V4 is being charged with theft. The Facility Abuse Policy, reviewed 9/2017 documents this facility affirms the right of our residents to be free from misappropriation of property. This facility therefore prohibits misappropriation of property. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of misappropriation of property.

Based on observation, interview, and record review, the facility failed to ensure progressive fall interventions were in place and staff were aware of these interventions for 1 of 4 residents (R5) reviewed for falls in the sample of 7. Findings include: R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, cerebral infarction, hypotension, dementia and abnormalities of gait and mobility. R5's Minimum Data Set, dated dated dated [DATE] documented R5 was severely cognitively impaired, used wheelchair and required partial assistance with walking. R5's Care Plan documents R5 is at risk for falls. R5's Fall Risk assessment dated [DATE] documented R5 was at high risk for falls. R5's Fall Investigation dated 10/9/24 documents R5 tripped while ambulating and fell . There was no injury. R5's Care Plan Update on 10/9/24 documents staff were educated to ensure R5 is wearing grippy socks at all times when out of bed. R5's Fall Investigation dated 4/13/25 documents R5 was found on the floor in the dining room with a small laceration and large bump on her forehead and skin tears on her right forearm. R5 was sent to the emergency room (ER) for evaluation. R5's ER Note dated 4/13/25 documents R5 sustained a hematoma to the forehead. R5's 4/13/25 Fall Investigation documents a (Non-Slip Mat) will be added to R5's wheelchair. On 5/1/25 at 1:11 PM, R5 was sitting in the dining room in her wheelchair with dark purple bruising under both eyes and yellowish green bruising on her forehead. She was wearing regular socks that did not have grips on the bottom. V9, Certified Nursing Assistant (CNA), stated she was not told to put gripper socks on R5. When asked if R5 has a (Non-Slip Mat), V9 stated, What's that? On 5/2/25 at 7:58 AM, V11, CNA, stated she did not know if R5 is supposed to have a (Non-Slip Mat) in her chair. On 5/2/25 at 10:40 AM, V12, Nurse Practitioner (NP), stated the purpose of implementing fall interventions is to prevent additional falls. On 5/2/25 at 11:15 AM, V1, Administrator, stated she expects progressive fall interventions to be in place and staff to be aware of them. The Facility's Fall Prevention and Management Policy last reviewed 6/2024 documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on observation, interview and record review the facility failed to ensure resident rights were respected regarding a social media post for 1 (R2) of 3 residents in a sample of 3. R2's Undated Face Sheet, documents R2 was initially admitted to the facility on [DATE] with diagnoses including pain, generalized anxiety disorder and mild cognitive impairment. R2's Quarterly Minimum Data Set (MDS) dated [DATE] documents resident is alert. On 3/28/2025 at 9:32 AM V1, Administrator stated she recently received an anonymous call on Monday morning 3/24/2025, the call ID was blocked, and the caller reported that (V5), LPN (Licensed Practical Nurse) posted on social media talking about a resident and the anonymous caller sent screen shots of the social media post to V1. She stated no residents or facility name was listed in the post. V1 forwarded the social media screen shots to human resources, and they stated no issues because no residents were named and no facility was named. V5's Social Media Post dated 9/10/2024, documents, Nobody can [NAME] me faster than an elderly nursing home patient with 5 teeth and a receding hair line. I thought you said you was getting them nails fixed Saturday, why they still look the same. I said dangggg I was sick I didn't go. Well when you do go have them wax your eyebrows too. On 3/28/2025 at 9:45 AM V5, LPN stated on 9/10/2024 the social media post was referring to R2 that resides at the facility, and it was a joke between her and the other employees at the facility. V5 stated she didn't feel it was an inappropriate social media post because she didn't document R2's name or the facility he resided at. V5 stated she's not documented social media jokes regarding residents since that one post in 9/2024. V5's Social Media Post, dated 9/10/2024 documents V15, LPN commented, Was that Mr. K? Cause he asked if I smoked crack girl I said W**. On 3/28/2025 at 12:09 PM V15, LPN stated she replied to (V5's) post on social media dated 9/10/2024 because she knew the resident who (V5) was referring to in the post which was (R2), and she thought it was funny. V5's Social Media Post, dated 9/10/2024 documents V16, Social Service Director commented, Can't go out like this. On 3/28/2025 at 12:09 PM V16 stated she recalled (V5) posted a social media post regarding (R2) and how he had 5 teeth and a receding hair line but she didn't comment on that she commented on the post saying you can't go out like this referring to not having your nails and eyebrows done up. V16 didn't have issues with what (V5) posted on social media on 9/10/2024 because she didn't document the resident's name or the facility that he resides at. V16 stated her and (V5) are friends and she knew she was making a joke regarding (R2) who resides at the facility. On 3/28/2025 at 10:20 AM R2 lay in bed with eyes open stated good morning, he was alert and stated nobody better be posting about him on social media because that would hurt his feelings if someone posted he has 5 teeth and a receding hair line, he stated no employee should post his business on social media because the employee described him and he knows the employee was talking about him and he stated that hurt his feelings. R2 stated would you want the fact that you have 5 teeth and a receding hair line posted on social media? He stated people should ask themselves that question prior to posting hurtful comments on social media. On 3/28/2025 at 10:33 AM V1, Administrator stated she asked (V5) what the resident's name was that she was referring to in the social media post and (V5) didn't state the resident's name. V1 stated (V5) is an agency nurse and stated the resident she was referring to in the social media post could reside in any nursing home that she works at not just this nursing home. The Facility's Resident Rights Policy dated 8/1/2022, documents the objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. The Facility's Undated Social Media Handbook, documents employees are prohibited from posting or comments which are disrespectful or discourteous to our patients.

Based on interview and record review the Facility failed to ensure progressive interventions were being implemented for 1 of 3 residents (R2) reviewed for falls in the sample of 6. Findings include: R2's Physician Order Sheet for October 2024 documents a diagnosis of encephalopathy, chronic obstructive pulmonary disease (COPD), hemiplegia affecting left non dominant side, cerebral infarction, diabetes, weakness, pain in right hip, unspecified convulsions, schizoaffective disorder, unspecified dementia, and unspecified psychosis. R2's Minimum Data Set, (MDS) dated [DATE] documents R2 was moderately impaired for cognitive impairment for decision making of activities of daily living. R2 requires use of a wheelchair. R2 requires moderate assistance with showering and personal hygiene. He requires set up for eating, oral hygiene, upper and lower body dressing and taking off and applying footwear. R2 also has a (urinary) catheter and is frequently incontinent of bowel. R2's Fall risk evaluation dated 8/25/2024 at 6:07 PM documented that R2 is a high risk for falls. R2's Progress notes dated 8/25/2024 documented a certified nursing assistant, (CNA) heard a thud from resident's room, immediately went to see and found resident on the floor up against the door. R2 appeared to hit head and stated a little pain. R2 unable to recall what happened. R2's Progress notes dated 8/25/2024 at 5:30 PM document Visit Type: Sound physician telehealth. Details: Chief complaint: Fall. Saw patient on video with staff. Patient had an unwitnessed fall. He denies any pain and no visible injury per staff. he is on Plavix (blood thinner). (R2) thinks he hit his head, but staff did not feel any bumps/bruises on his head. No headache. R2's Incident Report dated 8/25/2024 at 5:10 PM, documents, CNA heard a thud from resident's room, immediately went to see and found resident on the floor up against the door. Resident appeared to hit head and states a little pain. Resident unable to recall what happened. Resident was lying in bed watching TV and then I was on the floor. I am not sure what happened. R2's Incident Report does not document any fall interventions for this fall and/or any future fall preventions for any future falls. R2's Progress notes dated 8/26/2024 at 8:00 AM document (R2) was observed on floor in his room, next to his bed and nightstand. Positioned on his back with legs outstretched. R2 is unable to state what happened. Mental status and ROM (range of motion) both at his baseline. Assessed for pain/injury, none noted at this time. Stated he hit his head. Nurse practitioner, (NP) in facility, assessed resident and requested he be sent to ER (emergency room ) for evaluation. R2's Progress notes dated 8/26/2024 at 5:46 PM documented R2 returned from local ER at 3:00 PM and was started on antibiotics. R2's Fall Incident Report dated 8/26/2024 at 8:00 AM, documents, Resident found lying on floor in his room next to bed and night stand. Positioned on his back with legs outstretched. Unable to state what happened. Mental status at his baseline. ROM (range of motion) at baseline. NP (Nurse Practitioner) examined resident, and requested he be sent to ER for evaluation. Resident unable to give description. R2's Incident Report does not document any fall interventions for this fall and/or any future fall preventions for any future falls. R2's Progress notes dated 8/30/2024 at 7:42 PM documented nurse was in the hallway preparing medications for medication pass, when she heard a loud noise at 7:42PM. She looked down the hallway and saw the resident laying on the floor on his back with his lower half of his body in his room and the upper half of his body in the doorway to his room and his head on the hallway floor. At 7:45 PM VS (vital signs) (97.7, 68, 16, 111/45, 98% on RA). Neuro checks done at 7:46 PM with all being within normal limits. (R2) stated he didn't know what had happened, but that he did hit his head. Small laceration measuring approximately 0.5cm (centimeters) with a small amount of blood noted. (R2) denied any pain or discomfort at that time. At 7:51 PM, this nurse called 911 for EMS (emergency medical service). At 7:52 PM, this nurse called (R2's) power of attorney, (POA) but he did not pick up the telephone and a voice message was left to contact the facility. At 7:53 PM, this nurse contacted the facility administrator. At 7:56 PM, this nurse called resident's #2 contact, and she did not pick up the telephone and no message were left by this nurse at that time. At 7:59 PM, resident's POA (Power of attorney), returned this nurse's phone call and report was given to POA about incident and R2's condition. This nurse also informed POA of facility's bed hold policy and that the resident was informed of bed hold policy and given a copy along with his other paperwork that was given to emergency medical staff, (EMS) staff. POA verbalized understanding. At 8:00 PM, EMS arrived at this facility and placed resident on the stretcher. At 8:04 PM EMS left the facility with the resident to transport him to local hospital's ER for evaluation. Also, at 8:04PM, local hospital ER was contacted, and report was given to hospital nurse regarding R2's condition and that he did not receive the ordered 8:00 PM medications as he fell prior to administration by this nurse. R2's Incident Report dated 8/30/2024 at 7:42 PM, documents, Resident up and ambulating in his room, resident heard falling and was found with his lower half of his body inside his room while the upper half of his body was out in the hallway. This nurse heard a loud noise and looked down the hall and saw the resident laying on his back. Resident stated he didn't know what happened. Resident did say he hit his head. Resident was ambulating without assistance. The Incident Report does not document any fall interventions for this fall and/or preventions for any future falls. R2's Progress Notes dated 9/11/2024 at 12:53 AM, Resident fell and got himself up and onto the bed. Resident stated he hit the right, back side of his head. Resident states that he is unsure of how he fell . ROM (range of motion) WNL (within normal limits). NP made aware and gave order to send resident to ER due to resident being on an anticoagulant. R2's Care Plan for Falls documents R2 incurred a fall on 8/25/2024, 8/26/2024 and 8/30/2024. The interventions on the Care Plan for the Fall on 8/25/2024 documents, resident unaware how fall occurred. Resident with UTI (urinary tract infection), started on antibiotics. R2's fall on his Care Plan on 8/26/2024 2024 interventions documents, resident unaware how fall occurred. Resident with UTI (urinary tract infection), started on antibiotics. R2's Care Plan fall on 8/30/2024 resident unaware how fall occurred. Resident with UTI (urinary tract infection), started on antibiotics. (All three of R2's falls documented the same interventions, and no new and/or progressive interventions were documented). R2's Care Plan does not address his fall on 9/11/2024. On 10/03/2024 at 10:50 AM, V4, Assistant Director of Nursing (ADON) stated she was called down to the hallway after a CNA had heard a noise and found (R2) lying on the ground. She asked (R2) what had happened and (R2) told her he didn't remember what had happened. (R2) said he was in his bed and then was on the floor. We performed a video visit which didn't order an ER (emergency room ) visit. However, due to facility policy and (R2) receiving blood thinners, he was sent to the local ER. On 10/03/2024 at 10:55 AM, V5, Care Plan Coordinator stated whenever a resident has a fall, the staff meet together with the department heads and go over all falls and try and figure out the root causes, why the fall occurred, and ways to prevent any future falls. The management staff meet as an Interdisciplinary team, (IDT), regarding the course of action and what interventions to implement for each fall. We then meet again to ensure each intervention is working and no other falls have occurred. For every fall we must have a new intervention. On 10/03/2024 at 11:08 AM, V5, stated I was not doing the Care Plans at that time (R2) fell back in August and after I had talked to you I went back and looked at (R2's) Care Plan when I looked back at (R2's) records I realized there were no progressive interventions, and the same intervention was used all three times for his last three falls. It was an error. There should have been a new intervention for each fall, and nothing should have been repeated. This was an error. On 10/3/2024 at 11:33 AM, V1, Administrator stated, When we looked back at (R2's) Care Plan we realized we used the same interventions multiple times, and no new interventions were put into place on his falls in August. On 10/03/2024 at 12:15 PM, V2, Director of Nursing stated she was new to the position but would expect every fall to have an intervention and not to use the same intervention for multiple falls and have a new intervention for each fall. V2 also stated the care plan should reflect every fall and each intervention should implemented after every fall and assessed to ensure they were working for any future falls. The Facility Fall Policy with a revision date of 7/2022 documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All residents' falls shall be reviewed, and the residents' existing plan of care shall be evaluated and modified as needed.

