Every finding on record at Nexus at Palos

Based on interview and record review, the facility failed to follow its policy regarding notification of changes in resident condition by failing to notify the physician and/or nurse practitioner of a resident's new complaint of pain and inability to bear weight on the right lower extremity. This affected one of three residents reviewed for change in condition notification. The failure resulted in a delay in assessment and treatment of an undiagnosed right hip fracture. This failure affected one (R3) of three residents reviewed for notification.Findings include:R3 was admitted to the facility on [DATE] with diagnoses of history of malignant neoplasm of breast, weakness, mixed hyperlipidemia, unspecified fall, hypotension, anxiety disorder, insomnia, unspecified severe protein calorie malnutrition, major depressive disorder, constipation, alcohol abuse, gastroesophageal reflux disease, cognitive communication deficit, metabolic encephalopathy, difficulty walking. R3's Brief Interview for Mental Status (BIMS) assessment revealed a score of four/ fifteen on her Minimum Data Set (MDS) dated indicating severe impairment.R3's incident report dated 11/26/2025 documents: resident was observed to be lying on the floor on her right side next to her bed, following a loud noise noted from her room. The resident denied hitting her head. Lacerations and redness noted on right and left knee. Laceration noted on right ankle. Redness noted on the right hip. Resident reports no pain.R3's physical therapy (PT) notes dated 11/26/2025 documents: intermittent pain level of 3 out of 10 at rest to right hip and 8 out of 10. What relieves pain are prescribed medications and remaining still. What exacerbates pain is sitting and bending. On 11/28/2025, PT (physical therapy) notes document an intermittent pain level of 4 out of 10 at rest to right hip and a constant pain level of 8 out of 10 with movement to right thigh verbalized by R3. It documents that R3 performed sit to stand 3 times with walker support and took 2-3 small steps max assist secondary to pain on the right lower extremity.On 11/29/2025, PT (physical therapy) notes document an intermittent pain level of 3 out of 10 to right hip and thigh verbalized by R3. On 12/3/2025, PT notes document an intermittent pain level of 4/10 at rest to right hip and an intermittent pain level of 8/10 with movement to right thigh and hip. Patient unable to ambulate at this time secondary to severe pain on the right lower extremity. On 12/5/2025, PT (physical therapy) notes document an intermittent pain level of 4 out of 10 to the right hip at rest and a pain level of 8/10 with movement to right hip and thigh verbalized by R3. Patient presents with severe pain to the right lower extremity and unable to put weight on that leg and has difficulty standing.On 12/7/2025, PT notes document that right lower extremity range of motion is decreased due to contracture. On 12/8/2025, PT notes document an intermittent pain level of 7/10 at rest to right hip and an intermittent pain level of 7/10 with movement to right thigh and hip. On 12/12/2025, PT notes document an intermittent pain level of 3/10 at rest to right hip and an intermittent pain level of 8/10 with movement to right thigh and hip. Patients present with right lower extremity severe pain on the anterior thigh area and tightness on the right knee flexion tightness.R3's Occupational therapy (OT) notes dated 12/1/2025 documents: R3 verbalized a pain level of 5 out of 10 to RLE (right lower extremity) described as aching, limiting lower body ADL's (activities of daily living) and functional mobility tasks. What relieves pain are prescribed medications and remaining still. What exacerbates pain is sitting, standing, and bending. On 12/8/2025, OT (Occupational therapy) R3 verbalized a pain level of 5 out of 10 to RLE (right lower extremity) described as aching, limiting lower body ADL's (activities of daily living) and functional mobility tasks. What relieves pain are prescribed medications and remaining still. What exacerbates pain is sitting, standing, and bending.R3's progress noted dated 12/22/2025 at 2:00 PM (14:00) documents: received resident in bed no signs or symptoms of distress noted. Family to see resident with concerns and requesting resident to be sent to hospital. Nurse practitioner and Assistant Director of Nursing made aware. Progress note dated 12/22/2025 at 2:55 PM (14:55) shows local ambulance arrived at 2:40pm . All necessary documents are given in hand. Resident left the facility via stretcher, stable with no signs and symptoms of apparent distress. dressed appropriately for the