Based on interview and record review, the Facility failed to ensure residents were free from abuse for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 3. Findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, cerebral infarction, and unspecified dementia with agitation. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired, required partial assistance with bed mobility, was dependent with transfer, and ambulated via wheelchair. R1's Undated Care Plan documents R1 has potential to be verbally aggressive to other residents and staff related to poor impulse control. The Care Plan update on 11/26/22 documents, Pulled female resident's hair in dining room. The Care Plan update on 8/26/24 documents, Hit female resident in the mouth. R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including muscle weakness, major depressive disorder, and unspecified dementia without behavioral disturbance. R2's MDS dated [DATE] documented R2 was severely cognitively impaired, but was independent with ambulation and transfer. R2's Undated Care Plan documents R2 is at risk for abuse and neglect related to wandering and dementia. The Care Plan update on 8/26/24 documents, Physical abuse by another resident. The Facility's Initial Report sent to the Illinois Department of Public Health (IDPH) on 8/26/24 documents alleged abuse involving R1, perpetrator, and R2. The Report documents, On Monday 8/26/24 at approximately 9:10 am, (V3, Environmental Services Director) observed (R2) in the dining room near (R1). At first (R1) was swatting at (R2) in attempt to shoo her away. Before (V3) could get to (R2) to help redirect her, (R1) swatted and hit (R2) in the mouth. R2's Progress Note dated 8/26/24 at 9:10 am documents, On Monday 8/26/24 at approximately 9:10am, (V3, Environmental Services Director) observed (R2) in the dining room near resident (R1) At first, he was swatting at (R2) in attempt to shoo her away. Before (V3) could get to (R2) to help redirect her, (R1) swatted and hit (R2) in the mouth. The Facility's Undated Hand-Written Statement by V3, Environmental Services Director, documents, I walked into dinning {sic} room, and (R2) was standing next to (R1). (R1) was swatting at (R2) (didn't hit her yet) trying to get her away. I told (R1) to stop and tried to get (R2) to move. Before I could get (R2) to move (R1) swatted her mouth. I got (R2) to move shortly after. On 9/10/24 at 12:18 PM, V3, Environmental Services Director, stated she was walking through the dining room after breakfast and saw R1 shooing at R2, trying to get her to go away. She stated she was trying to get in and separate them, but before she could get there R1 tapped R2 on the mouth. The Facility's Final Report sent to IDPH on 8/29/24 documents, Based on the known facts from medical record review and interview, the following conclusions have been determined about the original allegation: physical abuse is founded. On 9/10/24 at 1:50 PM, V1, Administrator, stated she expects the Facility to keep residents free from abuse. The Facility's Abuse Policy and Prevention Program 2022 revised 10/2022 documents, 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. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interviews, observations, and record reviews the facility failed to promote a pest free environment by not removing flies from resident's rooms for 6 out of 6 residents, (R6, R103, R13, R46, R22, R11), reviewed for pest control in a sample of 41. Findings include: On 8/5/24 at 9:30 AM, R6 has flies her in room, R6 stated the flies are bad here. On 8/5/24 at 9:35 AM, R103 had flies in his room; R103 stated the flies are a [NAME] to him and have been bad. On 8/5/24 at 9:58 AM, R46 had flies in her room and there is a fly swatter on her bedside table. On 8/5/24 at 10:02 AM, R13 had flies in her room and a fly swatter. R13 stated the flies are bad here and complained about them but nothing has been done. On 8/5/24 at 10:15 AM, R11 has flies in her room. R11 stated the flies have been horrible for 3-4 months now and because she has to use a bedside commode, the flies get worse. R11 stated she has complained about the flies, but nothing has been done. On 8/6/24 at 10:30 AM, R22 has flies in her room. R22 stated because she has to use a bedside commode, the flies seem to be accumulating more because the facility does not clean the commode frequently, it is left dirty, and she hates it. R22 stated she feels horrible when she is left in a room with a dirty commode and flies all around. On 8/8/24 at 9:00 AM, R11 was eating her breakfast on the side of her bed with flies and a full commode filled with stool, urine, and tissues. On 8/8/24 at 9:15 AM, V2 (Director of Nursing-DON) observed R11's full commode and flies in her room. On 8/8/24 at 11:15 AM, V15 (Maintenance Director) stated we don't have many flies here, maybe one or two and we haven't had to do much. V15 stated we have put up sticky fly traps in the hallway corners but nothing in the resident's room. V15 stated he was unaware that some residents had fly swatters in their rooms. The last receipt from pest control services for Monthly Commercial Pest Control was dated 7/17/2024. The facility's Pest Control policy dated 10/2017, documents, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on interview, observation and record review, the facility failed to perform proper hand hygiene and/or the wearing of gloves while plating food and failed to check and maintain the temperatures of the food, including all diets (regular diets, special diets, and pureed foods), prior to serving the residents to prevent contamination and foodborne illness. This failure has the potential to affect all 50 residents living in the facility. The findings include: On 8/5/24 at 12:10 PM, Upon walking into kitchen, V8 (Cook) was already starting to plate food with no gloves on. When asked if temperature checks were done, V8 stated I checked them when I took them off the stove. When asked to check temperatures: Turkey was at 160 degrees Farenheight (F.), Gravy at 163 degrees F., Mashed potatoes at 160 degrees F., [NAME] beans at 192 degrees F., Cream corn at 135 degrees F., and Mechanical Soft turkey was reading 120 degrees F. The Mechanical Soft food was put in the microwave by V7 (Dietary Manager-DM), for 15 seconds, he rechecked the temperature which was reading 135 degrees F. The Pureed food was temped at 113 degrees F. and was put in the microwave and still temped at 136 degrees F. V9 (Dietary District Manager) took the pan of Pureed food and put it on the stove top and heated up, then re-temped until it was at 176 degrees F. On 8/5/24 at 12:25 PM, V7 stated (V8) did check the temp when she got the food out of the oven but did not check it before she began plating the food. On 8/5/24 at 12:30 PM, V9 stated The cook is supposed to check the temperatures of the food once out of the oven or stove, then again before plating the food. The kitchen's temperature sheet, documents temps were taken after the food was removed from the oven, but no other times were documented (see attachment). On 8/5/24 at 12:45 PM, V8 went to the back of kitchen, and brought a tray cart to the front to put room trays on, returned to the serving line and continued to plate the food with no hand hygiene done. V8 was seen multiple times leaving the serving station to get different items in the kitchen, then returning to the serving line and continued to serve food with no hand hygiene done. On 8/5/24 at 12:50 PM, V8 walked from serving line to back of the kitchen to get a bag of gluten free bread for a resident. V8 reached in with her bare hands and grabbed a piece of bread. V7, DM, noticed V8 doing this and advised her that she needed to get tongs to use on the bread. V8 dropped the bread back into the bag and then used tongs to get the piece of bread out and put it on a resident's plate. On 8/12/24 at 9:55 AM, V1 (Administrator) stated I would expect the kitchen staff to check the temperatures of the food when required, especially before plating the food to be served to the residents. I would expect the kitchen staff to do hand hygiene as necessary. On 8/12/24 at 10:10 AM, V7 stated I saw just what you saw and couldn't believe she was not doing what she was supposed to be doing. I would expect the cook to check the food temperatures when removing from the stove, prior to plating the food, then again at the end. The cook does not necessarily need to wear gloves while serving food if they are using utensils. I do expect them to do hand hygiene any time they leave the food line and prior to the serving of the food. I also expect the cook to use proper utensils while serving the food, including getting bread out of the bag. During this lunch observation, at no time was any staff member in the kitchen seen wearing gloves, including the cook who was serving/plating the food with no gloves on, and there were no further temperatures done on the food line while serving lunch to the residents. The Facility's Food Preparation Policy, dated 2/2023, documents All foods are prepared in accordance with the FDA Food Code. 1. All staff will practice proper hand washing techniques and glove use. 2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 F and/or less than 135 F, or per state regulation. 10. Time/Temperature Control for Safety (TCS) hot food items will be cooked to a minimum internal temperature, as follows: All poultry and stuffed foods 165 F (<1 second instantaneous). 11. When hot pureed, ground, or diced food drop into the danger zone (below 135.), the mechanically altered food must be reheated to 165. for 15 seconds if holding for hot service. 12. When reheating, foods will be rapidly heated to 165 F for 15 seconds. If the food is not reheated within 2 hours it must be discarded. 13. All foods will be held at appropriate temperatures, greater than 135 F (or as state regulation requires) for hot holding, and less than 41 F for cold food holding. 14. Temperature for TCS foods will be recorded at time of service and monitored periodically during meal service periods. 15. All staff will use serving utensils appropriately to prevent cross contamination. The Facility's Meal Distribution Policy, dated 2/2023, documents Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining. The Resident Census and Conditions of Residents, CMS 671, dated 8/5/24, documents that the facility has 50 residents living in the facility.

Based on observation, interview, and record review, the facility failed to remove expired medication from the medication room refrigerator, restock the medication shelf, and medication cart. Findings include: On [DATE] 10:05 AM Medication Storeroom refrigerator was inspected, and the following was found. 1. R47 was observed to have a COVID-19 (Spikevax injection) ,d+[DATE].5ml (milliliters) one time dose with an expiration date of [DATE]. 2. There were two Forteo (Teroparatide) insulin pens inject 0.08ml (20mcg [micrograms] total) under the skin daily labeled with R22's name and the label also documented discard after 28 days after initial use. One had an expiration date of [DATE] and the other had an expiration date of [DATE]. A foil package in the refrigerator was also observed and contained the following medications: 3. Two unopened vials of Novolin R 100 insulin units/ml with expiration dates of [DATE]. 4. One unopened vial of Humulin N insulin 100 units/ml with an expiration date of ,d+[DATE]. 5. One unopened vial of Humulin N insulin 100 units/ml with an expiration date of ,d+[DATE]. 6. Two unopened vial of Humulin R insulin 100 units/ml with an expiration date of ,d+[DATE]. 7. One unopened vial of Novolin N insulin 100 units/ml with an expiration date of [DATE]. 8. Daptomycin for injection 500mg per vial single-dose vial with an expiration date of ,d+[DATE]. On [DATE] at 10:15 AM, the medication storage room stock medications were inspected, and the following was found: two bottles of Aspirin 81mg with an expiration date of ,d+[DATE]. On [DATE] at 10:20 AM, V13, Licensed Practical Nurse (LPN) verified the medications had expired. She said the insulin found in the refrigerator if it didn't have a resident's name on it was for facility use. On [DATE] at 10:19 AM V1, Administrator stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) are to check the med storage room, refrigerator every month and she would expect the nurses to check the date on the medication before putting it on the medication cart and dispose of it if it needed to be disposed of. 44967 On [DATE] at 8:35 AM, V10, Registered Nurse (RN) was administering medications to R103. V10 placed a Multi-Vitamin (MVI) in a medicine cup to give to R103. Upon examination of the bottle, the expiration date was ,d+[DATE]. V10 was advised of the expiration date and removed the MVI from the cup. V10 went to the other medication cart and the MVI bottle in that cart was also expired. V10 stated that V2, Director of Nursing (DON), will be going to the local pharmacy to get some. R103's Physician Order (PO), dated [DATE], documents Multi-Vitamin Tablet. Give 1 tablet by mouth one time a day for supplement. The Facility's Storage of Medications Policy, dated ,d+[DATE], documents Purpose: To provide the staff with guidance on the proper storage of medications. 1. Medication and biologicals must be stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. 5. Medications labeled for individual residents should be stored separately from floor stock medications. 8. Over the Counter Medications will use the manufacture expiration date unless otherwise clinically indicated. 11. Outdated, contaminated, or deteriorated medications - and those in containers that are cracked, soiled or without secure closures should be immediately removed from stock and disposed of according to medication disposal procedure. If necessary, medications should be reordered from the pharmacy. 12. Outdated, contaminated, deteriorated medications will be moved from the Medication Carts and placed in pharmacy return bin within the Medication room. The Facility's Med Administration Policy, dated ,d+[DATE], documents All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: 6. Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident and time. 7. Read each order entirely. 8. Remove medication from drawer and read label three times; when removing from drawer, before pouring and after pouring. 9. If there is a discrepancy between the MAR and label, check orders before administering medications. 10. If the label is wrong, send medications to pharmacy for relabeling call pharmacy to send a new label. Verify order with physician. If the MAR is wrong, reenter the order. 11. Verify that the medication has not expired. 13. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. 21. Remain with the resident to ensure that the resident swallows the medication.

Based on interview and observation, the facility failed to properly administer medications to residents, including interpreting prescriber's order and ensuring the resident receives their medications, to meet their needs for 4 of 5 residents (R22, R33, R38, R103) reviewed for medication administration in the sample of 41. Findings include: 1. On [DATE] at 8:35 AM, V10, Registered Nurse (RN) was administering medications to R103. V10 placed a Multi-Vitamin (MVI) in a medicine cup to give to R103. Upon examination of the bottle, the expiration date was ,d+[DATE]. V10 was advised of the expiration date and removed the MVI from the cup. V10 went to the other medication cart and the MVI bottle in that cart was also expired. V10 stated that V2, Director of Nursing (DON), will be going to the local pharmacy to get some. V10 placed a Lisinopril 2.5 MG (milligram) tablet in a medicine cup to give to R103. The physician's order documented 5 MG, when V10 was advised of the physician order, V10 noticed it was incorrect, and stated she would have to verify and correct the order. R103's Physician Order (PO), dated [DATE], documents Multi-Vitamin Tablet. Give 1 tablet by mouth one time a day for supplement. R103's PO, dated [DATE], documents Lisinopril Tablet 5 MG (milligram). Give 0.5 MG by mouth one time a day for HTN (Hypertension). Lisinopril 2.5 MG Tablet. R103's PO, dated [DATE], documents Lisinopril Oral Tablet 2.5 MG. Give 1 tablet by mouth one time a day for HTN. This order was corrected by V10. 2. On [DATE] at 8:45 AM, V10 was administering medications to R22. V10 popped a Lorazepam 0.5 MG tablet out of its package and onto the dirty top of med cart. V10 then picked the tablet up with her hands and put it in the medicine cup, then administered it to R22. R22's PO, dated [DATE], documents Lorazepam Oral Tablet 0.5 MG. Give 1 tablet by mouth every 12 hours as needed for anxiety. 3. On [DATE] at 10:08 AM, R33 was seen lying in his bed with a medicine cup of medications sitting on his bedside table, along with a cup of water. The medicine cup had five pills in one cup, and one pill in another. R33 stated they were cleaning him up when the nurse came in, so she just left them for him to take. R33's Medication Administration Record (MAR), dated [DATE], documents R33 received ASA (Aspirin) 81 MG, Cetirizine 10 MG, Cholecalciferol 1000Units, Ativan 0.5 MG, and Incruse Ellipta inhaler this morning at 8:00 AM. The following medications are also scheduled for 8:00 AM, but was not signed off: Nifedipine 60 MG (check BP at that time), Escitalopram 20 MG, Methadone 10 MG. R33's PO, dated [DATE], documents Aspirin Tablet Chewable 81 MG. Give 1 tablet by mouth one time a day for Prophylaxis. R33's PO, dated [DATE], documents Cetirizine HCl Tablet 10 MG. Give 1 tablet by mouth one time a day for allergies. R33's PO, dated [DATE], documents Cholecalciferol Tablet 1000 Units. Give 1 tablet by mouth one time a day for supplement. R33's PO, dated [DATE], documents Ativan Oral Tablet 0.5 MG (Lorazepam). Give 0.5 MG by mouth two times a day for Anxiety. R33's PO, dated [DATE], documents Nifedipine ER (extended release) Tablet Extended Release 24 Hour 60 MG. Give 1 tablet by mouth one time a day for hypertension. R33's PO, dated [DATE], documents Escitalopram Oxalate Tablet 20 MG. Give 1 tablet by mouth one time a day for depression. R33's PO, dated [DATE], documents Escitalopram Oxalate Tablet 20 MG. Give 1 tablet by mouth one time a day for depression. R33's PO, dated [DATE], documents Methadone HCl (hydrochloride) Oral Tablet 10 MG (Methadone HCl). Give 2 tablets by mouth one time a day for pain. 4. On [DATE] at 10:25 AM, R38 had a bottle of Cinacalcet (Sensipar) 60 MG tablets in a wash basin next to his bed. This bottle appears to be full of pills. On [DATE] at 10:11 AM, R38 sitting up in his bed with a medicine cup of medications, along with a cup of water, seen on his bedside table. The medicine cup had eight pills in it. R38's MAR, dated [DATE], documents R38 received ASA 81 MG, Amlodipine 10 MG, Carvedilol 6.25 MG, Cholecalciferol 125 MCG (microgram), Lasix 80 MG, Losartin 100 MG, Bupropion 75 MG, and Fe (Iron) 325 MG. R38's PO, dated [DATE], documents Aspirin EC Tablet Delayed Release 81 MG (Aspirin). Give 1 tablet by mouth at bedtime for Prophylaxis. R38's PO, dated [DATE], documents Amlodipine Besylate Oral Tablet 10 MG. Give 1 tablet by mouth one time a day related to Acute on Chronic Systolic (Congestive) Heart Failure. R38's PO, dated [DATE], documents Carvedilol Oral Tablet 6.25 MG. Give 1 tablet by mouth one time a day related to Essential (Primary) Hypertension. 38's PO, dated [DATE], documents Cholecalciferol Oral Tablet 125 MCG. Give 1 tablet by mouth one time a day for supplement. R38's PO, dated [DATE], documents Furosemide Oral Tablet 80 MG. Give 1 tablet by mouth one time a day related to Acute on Chronic Systolic (Congestive) Heart Failure. R38's PO, dated [DATE], documents Losartan Potassium Oral Tablet 100 MG. Give 1 tablet by mouth one time a day related to Essential (Primary) Hypertension. R38's PO, dated [DATE], documents Bupropion HCl Oral Tablet 75 MG. Give 75 MG by mouth two times a day related to Major Depressive Disorder. R38's PO, dated [DATE], documents Ferrous Sulfate Oral Tablet 325 (65 Fe) MG. Give 1 tablet by mouth three times a day related to Anemia. On [DATE] at 10:30 AM, V2, DON, and V14, Regional Nurse Consultant, was advised of cups of medications at R33's and R38's bedside. V14 walked to each room and gathered the medications from R33 and R38 (including the bottle of medications) and stated The nurses should never leave medications at the resident's bedside; they should stay and make sure they take their medications. We will be starting education immediately and will be doing a room-by-room search of medications. On [DATE] at 11:15 AM, V10, RN, stated I did give (R33) his ASA, Cetirizine, Cholecalciferol, and his Methadone (2 pills) in one medicine cup. His Ativan was placed in another medicine cup on its own. I did not give him his Nifedipine or his Escitalopram, I guess I still need to do that yet. I am not sure why I just left his cup of meds there; I usually don't do that. On [DATE] at 11:17 AM, V10, RN, stated I gave (R38) his Amlodipine, ASA, Carvedilol, Cholecalciferol, Lasix, Losartan, Bupropion, Iron, Sertraline, and Sensipar. There should have been nine pills in the medicine cup. If there wasn't, he must have taken one or two of them. (R38) does not like me to stand there and watch him, I usually leave it on the table and will watch him from his doorway. I just got busy and left and did not stay to watch him this time. I think he must have gotten the bottle of medications (Sensipar) from Dialysis because that is not ours and I didn't realize he even had it. On [DATE] at 3:10 PM, V10, stated that she saw V2, and V14, walk by the desk with the cups of medications and she followed them into their office. V10 stated she got the cups from them, put R33's other two medications in the cup, and made sure both residents took their pills. On [DATE] at 10:00 AM, V2, DON, stated I would expect the nurses to ensure the resident receives their medications by watching them take the meds and not leaving them for the resident to take on their own. The Facility's Med Administration Policy, dated ,d+[DATE], documents All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: 6. Check medication administration record prior to administering medication for the right medication, dose, route, patient/resident, and time. 7. Read each order entirely. 8. Remove medication from drawer and read label three times; when removing from drawer, before pouring and after pouring. 9. If there is a discrepancy between the MAR and label, check orders before administering medications. 10. If the label is wrong, send medications to pharmacy for relabeling call pharmacy to send a new label. Verify order with physician. If the MAR is wrong, reenter the order. 11. Verify that the medication has not expired. 13. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. 21. Remain with the resident to ensure that the resident swallows the medication. The Facility's Storage of Medications Policy, dated ,d+[DATE], documents Purpose: To provide the staff with guidance on the proper storage of medications. 1. Medication and biologicals must be stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. 5. Medications labeled for individual residents should be stored separately from floor stock medications. 8. Over the Counter Medications will use the manufacture expiration date unless otherwise clinically indicated. 11. Outdated, contaminated, or deteriorated medications - and those in containers that are cracked, soiled or without secure closures should be immediately removed from stock and disposed of according to medication disposal procedure. If necessary, medications should be reordered from the pharmacy. 12. Outdated, contaminated, deteriorated medications will be moved from the Medication Carts and placed in pharmacy return bin within the Medication room.

Based on observation, interview, and record review the facility failed to provide 80 square feet of floor space per resident bed for 9 of 50 residents (R5, R11, R15, R19, R20, R22, R32, R33, and R103) reviewed for room size in the sample of 41. Findings include: On 08/12/24 at 10:19 AM V1 (Administrator) stated there has been no changes of the measurements and accuracy of the facility's waivered resident room numbers and certifications. V1 stated there were 5 rooms on the 100 hall and all rooms were Medicare and Medicaid certified and provide 77.5 square feet per resident per bed. R5, R11, R15, R19, R20, R22, R32, R33, and R103's rooms were measured on the 100 hallway and each room measured was less than 80 square feet per resident. Observations made throughout the survey from 08/05/24 through 08/12/24 demonstrated no concerns or complaints vocalized by residents in relation to waivered room size. On 08/06/24 at 11:00 AM, during the resident group meeting no residents voiced any complaints or concerns regarding room size. The facility provided a list of residents affected by the room size and (R5, R11, R15, R19, R20, R22, R32, R33, and R103) were all documented as receiving a room waiver. The Resident Census and Conditions of Residents, CMS 671, dated 8/5/24, documents that the facility has 50 residents living in the facility.

Based on interview, observation, and record review the facility failed to promote respect and dignity in an environment that promotes maintenance by not providing timely removal of urine and feces from a resident's bedside commode for 1 of 1 resident (R11) reviewed for dignity in a sample of 41. Findings include: R11 was admitted to the facility on [DATE] with diagnosis of, in part, anxiety and major depressive disorders, fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing and lack of coordination. R11's Minimum Data Set (MDS) dated [DATE] documents R11 as being moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 9. During this investigation, R11 was alert and oriented to person, place and time. R11's MDS further documents R11 requires partial/moderate assistance for: toilet transfer: The ability to get on and off a toilet or commode and toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. R11's MDS documents further that R11 uses a wheelchair and requires partial/moderate assistance to walk. R11's current care plan dated 7/19/2024 documents R11 requires assistance with daily care needs related to weakness, fracture of spine with interventions to assist R11 with activities of daily living (ADLs) and monitor for changes with daily care abilities, provide more or less assist if needed, and rounding at a minimum of every 2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry. On 8/5/24 at 10:15 AM, R11 stated she must use a bedside commode which also attracts the flies if staff don't clean it out timely. Stool is seen smeared on R16's floor by her commode. R11 stated she notified staff 4 hours prior that her commode needed to be emptied and is still waiting. R11 stated she hopes and prays the commode will be cleaned out by the time she has to use it again. R11 stated she doesn't ask for much but asking for her commode to be changed doesn't seem like a lot. On 8/5/24 at 11:00 AM, R11 was on her commode and stated it had not been cleaned yet, but she had no other choice but to use it. R11 pressed her call light and waited for 5 minutes for staff to respond but stated did not want to continue sitting over her dirty commode with all the flies. R11's commode was full of stool, urine, and tissues. Stool is still smeared on R16's floor. On 08/6/24 at 10:30 AM, R11's floor is still dirty with the same stool smears on the floor from yesterday. On 8/6/24 at 2:29 PM, bedside commode still not cleaned out. On 8/8/24 at 9:00 AM, R11 was eating her breakfast on the side of her bed with flies and a full commode filled with stool, urine, and tissues. On 8/8/24 at 9:15 AM, V2, Director of Nursing (DON), observed R11's full commode and flies in her room. V2 stated she would expect the commode to be changed out after R11 uses it, and she will clean it right now. The facility's Resident Rights Policy dated 10/2023, documents, The facility will provide a safe, clean, comfortable, and homelike environment .The residents' environment will be maintained in a homelike manner.

Based on interview and record review, the Facility failed to ensure an environment free from abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. This Failure caused R1 to be fearful of R2 and causes her to have trouble sleeping. Findings include: R1's Face Sheet documents, R1 was admitted to the facility on [DATE] with diagnoses, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, osteoarthritis, and muscle weakness and atrophy. R1's Minimum Data Set, (MDS), dated [DATE] documented, R1 was independent with cognitive skills for daily decision making with short term memory intact. The MDS documented R1 required substantial/maximal assistance with bed mobility and transfer and ambulated with manual wheelchair. R1's Undated Care Plan, documents, R1 is at risk for abuse and neglect. R2's Face Sheet, documents, R2 was admitted to the facility on [DATE] with diagnoses, including encephalopathy, multiple sclerosis, difficulty walking, lack of coordination, weakness, insomnia, bipolar disorder, schizoaffective disorder, and major depressive disorder. R2's MDS dated , 04/17/24, documented, R2 was moderately cognitively impaired with inattention and disorganized thinking, used wheelchair, and required partial/moderate assistance with bed mobility and transfer. R2's Undated, Care Plan, does not address risk for abuse or identified sexual behaviors. The Facility's 04/18/24, Room Roster, documents, R1 and R2 resided in room [ROOM NUMBER]. R2's Progress Note, by V9, Licensed Practical Nurse, (LPN), on 04/18/24, at 11:54PM, documents, R2 crawled into roommate's bed. R2's Progress Note, by V9, LPN, on 04/19/24 at 4:28AM, documents, Resident noted to be talking sexually to roommate making sexual comments stating that her roommate is her lover, yelling for staff, roommate, people to have sex with her, asked her roommate for help with masturbation, and making sexual comments and personal questions when roommate was receiving care. Resident was able to be redirected and asked to lower her voice, r/t, (related to), others sleeping, will continue to monitor. (V2) and (V1) notified of behavior. On 04/24/24, at 3:53PM, V9, LPN, stated, early in the morning of 04/19/24, the (unknown) CNA, (Certified Nursing Assistant), reported to her, that R2 tried to crawl in bed with R1. She stated, R1 pushed her call light and told the CNA. When V9 entered the room, R2 was saying inappropriate things, and she told R2 that was inappropriate, and she should try to get some sleep. On 04/25/24, at 8:35AM, V14, CNA stated, On the night of 04/18/24, I responded to (R1)'s call light and found (R2) sitting in (R1)'s bed rubbing her leg and asking her to help her masturbate. I separated them and put (R2) back in (her) bed and notified the nurse. When I (first) walked in the room (R1) mouthed, Help me, and said she felt extremely uncomfortable. Prior to that, (R2) kept interrupting (R1)'s care, making sexual comments when we were trying to care for (R1) and asking us to touch her. On 04/20/2024, at 4:20PM, R1 stated, One day (R2) came to my bed and was rubbing my legs, and telling me she could masturbate with me, and I could watch if I wanted or she could touch me if I wanted her to and I said, No. On 04/24/24, at 1:00PM, R1 stated, I was scared .afraid (R2) was going to do something to me. She came over to me and said, I masturbate a lot. Would you like to come over and watch? I told her, I don't think so. My eyes aren't so good, and I probably couldn't see anyway. She yelled, a lot and talked constantly in a very loud voice, so I had trouble sleeping, but I was also afraid to go to sleep, after that day she sat on my bed and was rubbing my leg. I asked her to get up and she wouldn't, so I told her I was going to call the nurse. Then she got up. I told staff about it the next day. I know (R2) was disturbed, but she made me very nervous. Honestly, she scared the hell out of me. On 04/25/24, at 11:50AM, V16, Nurse Practitioner, (NP), stated, she visited R2 for her initial evaluation in the Facility on 04/18/24. She stated, R2 had word garbage, was not able to have coherent conversation, had sporadic words, most of them vulgar, vulgar gestures, and was impulsive. V16 stated, at that point there was nothing that led her to believe, R2 was at risk for touching others and did not think there was anything the Facility could have done to prevent it. On 04/25/24, at 9:56AM, V1, Administrator, stated, she expects the Facility to follow its abuse policy. The Facility's Abuse Policy and Prevention Program 2022 revised 10/2022 documents, This facility affirms the right of our resident 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. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault.

Based on observation, interview and record review the Facility failed to ensure a safe transfer for 1 of 3 residents (R2) reviewed for transfers in the sample of 9. This failure resulted in R2 being picked up by staff after a fall and transferred to a chair and sent out to the hospital later where she sustained a tibia spiral fracture. Findings include: R2's Physician Order Sheet for January 2024 documents a diagnosis of : Chronic obstructive pulmonary disease, abnormalities of gait and mobility, lack of coordination, displaced supracondylar fracture without intercondylar extension of lower end of left femur, subsequent encounter for closed fracture with routine healing, abnormal weight gain, cognitive communication deficit, major depression, reflex neuropathic bladder, paraplegia, idiopathic peripheral autonomic neuropathy, anemia, acute infraction of spinal cord, pressure ulcer of sacral region, and altered mental status. R2's Minimum Data Set (MDS) documents she is moderately impaired for cognition. Bed mobility R2 was scored as 3/3 (extensive assist of two plus staff). Transfer 4/3, (total dependence on staff of two plus staff members). R2 does not walk, for toilet use she was scored a 4/3, and for personal hygiene 4/3. For Moving from seated to standing position, walking, turning around, and moving on and off the toilet she was documented as this activity did not occur. R2 was scored from surface to surface transfer (between bed and chair) as not steady and only able to stabilize with staff assistance). R2 is in a wheelchair. For Roll left to right, she requires Substantial/maximal assistance and for sit to lying, and lying to sitting she Dependent- staff does all of the effort. R2's Care Plan documents, R2 has Alteration in musculoskeletal status related paraplegia. Intervention: Monitor. Document for risk of falls, educate residents, family/caregivers on safety measures that need to be taken in order to reduce risks for falls. Alteration in musculoskeletal status related paraplegia. Fall (Focus Area) Resident is at risk for falls. Functional Deficits. 8/28/2023 Resident slid out of bed onto floor. Intervention, Bed changed to low position. 9/10/2022 Resident slid out of bed onto floor. Intervention: (Not documented). 12/21/2023 Fall in room, no noted injuries. Intervention: Canoe mattress. Rounding at a minimum of every 2 hours and prompt or assist for change in position, toileting, offer fluids. And ensure resident is warm and dry. ADL: Resident requires assist with daily care needs related paraplegia. Two person assist for transfers, assist resident with ADL's, Encourage/assist with turning and repositioning every two hours and as needed. On 1/2/2024 at 9:03 AM, V2, Director of Nursing stated, (R2) fell on [DATE]. She is a paraplegic, and when we asked her how she fell out of the bed she told us she had been up walking in her room, which is not possible. (R2) was confused. She has a history of falls as well. When the nurse was in her room, she saw she had a bruise on her leg and we then sent her out to the hospital where we later found out she had a fracture. (R2) is still in the hospital. On 1/2/2024 at 9:11 AM, V1, Administrator stated, I believe you are here because of (R2) having a fall. (R2) fell in her room, a few days later the nurse discovered a bruise. (R2) was sent to the hospital where we learned later that she had a fracture. (R2's) foot was turned out but that was nothing new, her foot always turned out. R2's Nurse's Notes dated 12/21/2023 at 4:20 PM, Heard resident state, 'girl'. As this nurse looked down hallway, observed resident on floor with head peeking out of the room. When asked what happened stated, I have been walking. Resident is a paraplegic and has been for years. ROM (Range of Motion) noted to be at baseline all extremities. Denies any pain at this time. Assisted with 3 with gait belt into wheelchair, then transported to the dining room to work on puzzles. R2's Initial Fall dated 12/21/2023 at 4:20 PM, documents, Resident was observed with her head out of her doorway lying on the floor. Resident description, I was walking, and my feet slipped. Resident is paraplegic for many years. Mental status confused/forgetful, orientated to situation. IDT (interdisciplinary team) meeting to discuss fall from 12/21/2023. Resident fell in room from bed. States she was walking. Resident is paraplegic. Resident is alert with confusion. BIMS 10 (moderately impaired). Resident requires dependence with ADL's and (mechanical lift) for transfers. Indwelling catheter. Incontinent of bowels. RCA: Attempting to walk: paraplegic. Poor safety awareness. All previously care planned interventions in place, adding canoe mattress. Continue to encourage use of wheelchair and call light. All parties agree with plan of care. Care plan reviewed and updated. R2's Final Investigation from 12/21/2023 documents, (R2) was evaluated at the ER and found to have acute appearing minimally displaced spiral-like fracture of the proximal tibia metadiadiaphysis. (R2) had an immobilizer placed at the hospital. (R2) did not return from the hospital so an interview was not able to be completed with her. Despite messages left for POA (Power of Attorney) she did not return Administrators call. On 1/2/2024 at 12:10 PM, V4, Licensed Practical Nurse (LPN) stated, I usually do not work (R2's) hall. I was working that night as a CNA and the nurse got sent home because they tested positive for COVID. (V10) the CNA working that hall came and got me because she said she was doing rounds and (R2's) leg looked weird to her and did not look right and she asked if I would come and look at it. When I saw (R2's) legs I was not even sure what was going on. (R2) had bruising on her leg but the bruising looked old to me because it was greenish purple in color. I immediately took a photo of it and sent it to the Nurse Practitioner and she had me send her out. What I remember the most is that (R2's) foot was turned in to a 90-degree ankle and that is not normal. Her leg looked bad to me and I sent her out. I found out later that she had a fracture but I knew something was not right with it. You could tell it was broken because it was twisted. On 1/2/2024 at 12:24 PM, V6, CNA, Activities stated, (R2) cannot walk and is unable to move any of her legs. She is able to move her upper body/arms. She is very confused and has gotten worse over the years. I think she came here a few years ago with a broken back. (R2) has been here for several years. (R2) is convinced that (V7) kidnapped her and brought her here to the facility. I know a few years back she was supposed to wear a brace on her leg, and she refused, and we stopped doing that. Her foot turned out a little but nothing major, not 90 degrees. She was not complaining of pain, and we were able to get her out of bed. (R2) could not move her legs but ways always saying she walked here, or she walked there. We have been getting her in and out of bed without any issues. On 1/2/2024 at 12:32 PM, V7, CNA stated, (R2) is very confused and gets things mixed up. For whatever reason she is convinced I kidnapped her after she walked here for hours to come and work, and now I will not let her leave. (R2) thinks she can walk but she cannot walk. (R2) is not even able to move her legs. (R2) can push herself up. I am not aware of her foot turning out. We have been transferring her from the bed to her wheelchair without any issues. On 1/2/2024 at 12:49 PM, V8, CNA stated I use to work here and then I left but I am back now. I remember (R2). From what I remember she is paralyzed and cannot move her legs, but she is able to move her arms. (R2) is confused and always telling everyone she was kidnapped, and she wants to leave here. On 1/11/2024 at 9:57 AM, V11, Registered Nurse (RN) stated, I remember (R2) was poking her head out of the room and I saw her on the floor. Her foley catheter was wrapped around her like a purse. She was laying on the ground and we attempted to attach her to the (mechanical lift) but the machine would not go down far enough. I do not usually work with the mechanical lifts the certified nursing assistants use them more than me. We had a pad underneath (R2) but I do not know if it was us not doing something right or if it was the machine now working properly because we could not get (R2) attached to the mechanical lift. I then grabbed (R2's) legs and (V6, CNA) and the agency CNA used a gait belt and put it around her shoulders, and we lifted (R2) back to her wheelchair. I did not use a blanket, we just grabbed her and put her back in her wheelchair. R2's Investigation from 12/21/2023 included statements from questions the facility had asked. The Facility asked V11 some questions regarding R2 and V11. It was documented that V11 told the facility We attempted (mechanical lift) but couldn't get it low enough. Two aids got around her top with gait belt and I grabbed her legs. We lifted her up into her wheelchair. On 1/11/2024 at 10:11 AM, V6, Certified Nursing Assistant (CNA) stated, I had seen (R2) earlier and she wanted to get up. I was in the middle of doing rounds and I told her after I was doing rounds I would come back and I would help get her up. It was not even five minutes and the nurse came and got me (V11) because she found (R2) on the floor sitting up on a pillow. We tried to transfer (R2) with the mechanical lift and she had a pad underneath here but it was not working so I put a gait belt around her waist and the other CNA and I pulled her up as (V11) grabbed her legs and we lifted her up into the chair. R2's Investigation from 12/21/2023 with a statement from V6 documents, (Mechanical Lift) wouldn't reach the floor so the agency nurse, (V11) and I got her up by picking her up. 2 CNAs were at shoulders, nurse (V11) got her legs with gait belt we lifted her up into chair. Despite her yelling at us to stand her up. R2's Hospital Records document, (R2) a [AGE] year-old female with history of neurogenic bladder paraplegic, neuropathy, constipation, COPD, marginal zone lymphoma presents from (nursing home facility), due to staff noticing bruising over right and left knees. Patient is paraplegic and reports not falling. She is not pleased with her care at the facility and describes the staff being rough with moving her from the bed to the wheelchair. She notes lying in the bed for multiple hours prior to receiving care when she is asking for help. She states feeling mistreated at the facility was placed approximately one year ago. Denies any pain or significant ROS. Unaware of when bruising occurred or reported any incident where patient fell or was dropped. R2's Hospital Records also document a complete foot drop, bruising present. There were bruises documented on both of R2's knees. On 1/11/2023 at 11:24 AM, V10, CNA stated, I am an agency CNA. I was doing my round and when I first went into R2's room she was covered up. A little later the call light went on and (R2) is confused and does not use the call light but her roommate (R6) does use the call light. I entered the room thinking (R6) needed something and I asked her what she needed but (R6) said no, I need you to check on (R2) because she has been moaning and I think she is in pain. Can you look at (R2)? (R2) can't move her legs. But I pulled back the covers to make sure everything was okay, and you do not have to be a rocket scientist to know that your foot does not rotate 360 degrees. (R2) had what appeared to be old bruising with green coloring and I immediately went and got the nurse because I could tell (R2) was injured. The nurse called the Nurse Practitioner and (R2) was sent out to the hospital where we learned later, (R2) had a spinal fracture. On 1/11/2024 at 9:11 AM, Mechanical lift was lowered to the lowest position and a pad was on the ground and it was attached to the lift by V7, CNA (Certified Nursing Assistant) with no issues. With the pad flat on the ground it was still able to be attached to the mechanical lift. There were two brands of mechanical lifts in the building and a total of two mechanical lifts observed total on the 100 hall without any issues. On 1/11/2023 at 9:22 AM, the other mechanical lifts on the 100 hall. machine was tested with V7, CNA on the 100 hall. The mechanical lift was in working condition and was able to be lowered and the mechanical pad was able to be attached from the floor with the strap, with the pads flat on the ground, they were still able to be attached to the lifts without any complications. R2's Hospital Records dated 1/1/2024 document, (R2) a [AGE] year-old female with history of neurogenic bladder paraplegic, neuropathy, constipation, COPD, marginal zone lymphoma presents from (nursing home facility), due to staff noticing bruising over right and left knees. Patient is paraplegic and reports not falling. She is not pleased with her care at the facility and describes the staff being rough with moving her from the bed to the wheelchair. She notes lying in the bed for multiple hours prior to receiving care when she is asking for help. She states feeling mistreated at the facility was placed approximately one year ago. Denies any pain or significant ROS. Unaware of when bruising occurred or reported any incident where patient fell or was dropped. R2's Hospital Records also document a complete foot drop, Capillary Refill: Capillary Refill takes less than two seconds. Findings: Bruising present. There were bruises noted on both knees. X-rays were taken and documents, Indication: Leg bruising under right knee without documentation of recent fall. Patient is paralyzed from waist down. X-rays show an acute proximal tibial fracture and a bilateral chronic displace femoral fractures. On 1/2/2024 at 3:04 PM, V12, Registered Nurse (RN) Hospital Nurse stated, I was working in the ER (emergency room ) when (R2) was brought in from the facility. The color of the bruising was almost dark red, you could tell by just looking at the leg because of the rotation of the foot and the degree in which the knee rotated out and that the leg was broken. I cannot say how long it had been like this. We took x-rays and she had a tibia sprial fracture. (R2) could not move or use her legs. I put my hand on her leg and she said she could feel the warmth of my hand but that was at. (R2) could not move her legs, she could only feel the temperature difference. (R2) was not in any pain. The x-rays showed she had a history of previous injuries, but this injury was new. (R2) has a lot of complications because of her spinal cord injuries and she also has issues with her hips and spine. I am not sure how she got the injury, but it was a new injury when she arrived at the hospital and she could not move her legs. On 1/5/2024 at 4:11 PM V14, Nurse Practitioner stated if a resident was a paraplegic and they had a fall she would expect the resident to respond differently than someone who had feeling it their legs. A lot depends on if their spinal cord is damaged the resident may not felt any injuries, and it could affect how the body would heal from that injury as well. For a paraplegic they may respond differently. I would expect the staff to monitor a paraplegic after a fall every 2 hours for 48 hours to ensure there were no injuries. I would expect staff to look for bruising, discoloration, swelling, disfigurement, things of that nature. I would expect them to be looking at the skin. I would expect a resident who is a paraplegic to always be transferred with a mechanical lift if they are not weight bearing. I would expect the staff to monitor as this is the crucial time frame if there was an injury. If a resident was transferred without a mechanical lift there is always the possibility if injuring the patient during the transfer. I did see (R2's) photo and the bruising appeared both new and old. It is possible her injury was sustained from the transfer and or the fall. I would expect all transfers to be with a mechanical lift and not a gait belt for (R2). The Facility Fall Policy with a review date of 9/2023 documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

The Facility failed to ensure a bruise of unknown origin was investigated and the appropriate corrective actions were initiated for 1 of 3 residents (R2) reviewed for injuries in the sample of 9. Findings include: R2's Physician Order Sheet for January 2024 documents a diagnosis of: Abnormalities of gait and mobility, lack of coordination, displaced supracondylar fracture without intercondylar extension of lower end of left femur, subsequent encounter for closed fracture with routine healing, abnormal weight gain, cognitive communication deficit, major depression, paraplegia, idiopathic peripheral autonomic neuropathy, anemia, acute infraction of spinal cord, pressure ulcer of sacral region, and altered mental status. R2's Minimum Data Set (MDS) documents she is moderately impaired for cognition. Bed mobility R2 was scored as 3/3 (extensive assist of two plus staff). Transfer 4/3, (total dependence on staff of two plus staff members). R2 does not walk, for toilet use she was scored a 4/3, and for personal hygiene 4/3. For Moving from seated to standing position, walking, turning around, and moving on and off the toilet she was documented as this activity did not occur. R2 was scored from surface-to-surface transfer (between bed and chair) as not steady and only able to stabilize with staff assistance). R2 is in a wheelchair. For Roll left to right, she requires Substantial/maximal assistance and for sit to lying, and lying to sitting she Dependent- staff does all the effort. R2's Care Plan documents, R2 has Alteration in musculoskeletal status related paraplegia. Intervention: Monitor. Document for risk of falls, educate residents, family/caregivers on safety measures that need to be taken in order to reduce risks for falls. Alteration in musculoskeletal status related paraplegia. Fall (Focus Area) Resident is at risk for falls. R2's Shower Sheet dated 12/19/2023 documents red area with an arrow pointing towards the high thigh area on the left side. R2's Shower Sheet dated 12/24/2023 documents a bruise on the right knee area. All abuse investigations were requested on for the past three months and there were no abuse investigations including injury of unknown origin for R2. On 1/2/2024 at 3:04 PM, V12, Registered Nurse (RN) Hospital Nurse stated, I was working in the ER (emergency room ) when (R2) was brought in from the facility. The color of the bruising was almost dark red, you could tell by just looking at the leg because of the rotation of the foot and the degree in which the knee rotated out and that the leg was broken. I cannot say how long it had been like this. We took x-rays and she had a tibia spiral fracture. (R2) could not move or use her legs. I put my hand on her leg and she said she could feel the warmth of my hand but that was all. (R2) could not move her legs, she could only feel the temperature difference. (R2) was not in any pain. The x-rays showed she had a history of previous injuries, but this injury was new. (R2) has a lot of complications because of her spinal cord injuries and she also has issues with her hips and spine. I am not sure how she got the injury, but it was a new injury when she arrived at the hospital, and she could not move her legs. On 1/11/2024 at 4:11 PM, V18, Certified Nursing Assistant (CNA) stated, I gave (R2) a bed bath, and I noticed bruising on her knee and marked it on the shower sheet, but I did not report it to the nurse. I did not report it to the nurse because it was an old bruise and had yellow coloring to it, so I thought it had already been reported. I did not report it to the nurse. On 1/11/2024 at 4:35 PM, V2, Director of Nursing stated, I would expect any staff if they saw a bruise new or old to inform a nurse so we can make sure we investigate. I am not sure why (V18) did not report it but she should have reported it. On 1/2/2024 at 12:10 PM, V4, Licensed Practical Nurse (LPN) stated, I usually do not work that hall. I was working that night as a CNA and the nurse got sent home because she tested positive for COVID. (V10) the CNA working that hall came and got me because she said she was doing rounds and (R2's) leg looked really weird to her and did not look right and she asked if I would come and take a look at it. When I saw it, I was not even sure what was going on and she had bruising on her leg, but it looked old to me because it was greenish purple in color. I immediately took a photo of it and sent it to the NP, and she had me send her out. What I remember the most is that her foot was turned in to a 90-degree ankle and that is not normal. Her leg looked bad to me, and I sent her out. I found out later that she had a fracture, but it did not surprise I could tell something was off. On 1/11/2023 at 11:24 AM, V10, CNA stated, I am an agency CNA. I was doing my round and when I first went into R2's room she was covered up. A little later the call light went on and (R2) is confused and does not use the call light but her roommate (R6) does use the call light. I entered the room thinking (R6) needed something and I asked her what she needed but (R6) said no, I need you to check on (R2) because she has been moaning and I think she is in pain. Can you look at (R2). (R2) can't move her legs because she is a paraplegic. But I pulled back the covers to make sure everything was okay, and you do not have to be a rocket scientist to know that your foot does not rotate 360 degrees. (R2) had what appeared to be old bruising with green coloring and I immediately went and got the nurse because I could tell (R2) was injured. The nurse called the Nurse Practitioner and (R2) was sent out to the hospital where we learned later, (R2) had a spinal fracture. On 1/11/2023 at 11:44 AM, R6 stated she was roommates with (R2) and she really missed her. She stated she remembers that night (R2) left because she had not been (R2) acting herself the past few days. She was more confused and a little off. She also said she was moaning in her sleep and thought she might be in pain, so she put on the call light to have the CNA come and make sure everything was okay with (R2). The CNA ran and got the nurse to come and look at (R2's) legs. I cannot get out of bed so I cannot tell you what (R2's) legs look like but I heard that she had bruising on both of her legs and was sent out to the hospital and had broken some bones. (R2) is so fragile, poor thing. R2's Hospital Records dated 1/1/2024 document, (R2) a [AGE] year-old female with history of neurogenic bladder paraplegic, neuropathy, constipation, COPD, marginal zone lymphoma presents from (nursing home facility), due to staff noticing bruising over right and left knees. Patient is paraplegic and reports not falling. She is not pleased with her care at the facility and describes the staff being rough with moving her from the bed to the wheelchair. She notes lying in the bed for multiple hours prior to receiving care when she is asking for help. She states feeling mistreated at the facility was placed approximately one year ago. Denies any pain or significant ROS. Unaware of when bruising occurred or reported any incident where patient fell or was dropped. R2's Hospital Records also document a complete foot drop, Capillary Refill: Capillary Refill takes less than two seconds. Findings: Bruising present. There were bruises noted on both knees. X-rays were taken and documents, Indication: Leg bruising under right knee without documentation of recent fall. Patient is paralyzed from waist down. X-rays show an acute proximal tibial fracture and a bilateral chronic displace femoral fractures. On 1/2/2024 at 3:04 PM, V12, Registered Nurse (RN) Hospital Nurse stated, I was working in the ER (emergency room ) when (R2) was brought in from the facility. The color of the bruising was almost dark red, you could tell by just looking at the leg because of the rotation of the foot and the degree in which the knee rotated out and that the leg was broken. I cannot say how long it had been like this. We took x-rays and she had a TibFib, (Tibia, Fibula) fracture. (R2) could not move or use her legs. I put my hand on her leg and she said she could feel the warmth of my hand but that was it. (R2) could not move her legs, she could only feel the temperature difference. (R2) was not in any pain. The x-rays showed she had a history of previous injuries, but this injury was new. (R2) has a lot of complications because of her spinal cord injuries and she also has issues with her hips and spine. I am not sure how she got the injury, but it was a new injury when she arrived at the hospital, and she could not move her legs. The Facility Abuse Policy and Prevention Program dated 2022 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivations of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The purpose of this policy 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. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator, or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration or pain.

Based on interview and record review, the facility failed to prevent abuse for 4 of 5 residents (R4, R13, R38, R102) reviewed for abuse in the sample of 43. This failure resulted R102 who is demented being fondled by R38 in the dining room and a reasonable person would not want to be sexually fondled/abused. Findings include: 1.R38's Face Sheet, with print date of 10/192/3, documents R38 has diagnoses of personal history of traumatic brain injury, major depressive disorder, schizoaffective disorder, bipolar type, and altered mental status. R38's Care Plan, dated 9/11/23, documents Resident's memory is impaired, and resident has difficulty with decision-making, insight, logic, planning, and organization of the thoughts. The Care Plan Interventions documented Provide clear explanations regarding expectations and procedures prior to providing care. R38's Care Plan documents Resident has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the admission screening process and is therefore considered appropriate for admission. The history includes: kicking at other residents and their wheelchairs, and aggressively grabbing at staff. The Interventions documents Intervene when any inappropriate behavior is observed. Communicate assertively that the resident must exercise control over impulses and behaviors (Social skills training). R38's Minimum Data Set, MDS, dated [DATE] documents R38 is moderately cognitively impaired. R102's Face Sheet, undated, documents R102 has diagnosis of Unspecified Dementia without behavioral disturbance. R102's MDS dated [DATE] documents R102 is severely cognitively impaired. R38's Nurse's Note dated 10/17/23 at 6:15 PM documented CNA (Certified Nursing Assistant) came to this nurse with report that this resident (R38) had potentially abused another resident (R102). Administrator notified at 6:16 PM. Resident is being monitored on one on one per staff. R102's Nurse's Note dated 10/17/23 documents CNA brought resident to this nurse with report of potential abuse from another resident @ 615pm. Resident questioned and denied pain. Resident stated when asked what happened that's about how it goes. Administrator notified at 6:16pm. Skin assessment completed with no new skin issues found. Son notified and MD notified. Facility Reported Incident, dated 10/17/23, documents This resident was found with alleged perpetrator standing over her with his hands on her brief. The Report documented the Police, Medical Director and Power of Attorney were contacted and notified. V24, Certified Nurse's Assistant, CNA, statement, dated 10/17/23 at 6:28 PM documents At approx. (approximately) 6:15 PM I walked in the dining room and witness (R38) standing over (R102). When I walked up closer, I witnessed one of (R38's) hands two knuckles down in (R102's) (incontinent brief), and the other hand on her (R102) strap of her (incontinence brief). I immediately remove his (R38's) hands and remove (R102) from the dining room and took her with me for safety. I reported what I saw to the nurse. On 10/19/23 At 12:44 PM V24 stated, I was walking a couple of residents to go smoke I saw (R38) standing over (R102). I saw his hands down her pants I took her to the nurse and reported what I seen. V27's, Dietary Aide, statement dated 10/17/23 documents I (V27) had just told (R38) that he cannot help (R102) with incontinence brief and that a nurse or a CNA will have to help (R102) with her incontinence brief, and that was around 5:45 PM 6:00PM last night. On 10/19/23 at 12:48 PM V27 stated, I prepared the residents dialysis breakfast and took it to the nurses the station. When I returned, I saw (R38) standing close to her (R102), and her incontinent brief was unfastened. I told him to go sit down. V23's, Licensed Practical Nurse (LPN) Witness Statement dated 8/17/23 documents I asked (R38) why he was touching (R102's) (incontinence brief) and he smiled at me and stated you have no proof. On 10/19/23 at 1:5 PM, V23 stated At 6:15 PM a CNA brought (R102) to me and said that (R38) had his hand down inside of her incontinence brief and looked like her vaginal area. When she brought (R102) to me the right side of her (incontinent brief) was unfastened and the front of her pants were pulled down. I did skin assessment, and no skin issues were found. She denied pain. I asked (R38) if he had touched (R102), and he stated, 'you have no proof.' I made him a one to one. V25's Witness Statement, dated 10/17/23 documents At about 6:15 PM me and (V24) was walking through the dining area to take the residents out for a smoke break. Upon entering the dining area, I saw (R38) standing over (R102) holding her underwear. Her shirt was midway up her stomach. (V24) immediately removed (R102) and took her (R102) to the nurse to report. I asked (R38) what was he doing with her (R102), and he (R38) stated nothing. I asked him (R38) what was nothing, and why was he tugging on her (R102) underwear and he didn't respond. On 10/19/23 at 1:22 PM V19 LPN stated, He (R38) has grabbed my butt He (R38) tries to flip other residents out of the wheelchair. On 10/19/22 23 at 1:24 PM V30, CNA stated, He (R38) says weird stuff he (R38) tries to push people wheelchair. He is very aggressive. He (R38) tries to elope. On 10/19/23 at 1:32 PM V32, CNA stated, He (R38) has inappropriate behaviors all the time. He (R38) pulls his penis out of his pants and pees on the floor. He grabbed butts and he took (R21's) drink and tried to give it to her. On 10/19/23 at 1:40 PM V1 Administrator stated, We are trying to get him to a more appropriate facility. We have referrals sent out. 10/20/23 at 3:21 PM V29, Nurse Practitioner stated, I think he is appropriate for the facility. They are both confused. It's the staff's job to watch, and they got to him quickly and removed his hand. Care Plan Meeting note dated 7/5/23 Attendance: Administrator, Social Services, Wound Nurse, MDS/Care Plan Coordinator, Activities Invitation to Resident and Care Plan Representative: Daughter and Son-in-law Meeting Note: Family state that they are aware resident needs a more structured facility more structured for Traumatic Brain Injury (TBI) patients. Family state that they cannot care for him at home. Social services stated that they are inquiring to other facilities to meet resident's needs. It was discussed with resident's daughter some of his recent behaviors i.e.: Trying to elope, trying to take other residents out, getting more aggressive with staff. Family stated they are glad resident has come to (facility) as resident (R38) is well enough to leave facility for a facility to assist with his TBI needs. Resident states he is just waiting to see what facility is found for him. Daughter was assured that staff will touch base with them and keep them in the loop as to what facilities referrals are sent to. 35156 2. On 1/18/2023 at 10:11 AM, R13 stated he had $300.00 dollars that someone took back in January and the facility never replaced it and he did not think it was right. R13's MDS dated [DATE] documents R13 was cognitively alert and orientated for activities of daily living. Investigation Report undated documents, Social Service Director (SSD) spoke with (R13). (R13) stated that the last time he saw his $300.00 was about nine days ago. He had three one-hundred-dollar bills in his wallet which he kept under the seat of his rollator walker. He did not see anyone else in the room besides the aids and nurses. He denies giving anyone any money. Statement V15, Housekeeping Supervisor dated 1/12/2023 documents, To whom it may concern: I (V15) is [sic] aware that resident (R13) kept three $100.00 dollar bills in his blue walker, zip up pocket. (R13) has had this amount of money for quite sometimes as he showed me back in April of 2021. Facility Incident Report event occurred 1/5/2023 at 11:30 AM, Resident reported to staff alleged misappropriation of resident funds. Statement from V16, Physical Therapist, dated 1/11/2023 documents, I (V16), was asked by (R13) on an unknown date in December to get $1.00 out of patient's wallet to give resident to buy a soda. When retrieving the dollars in his wallet. I asked if he was aware of the money and he said, 'yes.' I also educated resident that he can give the money to facility staff to keep in safe, but he declines. Last week, (R13) asked me to get him another $1.00 for a soda. He said he had $18.00 and the three $100.00 dollars, but there was no money in his wallet. Facility staff notified immediately. On 10/24/2023 at 10:05 AM, V16 stated, (R13) always had money in his wallet and he had a hard time opening his wallet and needed assistance to get in and out of his wallet and take the money in and out. After therapy he was always asking staff to assist him, and I know he always had three large one hundred dollar bills in his wallet along with a few dollars here and there for his sodas. He always likes to get sodas. When (R13) told me his money was missing I looked for it and we could not find his money. It makes me sad that anyone would steal from him. On 10/18/2023 at 3:32 PM, V1, Administrator stated, We were able to determine that (R13) had the money and we are going to be replacing the money now. 3. R4's Physician Order Sheet for April 2023 document diagnoses of chronic obstructive pulmonary disease, multiple sclerosis, abnormal posture, schizoaffective disorder, seizures, and anxiety disorder. R4's MDS dated [DATE] document R4 was cognitively alert for decision making. R4's MDS documents R4 requires extensive assistance of two staff for med mobility and transfers. On 10/24/2023 at 9:40 AM R4 stated that when staff were putting her to bed, they hit her head and, on the headboard, and it surprised her and hurt her head. R4 stated I was upset, and I told (V13 Certified Nursing Assistant) and she got mad at me and yelled at me and told me not to point my finger at her and if I did just wait and see what happens. I do not think staff should threaten me and it really did scare me. There was another CNA in the room (V12). She did not do anything. The Facility Incident Report date of Incident 4/5/2023 documents, (V12, Certified Nursing Assistant) reported to (V1, Administrator) that while putting (R4) up in bed on Wednesday, they pulled her up too far and her head hit the headboard. (R4) pointed her finger at (V13, Certified Nursing Assistant (CNA) and told her that she did it on purpose. (V13) responded by telling her to see what happens if she points that finger at her again. R4's Final Report, undated documents Conclusion unsubstantiated. At the conclusion of the investigation, it appears no abuse occurred. Based on witness statements, (R4's) head getting hit was not intentional. There was poor customer service in the way (V13) responded to the resident. V13's Personal File documents she was terminated from the facility on 5/8/2023 for customer service. R4's Care Plan documents does not document she is at risk for abuse. R4's Investigation documenting Date/Time Administrator was reported 4/7/2023 at 10:45 AM. Immediate Assessment: No physical injuries noted, stated she did have a headache that day but no longer does. Resident states she feels safe when (V13) is not here. The Facility Investigation report for R4 dated 4/7/2023 document, The administrator attempted to reach (V13) but was only able to leave a voice message asking her to call the facility and speak with the Administrator. 4/11/2023 The administrator interviewed (V13) regarding the concerns reported by (R4). (V13) stated that last Wednesday while in (R4's) room, (V13) almost poked her in the eye three times. Each time (V13) did it, (R4) said that she told (V13) not to poke her or put her finger in her face. When asked if she made the statement 'see what happens if you point that finger at me again,' (V13) stated that was a lie. A statement from V12 dated 4/7/2023 documents, On 4/5/2023 CNA (V13) and I went to pull (R4) up in bed, and she hit her head on the headboard; we both apologized to the resident, which then started yelling out (V13) stating very upset pointing in (V13's) face yelling. (V13) became upset with resident yelling back at resident. A statement from V14,CNA, dated 4/7/2023 documents, I have been told by several residents that (V13) has been verbally abusive and when they ask for something she does not get it. She takes forever to answer call lights, A lot of residents have said they wait too long before their lights get answered. The Abuse Policy and Prevention Program 2022 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivations of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The purpose of this policy 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. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault (42 CFR.483.12 interpretive Guidelines) including nonconsensual or noncompetent to consent sexual activity. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines).

Based on interview, record review and observation the facility failed to implement fall safety measures for one of three residents, (R3) reviewed for falls in the sample of 8. This failure resulted in R3 falling and fracturing the distal end of her clavicle. Findings Include: R3's Minimum Data Set, (MDS), dated [DATE] documents R3 is an extensive assist of two staff members for transfers and bed mobility. R3's MDS also documents, for balance moving on and off the toilet and moving from seated to standing is not steady only able to stabilize with staff assistance. R3 is moderately cognitively impaired. R3's Transferring Care Plan dated 3/10/23 documents (R3) has a self-care deficit in transferring r/t, (related to), hemiplegia secondary to past CVA, (Cerebrovascular Accident). She requires extensive assist to complete tasks currently. 1. Explain procedure. 2. Lock wheelchair brakes. 3. Apply gait belt. 4. Instruct and assist to standing position using extensive assist and gait belt. 5. Instruct and assist to pivot and sidestep towards the front of the chair. 6. Instruct and assist to slowly sit down in w/c, (wheelchair). 8. Praise all efforts. 9. Provide encouragement during transfer if becomes fearful. 10. Attempt transferring using limited assist x, (times), 1, three times per week, provide more assist if unable. Fall Care plan dated 3/10/23 documents (R3) slid out of her wheelchair on 3/9/23 and a note was added to her wheelchair as well as educate the resident to call for help. The fall care plan dated 3/10/23. The fall of 4/11/23 documents the intervention: is staff educated to not leave (R3) unattended in the bathroom. R3's Fall Risk Evaluation dated 4/12/23 documents R3 is a high risk for falls. R3's Nurses Note dated 4/11/23 documents, resident fell in her bathroom and hit her head. (R3) was lying on her left side. No c/o, (complaint of), pain or discomfort. Resident refused to go to the hospital. POA, (power of attorney), made aware and said, if vitals are stable, it was okay for the resident to stay in the facility and not go to the hospital as the doctor requested. R3's Nurses Note dated 4/12/23 documents, (R3) is complaining of pain to her left shoulder, (R3) fell yesterday in her bathroom and has refused to go to the hospital to get checked out. Request was made to (V17), Nurse Practitioner, (NP), for X-ray, (V17) ordered resident be sent to ER, (emergency room ), resident continues to refuse to go to ER. Educated (R3) on importance of getting checked out, prn, (whenever necessary), pain medication given. R3's Nurses Note dated 4/12/23 at 6:32PM documents, order received for X-ray of left shoulder faxed. R3's Nurses Note dated 4/12/23 at 9:32PM documents, technician completed X-ray of residents left shoulder and clavicle. R3's Nurses Note dated 4/12/23 at 10:30PM documents, comminuted FX, (fracture), of distal end of clavicle. Nurse contacted (V6), Primary Care Physician, new order for referral to ortho, (orthopedics). R3's Nurses Note dated 4/14/23 documents, (V18), daughter, of R3 spoke with this writer and she has arranged an ortho appointment for (R3) at (local) Orthopedics and Sports medicine for Friday, April 21st at 9am. Transportation is arranged through residents' insurance. Resident made aware of upcoming appointment. Plan of care continues. R3's Nurses Note dated 4/21/23 documents, Ortho appointment for resident has been rescheduled for Tuesday May 2nd at 1:30PM. Arrangements for transportation will be made. (V18), daughter/POA, made aware. On 4/25/23 at 2:40PM V7, Social Service Assistant/Transportation, stated, they went to the wrong address to pick her up for her appointment. They had the wrong address on file. Even though I gave them the correct address. On 4/26/23 at 10:40AM V13 and V14, (CNAs), Certified Nursing Assistants, entered the room and asked R3, if they could toilet her. V14 placed a gait belt around R3's waist and rolled her into the bathroom. V13 and V14 locked her chair. R3 stated, I'm scared I don't want to fall again, they let me fall. V13 and V14 lifted her up out of her chair with the gait belt and asked her to pivot to the toilet. Once lined up with the toilet they removed her BM, (bowel Movement), soiled incontinence brief and sat R3 on the toilet, where she urinated. Incontinence care was provided with no issues, and R3 was transferred back to her wheelchair. R3's Initial/Final Report dated 4/11/23 documents reported by nurse on duty, (R3), was being toileted and attempted to reposition self on toilet and fell . Final Report documents, slightly comminuted fracture of Distal end of the Left Clavicle. The Final Report also documents, (V10), stated, she was in the room outside of the bathroom completing a task for the resident's roommate. V12 stated, that she placed the resident, (R3), in the bathroom and began to complete another task in bedroom right outside the bathroom. They both stated, they heard a noise and noted the resident, (R3), laying on her left side near the toilet. Intervention of educating staff to not leave resident unattended in bathroom. On 4/26/23 at 9:39AM, V10, CNA, stated, I went in there with the other CNA, (V12), sat her on the toilet. The bathroom in her bedroom, the door to the bathroom was open. I was making her bed, and (V12), was making the other resident's bed and (R3) fell off the toilet. (V12) ran to get the nurse, and I stayed with (R3). (R3) was yelling I'm not going to the hospital. On 4/26/23 at 9:43AM, V11, Licensed Practical Nurse, (LPN), stated, They call me down there, because she, (R3), was on the floor, on her left side. We started Neuro checks, and V6, Primary Care Physician, wanted her, (R3), to go out to the hospital, but she refused. She wanted to go smoke. They will not let her smoke in the hospital. There was no complaint of pain all night and the next day. She complained after I went home. On 4/26/23 at 1:35PM V12 stated, I was the one who actually put her on the toilet. I take her to the bathroom in her room. (V10) came with me, we sat her on the toilet. Her wheelchair was right there in the doorway I was going to make her bed. I turned to see her leaning, but she had already hit the ground. On 4/27/23 at 10:55AM, V17 stated, No she should not have been left in the bathroom alone. The facility policy Fall Prevention and Management dated 7/2022 documents this facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. All incidents and accidents with serious physical injury will be reported to IDPH, (Illinois Department of Public Health), within 24 hours. A full written investigate report is required by IDPH within 5 days of the incident.

Based on observation, interview and record review, the Facility failed to provide timely care and treatment to address a change in condition for 1 of 5 residents (R2) reviewed for quality of care in the sample of 13. This resulted R2 having 16-hour delay in treating his pneumonia. Findings include: R2's Admission Record, print date of 12/8/22, documents R2 was admitted to this facility on 4/18/22. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is cognitively intact (BIMS of 13) and requires extensive assistance from two staff members for all Activities of Daily Living. R2's Nurse's Note, dated 12/4/22 at 6:45 AM, documents At approximately 4:00 AM, resident asked CNA (Certified Nursing Assistant) to get him up and take him to the dining room to watch tv (television). When he was up, he told CNA to go and tell the nurse to call an ambulance because he wanted to go to the ER. This nurse asked resident what was wrong, and he said that when (V7, Registered Nurse) and (V6, Physician) had seen him yesterday that (V6) had touched him and put an evil spell on him and (V7) had given him a shot of something on her way out the door. Resident said that those things had caused him to lose his ability to move. This nurse took his vital signs and assessed him physically. temperature = 99.1 166/100 (blood pressure), 76 (pulse), 96% on room air, Respirations = 18, neuro checks at baseline, bowel sounds four quadrants, lung sounds severely diminished. Temperature and blood pressure were high, but at the time they were taken, resident was yelling at nurse and calling her a f****** b****. This nurse attempted to convince resident that it would be best to run some tests at facility instead of going to the emergency room , because the ER is meant for emergency situations. R2's Nurse's Note, dated 12/4/22 at 10:12 AM, documents Resident has been agitated this morning. He stated that (V6) came to visit him last night and put an evil spell on me. Resident stated he cannot walk, but he is not ambulatory. Resident did take morning medication. He also stated, I know someone put something in my food, VS (Vital Signs) 100.5 (temperature)-68 (pulse)-18 (respirations)-128/78 (blood pressure). O2 sat, 94% on room air. Lung sounds are diminished with scattered rales. Occasional non-productive cough. I called (V6) and informed him about resident's condition. New orders were received for chest x-ray and laboratory tests. I will continue to monitor resident. R2's Chest Xray Results, with reported date as 12/4/22 and time 6:10 PM, documents Findings: There appear to be patchy interstitial infiltrates in the right lower lung field extending from the right infrahilar region. The lung fields are otherwise essentially clear. Impression: Chest: Heart is within normal limits with patchy interstitial infiltrates in the right lower lung field extending from the right infrahilar region. R2's Nurse's Note, dated 12/4/22 at 7:29 PM, documents Received STAT (Emergent) CXR (Chest X-Ray) results and reported to (V6) with new orders received for Ceftin BID (twice a day) for 7 days related to PNA (Pneumonia) and Probiotic BID (twice daily) for 10 days. Resident made aware and agrees with plan of care. R2's Physician Order, dated 12/4/22, documents Cefuroxime Axetil (antibiotic) Tablet 500 MG. Give one tablet by mouth two times a day for pneumonia for 7 Days. R2's December 2022 Medication Administration Record, documents R2 received his first dose of Cefuroxime Axetil at 10:00 PM. This was 16 hours after R2 had requested to be sent to emergency room and nurse had assessed him with lung sounds severely diminished. R2's Social Service Note, dated 12/6/22 a 11:55 AM, documents 11:48 AM, Spoke with nurse (V2, Director of Nursing/DON) who informed this writer that (R2) is running a fever. She gave Tylenol approximately 60 minutes ago. 11:50 AM, SSD (Social Service Director) spoke with resident to see how he was feeling and ask if he wanted to go to the hospital. He stated he does want to go. 11:56 AM, Face sheet, med list and POLST (Physicians Order for Life Sustaining Treatment) forms printed for ER and EMS. 12:00 PM, (Local) EMS called for transport. R2's Physician Order, dated 12/6/22, documents Send to ER for evaluation. R2's Nurse's Note, dated 12/6/22 at 6:32 PM, documents Resident returned to facility via ambulance with two EMT'S (Emergency Medical Technicians) present. Resident assisted to bed per EMT'S and staff no c/o (complaint of) pain, voiced no s/s (signs/symptoms) of distress, noted N.O. (New Order) received Azithromycin 250 MG tablet one tablet PO (oral) daily. Take first two tablets together, then one tablet every day until finished. Order faxed to pharmacy. R2's Physician Order, dated 12/6/22, documents Azithromycin Tablet 250 MG. Give 500 MG by mouth one time a day for infection for one day, then give 250 MG by mouth one time a day for infection for four Days. R2's Hospital Visit Summary, dated 12/6/22, documents Diagnosis: Pneumonia due to infectious organism, unspecified laterality, unspecified part of lung. On 12/7/22 at 12:50 PM, R2 stated I told the nurse (V3, Registered Nurse/RN) that I wanted to go to the hospital because I didn't feel good and she said no because I didn't have enough symptoms to go to the ER, and that the ambulance was going to cost me money. She took my temperature and blood pressure and still did not send me. My temperature went up to 101. A couple days later, I told another nurse that my whole body was hurting and that I asked (V3) to send me to the hospital but she didn't, and that nurse told me that I had a right to go to the hospital whenever I wanted. When I finally went to the hospital, the doctor said I had Pneumonia. I am on antibiotics now and feel a whole lot better. R2 appeared very upset over this incident of not getting sent to the ER. R2 stated multiple times that he has a right to go to the hospital when he wants. On 12/8/22 at 9:40 AM, R2 stated I did see (V6, Medical Doctor) on Saturday (12/3/22). I told him that my muscle spasms were getting worse, and I was having some arms and shoulder pain and was achy all over. He told me I probably needed some therapy. As soon as the doctor left, I started feeling bad. Then that night or early the next morning (12/4/22) is when I wanted to go to the ER and was told that I couldn't go. Then later that morning, another nurse came in and I told her I wasn't feeling good, so she called the doctor, and I had an x-ray done that day. They then started me on antibiotics that evening. Then on Tuesday (12/6/22), I was feeling really bad and had a high fever, that's when (V2, DON/Director of Nurses) came in and said that I was hot and burning up and she sent me to the ER. On 12/7/22 at 2:35 PM, V4, Licensed Practical Nurse (LPN), stated If a resident wants to go to the ER and is totally alert, I will send them. They have a right to go. I would assess them first and maybe let them know what my findings are, but if they still want to go, I will call for them to go. I would then call their physician and let them know. On 12/7/22 at 3:35 PM, V5, LPN, stated If a resident request to go to the hospital, I would call the physician, the Administrator and the POA (Power of Attorney) to make them aware. I would do a complete assessment on that resident and if they are in their right mind, will send them to the ER. They have that right to go when they want to. On 12/7/22 at 3:40 PM, V2 stated If a resident wanted to go to the ER, I would do a thorough assessment, obtain their vital signs, maybe read some past notes in their medical record and talk to some of the staff about it. I will always do what's best for the resident. If they're insistent on going, I will send them, they know their body if it's hurting or not, more than I do. Based off my nursing judgement, I would have sent (R2) to the ER. He had a change of condition and appeared worse to me the morning I saw him. He was normally alert as he was the morning, I cared for him. On Tuesday (12/6/22) at around 10:00 AM, (R2) appeared worse to me and he asked to go to the hospital and since he was alert and oriented, I went ahead and sent him out. He's normally not like that so he probably should have been sent when he was saying crazy things. On 12/7/22 at 3:50 PM, V1, Administrator, stated We try to not send our residents to the hospital. We are a twenty-four-hour medical service here and can do a lot for our residents to avoid going to the hospital. Our standard procedure is to assess the resident, call the physician to get orders if needed, and can treat that resident here at the facility without sending them to the hospital. I believe that is what our nurse was doing that morning. On 12/8/22 at 10:45 AM, V6, Physician, stated I was at the facility on Saturday evening (12/3/22) to see some other residents, but I have been taking care of (R2) for a long time now, so I stopped in to see him. (R2) was full of complaints about his contractions hurting his arms and shoulders. I assessed him and did not see anything. He was not tachycardic, and I did not see him coughing at that time. I did not see anything at that time that would have met the criteria for a hospital admission, or I would have sent him then. I got a call the next day about his complaints, and I ordered an x-ray. When I got the results indicating an infiltrate, I ordered an antibiotic. (R2) does have a right to go to the ER when he wants to. I didn't even know he went to the hospital on Tuesday (12/6/22). I do think that sixteen hours to get an antibiotic started is too long for someone with Pneumonia. The Facility's Change in Condition Policy, dated 9/2022, documents It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental, or emotional status. c. There is a pattern of refusing treatment or medication. d. The resident wants to be discharged or leaves AMA. e. It is deemed necessary or appropriate in the best interest of the resident. 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 3. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents. 4. The resident's care plan will be updated as appropriate.

Based on observation, interview, and record review, the Facility failed to conduct ongoing assessment and monitoring of a resident with significant weight loss for 1 of 5 residents (R12)reviewed for nutrition in the sample of 26. This failure resulted in continued weight loss for the resident. Findings include: On 8/31/22 at 1:14 PM, R12 was sitting in a geriatric chair at a table in the dining room and stated, I've been here before. R12 was feeding herself pureed spaghetti, mixed vegetables, ice cream, and cake fortified with powdered milk. R12's Face Sheet documents R12 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Minimum Data Sheet (MDS) dated [DATE] documents R12 has significant cognitive impairment and requires extensive 2+ person assistance with eating. R12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Health Shakes two times a day for weight loss, 120cc. The Facility's Monthly Weight Report documents R12 weighed 132.8 pounds in November 2021 and 119.4 pounds in May 2022. This reflects a 13.4 pound or 10% weight loss over 6 months which is significant. R12's Care Plan dated 6/20/2022 documents, I have a nutritional/potential nutritional problem r/t (related to) not wanting to eat my meals. Monitor/record/report to MD (medical doctor) PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss: 3 lbs (pounds) in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. RD (Registered Dietitian) to evaluate and make diet change recommendations PRN. Resident had experience unplanned weight loss related to decreased appetite, post hospitalization , acute illness. R12's Progress Note from Registered Dietitian (RD) dated 5/13/2022 at 9:48 AM documents, RD annual assessment. 91 y/o (year old) female with dx (diagnoses) including dementia, MDD (major depressive disorder), GERD ([CONDITION(S)]), HLD ([CONDITION(S)]), [CONDITION(S)], hypothyroid, L (left) femur fx (fracture), h/o (history of) falling, cerebral infarction, [CONDITION(S)] (hypertension), malnutrition. Current medications include [MEDICATION(S)], [MEDICATION(S)], DSS ([MEDICATION(S)] sodium), omeprazole, [MEDICATION(S)], [MEDICATION(S)]. Current diet ordered is regular with mech (mechanical) soft texture, fortified foods with all meals; ice cream (with) lunch and supper, 90 mL (milliliters) house supplement TID (three times daily). PO (oral) intake ranges 0-100%. Current ht (height) 64, wt (weight) 119.4# (pounds), BMI (body mass index) 20.4. Noted wt (weight) fluctuation since admission. No skin concerns noted. No new labs available for review. Estimated nutrition needs: 1626 kcal (kilocalories) (30 kcal/kg (kilogram)), 65 g (grams) protein (1.2 g/kg), and 1626 mL fluid (30 mL/kg). Continue with prescribed diet and supplementation as tolerated. Noted recent addition of [MEDICATION(S)], which will likely have positive effect on appetite. Continue to monitor intake and wt. Refer to RD as needed. R12's Monthly Weight Report documents R12 weighed 119.4 pounds in May 2022 and 112.0 pounds in August 2022. This reflects an additional 6.2% weight loss over the time R12 was not being monitored by a RD. On 8/31/22 at 9:03 AM, requested that V1, Administrator, provide RD phone number and/or additional documentation from RD. On 9/1/22 at 8:34 AM, requested that V1 provide RD phone number and/or additional documentation from RD. On 9/1/22 at 9:42 AM, V11, Nurse Practitioner, stated, The team meets weekly and reviews weight losses. Then I am notified of any weight loss and recommendations by the dietitian. I would have expected to be notified by the team of (R12's) weight loss. On 9/1/22 at 10:12 AM, requested that V7, Dietary Manager, provide RD phone number. He stated he would have to check with V1, Administrator. On 9/1/22 at 12:12 PM, V1 stated, I have no additional RD documentation since May. She wasn't seen. On 9/2/22 at 10:40 AM, no contact information for RD was received from the Facility. V1, Administrator, stated, We do not have a policy on Nutrition Assessment.

A. Based on interview and record review, the facility failed to provide a safe environment to prevent accidents for one of one resident (R14) reviewed for safe environment in the sample of 35. This failure resulted in R14 falling and sustaining an oblique [MEDICAL CONDITION] fibula of the right ankle. Findings include: 1. R14's current [DIAGNOSES REDACTED]. R14's Care Plan, dated 04/19/2018, documents, The resident is at risk for falls r/t (related to) ambulates and ad lib (at will), gait steady at this time. The Care Plan Interventions documents, (R14) needs a safe environment with: even floors free from spills and/ or clutter. R14's Minimum Data Set (MDS), dated [DATE], documents R14 has a Brief Interview of Mental Status (BIMS) score of 3 indicating R14 is severely cognitively impaired. This MDS also documents R14 requires supervision and physical assist of 1 staff member for ambulation on and off the unit. This MDS documents R14 is not steady, but able to stabilize without staff assistance and R14 may use a wheel chair. R14's Fall Risk Assessment, dated 7/9/2018, documents R14 has a fall risk score of 14 indicating R14 is at risk for falls. R14's Witnessed Fall Document, dated 7/18/2018, documents, Nursing Description: resident slipped in water that was on the floor next to ice chest. The form documents Action Taken: assessed for injuries, ROM (range of motion) WNL (within normal limits), c/o (complaint of) right ankle and foot discomfort. The form continued to document Causing Environmental Factors: Wet Floor Statement: resident was ambulating by ice chest and slipped and fell in water that was on floor. R14's Nurse's Note Narrative, dated 7/18/2018 at 4:35 PM, documents, X-ray results received, (V23, Physician) notified, with N.O. (new order) to send to ER (emergency room ) for eval (evaluation) and treat. R14's X-ray Right ankle and foot, dated 7/18/18, documents, Impression Right ankle: oblique [MEDICAL CONDITION] fibula with no significant displacement. R14's Fall Interdisciplinary Team Note, dated 7/19/2018, documents, in part, Summary of fall: Resident slipped on water on floor next to ice chest. Root cause of fall: Environmental. Water on floor. Intervention and Care Plan update: Resident sent out to ER for eval and treat. R14's Illinois Department of Public Health Follow-up Summary Report, dated 7/23/2018, documents, (R14) is A/O (alert and orientated) x 1 baseline. Resident is independent with ambulation. On 718/18 resident had a witnessed fall in hallway next to the dining room. Two staff members witnessed the fall. Both staff members called for assistance to the resident. Resident was asked if she had any pain, to which the resident stated her right ankle. Upon environmental inspection of the floor, it appeared the resident had slipped on a small piece of ice that was in front of the ice chest. The ice chest is housed in a cubby next to the DR (dining room) that the staff can access. The ice chest was removed immediately, and the ice and water cleaned up by housekeeping. Results obtained per X-ray company. Findings stated soft tissue swelling with oblique fracture of distal fibula. Resident sent to emergency room . Resident evaluated by ER and returned to facility with new order for walking fracture boot. 7/19/18 call placed for orthopedic follow up. On 2/25/2019 at 8:30 AM, V1, Administrator, stated, I was not the Administrator at the time of (R14's) fall, but if you have an ice chest in the hallway staff need to vehemently make sure there is no ice or water on the floor and monitor the ice chest to prevent residents from getting into it. On 2/25/2019 at 12:40 PM, V23, Physician, stated, If the floor had been clean and dry (R14) would not have fallen and broken her ankle. The facility policy and procedures Fall Prevention Program, dated 11/21/17, documents, The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards. B. Based on observation, interview and record review, the facility failed to assess and provide safe smoking for two of three residents (R16 and R18) review for safe smoking in the sample of 35. Findings include: 1. On 02/20/19 at 1:10PM, R16 came outside with a lit cigarette to the smoking area without staff supervision. On 02/20/19 at 2:10 PM, R16 was outside by the ashtray smoking a cigarette, without staff supervision On 2/20/19 at 3:00 PM, R16 stated that he keeps his cigarettes with him, but not a lighter. R16's package of cigarettes was on his table. R16's Physicians Order sheet dated 2/26/19 documents, [DIAGNOSES REDACTED]. R16's Minimum Data Set (MDS), dated [DATE], documents, a Brief Interview for Mental Status (BIMS) score of 14, cognitively intact and current tobacco use. R16's Smoking Safety Risk Assessment, dated 1/7/19, documents, Requires supervision only (no assistance) with smoking and not able to store smoking materials. R16's Care Plan, dated 1/19/19, does not document supervision while smoking or that he is able to store his smoking material. On 2/26/19 at 8:30 AM, V20, Social Services Director, stated, Staff provides supervision for smokers. On 2/26/19 at 11:35 AM, V1, Administrator, stated I expect my staff to follow the smoking policy and to do the Smoking Safety Risk Assessments timely. 2. On 02/20/19 at12:40 PM, R18 was outside in the smoking patio. On 02/20/19 at 01:05 PM, R18 stated Smoking time is at 1pm and since I'm only up for 1 hour, I smoke when I can. R18's MDS, dated [DATE], documents a BIMS score of 15, cognitively intact and current tobacco use. R18's Admissions Record, dated 7/17/18, documents [DIAGNOSES REDACTED]. R18's Smoking Safety Risk Assessment, dated 2/20/2019, documents, Independent in smoking, storage and handling of smoking materials. There was no Smoking Safety Risk Assessment in R18's Electronic Medical Record until requested from V20, Social Services Director, on 2/20/19. R18's Care Plan, dated 1/30/2019, documents, Resident will participate in smoking assessments as needed. and The resident requires SUPERVISION while smoking. On 2/26/19 at 8:30 AM, V20, Social Services Director, stated, Staff provides supervision for smokers. On 2/26/19 at 11:35 AM, V1, Administrator, stated I expect my staff to follow the smoking policy and to do the Smoking Safety Risk Assessments timely. The facility's Smoking Safety policy and procedure, dated 1/22/18, documents, The facility has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety and security reasons. It continues, A Smoking Safety Assessment will be completed to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. The plan of care shall reflect the results of this assessment. This assessment will be completed upon admission, quarterly and with significant change. Based on observation, interview and record review, the facility failed to provide safe transfer when using mechanical lifts for two of two residents (R26, R30) reviewed for mechanical lift transfers in the sample of 35. Findings include: 1. On 2/19/19 at 10:56 AM, V11 (R26's husband), stated he was in R26's room and witnessed the incident on 1/29/19. He stated that the staff was transferring R26 from the bed to her electric chair. One staff member grabbed onto the top of the lift, and at the same time, theother staff had kicked one leg of the lift. V11 then stated, when the staff grabbed the top of the lift and kicked the leg of the lift, the lift then began to lean and R26 landed on the floor. V11 stated R26 bumped her head on the floor. On 2/21/19 at 3:00 PM, V9, Minimum Data Set Coordinator, stated, No, the (name) lift was not update into the care plan. On 2/25/19 at 8:45 AM, V2, Director of Nursing (DON) stated, I didn't see the fall, but I did ask the staff if they made sure that the legs of the lift were allowed to open in order to balance the lift. V2 stated she had started neuro checks immediately after the fall. R26's Fall Investigation dated 1/29/19 documents, in part, Resident was being transferred with a (Name of Lift) and the lift lost balance and tipped over. Nursing assistants were interviewed and both stated they were transferring the resident by ( Name of lift) and moving the lift and it tipped over. Staff asked if the legs of the lift were completely apart and they stated as they recall they were. Resident was anxious and moving her legs and body around which caused side to side rocking and the lift to lose balance. The Facility's Witness Fall Report dated 1/29/19, documents, in part, Description: resident assessed for injuries. C/0 (complained of ) bumping her head, contusion noted to scalp/forehead and left side of forehead noted. Resident was assisted into wheelchair with lift and 2 staff. Resident Taken to Hospital? N (No). V25 and V26 both Certified Nurse Aides, (CNAs) were witnesses to R26's fall. V25's witness statement documents, resident on lift, while moving resident, lift tipped. V26's witness statement documents, was moving lift and it tipped over. People Notified: 1/29/2019 Physician and POA (Power of Attorney). R26's Progress Note dated 2/1/19 at 11:30a documents, in part, Intervention and care plan updated: Therapy to eval (evaluate) for transferring and positioning. R26's Post Fall 72-Hour Monitoring Report dated 1/29/19 at 16:30 (4:30 PM) documents, in part, neuro checks were initiated on 1/29/19 at 16:30 to 1/30/19 at 5:00 AM No abnormal neuro checks noted. 2. On 2/21/19 at 10:45 AM, V4 and V18, both Certified Nurse Aides (CNA) performed a mechanical lift transfer for R30 from the bed to the reclining geriatric chair. V18 operated the lift so R30 was raised off of the bed and V4 proceeded to guide the mechanical lift over to the reclining geriatric chair. During the transfer, as soon as R30 was raised off of the bed, V4 walked and stood to the side of the reclining geriatric chair. During the transfer, no staff was holding onto the sling and the sling was swinging in the air with R30 in it. On 2/25/19 at 8:35 AM, V2, Director of Nursing (DON) stated the staff should hold onto the sling while the resident is being transferred with a mechanical lift. V2 stated, there are loops on the slings which the staff should use. R30's Care Plan, dated 6/17/18, documents, in part, TRANSFER: The resident is totally dependent on two staff with use of (name) lift for CNA (Certified Nurse Aide) transferring. The Facility Policy Transfers-Manual Gait Belt and Mechanical Lifts, dated 1/19/18, does not address proper (name) lift technique. \

Based on interview and record review, the facility failed to promote the highest practicable level of psychosocial well being for one of 11 residents (R2) reviewed for dignity in the sample of 11. This failure resulted in R2's call light not being answered timely causing her to have multiple episodes of being incontinent of bowel. This caused her to have feelings of humiliation and embarrassment. Finding includes: R2's Physician order [REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 15, indicating R2 is cognitively intact. R2's MDS further documents R2 requires extensive assist for toileting needs and is frequently incontinent of bladder and bowel. R2's Care Plan dated 3/9/18, documents (R2) has a Activity of Daily Living (ADL) self-care performance deficit related to Chronic back pain, history of lumbar fracture, spinal stenosis, [MEDICAL CONDITION] arthritis of lumbar spine and Left Above the Knee Amputation. Interventions include Toilet use: (R2) requires extensive assist by one staff for toileting. Uses bedpan at this time. Is occasionally incontinent of bowel and bladder, offer toileting check every 2 hours and as needed. On 12/19/18 at 9:30 AM, R2 stated I use the bedpan when I have to go to the bathroom. The staff have to put me back in my bed from my wheel chair. I have had to wait to get my call light answered anywhere from 30 minutes up to an hour. I am able to use the bedpan for my toileting needs if the staff gets to me on time. I have had a bowel movement in my wheel chair three times in the past month and a half and it's a terrible humiliating feeling. I get very embarrassed. R2 further stated I am sometimes incontinent with my urine but I have never had issues of being incontinent with my bowels. It's just when I have to wait so long to get laid down to use the bedpan. On 12/19/18 at 10:29 AM, V1, Administrator, stated he was aware there was an issue with call lights not being answered timely. He stated V2, Director of Nurses, had identified this as an issue when reviewing video tape footage from the facility in regards to call lights. On 12/19/18 at 11:20 AM, V7, Certified Nurse Assistant (CNA), stated (R2) is alert and oriented and is able to make her needs known. (R2) is able to use her call light and she uses the bed pan for her toileting needs. Resident Council Minutes, dated 10/4/18, document Residents expressed concerns for lengthy wait times for their call lights to be answered. Resident Council Minutes, dated 12/6/18, document Call lights not being answered in a timely manner is still a concern. The facility's policy titled Call Light, dated 2/2/18, documents Purpose: To respond to resident's requests and needs in a timely and courteous manner. The Policy documents Guidelines: Resident call lights will be answered in timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. The Policy documents Procedure: 1. Answer light promptly.

Based on observation, interview and record review, the facility failed to assess monitor and provide dental services for one of one resident (R13) reviewed for dental services in the sample of 12. This failure resulted in R13's teeth decaying to the gum line causing her pain and her inability to eat regular food to maintain nutritional status. Findings include: On 12/12/17, at 9:06 AM, R13 stated she was on [MEDICAL TREATMENT]. R13 stated she needed more protein and she only weighed around 95-100 pounds. On 12/12/17 at 11:09 AM, R13 was in her room. R13 stated she had teeth that needed to be extracted. R13 stated her gums were painful. R13 opened her mouth. R13's bottom front teeth were brownish black and broken. Her back bottom teeth had decayed to the gum line, leaving only a small portion of brownish black tooth material visible at the gum line. Her gums were inflamed. Her breath was foul smelling. R13 stated That is why I only eat noodles. I can't eat meat and I know I need more protein. On 12/14/17 at 1:46 PM, V10, Cook, stated she was aware that R13 had issues eating meat and frequently request noodles. On 12/19/17 at 3:00 PM, R13 returned from [MEDICAL TREATMENT]. R13 again stated she is not able to eat meat due to the condition of her teeth. R13's Initial Minimum Data Set (MDS), dated [DATE], documented R13 had all of her teeth with no dental/oral issues. R13's Quarterly MDS, dated [DATE] documented R13 had all of her teeth with no dental or oral issues. R13's Care Plan, dated 2/9/17, documented Is at risk for nutritional deficit r/t (related to) Dx (Diagnosis) Acute [MEDICATION NAME], Metabolic [MEDICAL CONDITIONS], Protein-calorie malnutrition, Gastrostomy, Diabetes, Dysphagia,[MEDICAL CONDITION](Hypertension),[MEDICAL CONDITION](Gastro [MEDICAL CONDITION] Reflux Disease) . admitted with a feeding tube but has been upgraded to Regular diet. Her Care Plan Intervention, dated3/29/17, The resident requires extensive assist by one staff with personal hygiene and oral care. Has own teeth. Her Care Plan did not address her poor oral/dental status, pain related to oral status and her inability to chew regular meat. R13's medical record had no documentation regarding a dental assessment or plan to address R13's decaying teeth, inflamed gums and poor oral health. R13's physician's orders [REDACTED]. R13's Weight Record documented her November 2017 weight as 102.6 pounds, and her December 2017 weight as 94.2 pounds. R13's Nutritional Progress Record, dated 11/27/17., documented cont'd (continued) diet therapy, cont extra Protein, enc (encourage) PO (by mouth) intake, No wt (weight) (decline). There was nothing in R13's Progress Record regarding R13's poor oral/dental status and her inability to chew meat. R13's Nutrition and Lipid Laboratory Results, drawn on 11/30/17, documented her [MEDICATION NAME] was 3.2 g/dl (Normal from 3.5-5.7). On 12/19/17 at 3:03 PM, V3, Minimum Data Set/Care Plan Coordinator, stated that nurses do the initial oral assessment of residents. V3 stated she had not looked at R13's teeth and was unaware of her oral/dental status. On 12/19/17, at 12:27 PM, V16, (Activity/Social Service) looked at the facility's dental list. V16 stated R13 was on the list for November 2017 but was not sure what they did for her. At 2:42 PM, V16 stated that the listed documented R13 was seen on November 16, 2017 and had a cleaning but no other issues regarding R13's oral/dental condition was documented. On 12/19/17 at 3:46 PM, V16 stated the reason there was nothing written on the dental list was that the two times the dental company has been in the facility, R13 was out to [MEDICAL TREATMENT]. V16 stated They didn't see her because she was at [MEDICAL TREATMENT].

Based on observation, interview and record review the facility failed to provide supervision to prevent accidents and failed to provide progressive interventions for falls for 2 of 6 residents (R3, R32) reviewed for accidents/falls in the sample of 12. This failure resulted in R32 being dropped during a transfer and sustaining a rib fracture. Findings include: 1. R32's December 2017 physician's orders [REDACTED]. R32's Care Plan, initiated 6/14/17, documented she was at risks for falls and required assistance with transfers. The Care Plan documented she had left sided weakness secondary to a stroke and was non-ambulatory. The Care Plan Intervention, dated 5/27/17, documented 2 assist for all transfers. R32's Minimum Data Set (MDS), dated [DATE], documented R32 had a Brief Interview of Mental Status (BIMS) score of 15, indicating she was cognitively intact. On 12/12/17 at 10:51 AM, R32 stated a Certified Nurse's Aide (CNA) was transferring her and dropped her. R32 stated the incident occurred about a month or two ago. R32 stated she bruised her ribs. R32's Nurse's Note, dated 9/27/17 documented Called to assess resident as CNA reported bruising to back of head. (V14, Physician) in house and also assessed resident hematoma to back of head, neuro status at her baseline, N.O. (new order) to send to ER (emergency room ) as she c/o (complains of) SOB (shortness of breath) stated 'the girl dropped me. She didn't mean to.' The Facility's Initial Report to IDPH (Illinois Department of Public Health) Regional Office, dated 9/27/17, documented R32 was sent to the hospital due to a hematoma to the back of her head. The Report noted R32 sustained a hematoma and rib fracture. Hospital X-ray report, dated 9/27/17, documented she had a displaced left eighth rib. The Facility's Final Abuse Investigation Report, faxed on 10/5/17, and documented (R32) stated she fell the night before last as she was being helped from her wheelchair to the recliner (R32) stated she fell and the aide was in distress over her fall. (R32) stated she reassured the aide that she was fine and accidents happen. The Report documented R32 could not recall the name of CNA. The Report documented that V15 , Certified Nurse Aide, was the assigned care giver for R32 when the incident occurred. On 12/13/17 at 10:00 AM, V2, Director of Nurses (DON), confirmed R32 was dropped and V15 was terminated. V2 stated R32 would not give the name of the CNA who dropped her; however, through the facility's investigation, they determined V15 (CNA) dropped R32 and did not tell the nurse it occurred. On 12/13/17 at 11:46 AM, V11 and V8, CNAs, both stated that R32 has always required two persons to transfer her. V8 stated R32 was very unsteady. On 12/19/17 4:00 PM, V2 stated that R32 had a stroke and was unable to move her one leg. V2 stated R32 has always required assistance of two persons when transferred. 2. R3's Minimum Data Set ((MDS) dated [DATE] documents R3 has severe cognitive impairment of daily decision making skills, and is able to walk in room and hallway with minimum assist of one person. R3's Fall Risk assessment dated [DATE] documents a score of 23 (10 or above represents High Risk for falls). R3's Care Plan with goal date 1/4/18 documents, Is at risk for falls/history of falls, Bilateral Lower Extremity weakness, Confusion secondary to [DIAGNOSES REDACTED]. Ambulates with walker and assist, attempts to ambulate ad lib, forgets walker frequently. Will sit/lay on floor on purpose (will ask staff to sit with her). R3's Occurrence Report dated 6/1/17 at 11:15 AM documents R3 ambulated from the dining room without her walker and fell . Action taken (6/1/17): 15 minute checks until calm, redirected to walker, therapy screen with no recommendations for treatment since R3 was at baseline. No root cause analysis was done. R3's Occurrence Report dated 7/13/17 at 9:15 AM documents R3 was found sitting on her butt in hallway, with notable abrasion to nose, denies any discomfort, denies headache. Action taken (7/13/17): neuro checks, 15 minute checks, and to keep R3 in staff view while agitated or anxious. On 12/14/17 at 3:05 PM, V3, Care Plan/MDS Coordinator, stated no new intervention was put in place after this fall. R3's Occurrence Report dated 8/23/17 at 3:00 PM, documents R3 was found lying on right side on floor in her room with head against baseboard next to closet/dresser. Action taken: Neurochecks, placed in standing position, keep in area to monitor closely, remind to continuously use wheeled walker when ambulating. R3's Occurrence Report dated 9/16/17 at 3:10 PM documents R3 slid out of recliner on to hands and knees. Action taken: Give activities to do and monitor closely with increased restlessness. R3's Occurrence Report dated 10/15/17 at 5:20 PM, documents R3 got feet tangled up in chair and tipped chair along with herself, fell backwards. Unable to determine if R3 hit her head. Action taken: Nero checks, keep reminding resident to use walker when up ambulating, offer to walk resident, bring to nurses station. R3's Occurrence Report dated 11/11/17 at 7:30 PM documents R3 was found on knees leaning on right side in front of roommate's bedside table with top drawer open. Last seen by staff at 6:45 PM resting in bed. Action taken: Brought to the nurses' station for closer monitoring. R3's Occurrence Report dated 12/6/17 at 4:10 PM documents R3 was standing up out of wheelchair all evening, asked to sit down and missed the wheelchair. Action taken: Staff to properly position wheelchair when assisting resident to sit. R3's Occurrence Report dated 12/11/17 at 9:30 PM documents R3 fell in hallway. Action taken: Neuro checks done, placed in standing position. When becoming restless offer and provide snacks and beverages. On 12/14/17 at 3:03 PM, V2, Director of Nursing (DON), stated she acknowledged that the facility is not looking at root cause analysis to be able to provide appropriate interventions to prevent future falls. V2 stated that reminding R3 to use her walker is not an effective intervention because of R3's cognitive status. The Facility Policy on Fall Prevention Program dated 1/3/17 documents, Policy: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive device are utilized as necessary. The Policy further documents, Care Plan incorporates: a. Identification of all risk/issue. b. Interventions are reviewed with each fall, and updated or revised as deemed appropriate. 3. R3's MDS, dated [DATE], documented she has severe cognitive impairment of daily decision making skills and requires limited assistance of one staff for eating. Limited Assistance means staff provide guided maneuvering of limbs to complete the ADL. R3's Occurrence Report dated 11/22/17 at 4:00 PM documents, Injury type: Burn. Injury location: Chest area/lower sternum and right hip. Nurse Statement: Coffee was given to resident without cooling it down, was left unattended. Action taken: Area assessed, [MEDICATION NAME] applied. Cool coffee some prior to leaving with coffee. On 12/14/17 at 3:25 PM, V5, Dietary Staff, stated she was the one who served R3 the cup of coffee and stated she should have cooled it down before serving it. On 12/14/17 at 3:20 PM, V2, DON, stated she expected staff to be monitoring R3 while in the dining room getting served hot coffee.

Based on record review and interview the facility failed to properly use an assistive transferring device which resulted in 2 (R1 and R2) of 2 residents to receive injuries.This failure resulted in R1 receiving 16 sutures to a right lower leg laceration, and R2 receiving facial bruising, right forearm laceration/skin tear, and head trauma. Findings include 1. R1's Minimum Data Set (MDS), dated [DATE], documented R1 as an alert and oriented resident who was totally dependent on two plus persons assistance with mobility and transfer, functional limitation in range of motion for leg and foot and impaired sitting and standing balance. R1's Care Plan, identification date 3-30-10, documented impaired mobility related to decreased transfer skills, ambulation skills and range of motion with a documented intervention to transfer R1 with "Hoyer/SaraLift (assistive transferring devices) and 2 - 2 plus assist for safety." R1's Final Report, dated 12-7-10, documented "CNA's (Certified Nursing Assistants) were transferring resident to wheelchair from bed with hoyer lift. Legs of hoyer apart while resident in hoyer. CNA's came from side of wheelchair with the hoyer causing hoyer to tilt resulting in resident contact with leg rest extension on wheel chair resulting in a right lower leg laceration." R1 was sent to a local hospital and "returned to facility 12-4-10 at approximately 12:50a.m. with 16 sutures noted to right lower leg laceration." R1's Care Plan, dated 12-3-10, documented "right lower leg laceration as result of hoyer lift transfer in w/c (wheelchair)." R1 stated, on 1-6-11 at 9:30a.m., "I'm scare now of that thing...it came down on me....I'm scared now." E8, Assistant Director of Nursing (ADON), stated, on 1-7-11 at 9:25a.m., that staff were inserviced on the use of and how to use the "hoyer lift." 2. R2's MDS, dated [DATE], documented R2 as a cognitively impaired resident who was extensive to totally dependent on one to two plus persons physical assistance with mobility and transfer and impaired standing and sitting balance. R2's Care Plan, initial date 7-6-10, documented R2 as self care deficit and a high risk for falls with a documented intervention "hoyer lift utilized for all transfers." R2's Occurrence Report, dated 9-30-10, documented R2 was sent to a local hospital for facial bruising to brow, eye and cheek, right forearm laceration/skin tear and head trauma. It was also noted "CNA's state hoyer arm malfunctioning with accelerated rate on decline as hoyer lift titled onto side striking pts (patients) (R) (right) frontal lobe et (and) cheek." It was also noted that the "assistive transferring device was checked" and "staff were inservice on how to use hoyer." R2's Care Plan, dated 9-30-10, documented "sent to ER (emergency room ) r/t (related to) hoyer lift bar." E8, ADON, stated, on 1-7-11 at 9:25a.m., that staff were inserviced on the use of and how to use the "hoyer lift."