weather. accompanied by two men crew. escorted to local hospital.R3's progress notes do not document any notification to the doctor or nurse practitioner about pain or changes to right lower extremity.R3's hospital record dated 12/22/26 documents: R3 coming to the hospital for confusion and generalized weakness. R3 complaining of right hip pain. Under musculoskeletal it documents there is tenderness to palpation of the right hip and tenderness with any range of motion of the right hip. Right hip x-ray dated 12/22/25 documents: superolateral displaced right femoral neck fracture. Under HPI: R3 states she may have fallen two weeks ago, Daughter was called who states the last time she saw R3 walking was four weeks ago. Right femoral neck fracture may have been due to a fall 2 weeks prior to presentation and was contributed to by osteoporosis.On 5/27/26 at 1:06PM, V11 (APRN) said he saw R3 during her stay at the facility. V11 said staff will usually verbally report to him any changes to the residents. V11 said he does not recall ever being notified of any pain in R3's right leg or inability to ambulate. V11 said if he was notified of the pain or changes to her leg, he would have done a thorough assessment of R3's leg and probably would have ordered an x-ray.On 5/27/26 at 3:09PM, V16 (NP) said she was not notified of R3 having any pain or inability to bear weight on right leg. V16 said if she was notified, they would have ordered an x-ray.On 5/27/26 at 10:45AM, V2 (Director of nursing, DON) said if a resident has complaints of pain the doctor or nurse practitioner should be notified of the pain. If resident experiences pain during therapy, its expected the therapist should notify the nurse. Nurses should then report to the doctor and document any interventions provided. V2 does not recall any concerns related to R3 pain or changes in condition.Facility policy change in resident condition review 9/2025 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. Nursing will notify the resident's physician or nurse practitioner when there is a significant change in the resident's physical, mental, or emotional status. 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.Facility policy pain management review date 10/2025 documents: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. Licensed nursing may notify the health care provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors.

Based on interview and record review, the facility failed to provide appropriate nursing care and follow physician recommendations by failing to obtain a right hip x-ray after a Resident experienced a fall and subsequently exhibited redness to the right hip. This deficient practice affected one of three residents reviewed for improper nursing care. This failure resulted in a delay in diagnostic evaluation, assessment and treatment of a injury. Following a change in condition, R3 was transferred to the hospital, where diagnostic imaging revealed a right hip fracture.Findings include:Based on interview and record review, the facility failed to provide appropriate nursing care and follow physician recommendations by failing to obtain a right hip x-ray after a resident experienced a fall and subsequently exhibited redness to the right hip. This deficient practice affected one of three residents reviewed for improper nursing care. This failure resulted in a delay in diagnostic evaluation, assessment and treatment of an injury. Following a change in condition, R3 was transferred to the hospital, where diagnostic imaging revealed a right hip fracture.Findings include:R3 was admitted to the facility on [DATE] with diagnoses of history of malignant neoplasm of breast, weakness, mixed hyperlipidemia, unspecified fall, hypotension, anxiety disorder, insomnia, unspecified severe protein calorie malnutrition, major depressive disorder, constipation, alcohol abuse, gastroesophageal reflux disease, cognitive communication deficit, metabolic encephalopathy, difficulty walking. R3's Brief Interview for Mental Status (BIMS) assessment revealed a score of four/ fifteen on her Minimum Data Set (MDS) dated indicating severe impairment.R3's incident report dated 11/26/2025 documents: Resident was observed to be lying on the floor on her right side next to her bed, following a loud noise noted from her room. The resident denied hitting her head. Lacerations and redness noted on right and left knee. Laceration noted on right ankle. Redness noted on the right hip. Resident reports no pain.R3's physician progress note dated on 11/26/2025 at 01:38 AM documents under subjective: [AGE] year-old female with multiple falls, here for rehabilitation, unfortunately fell again, this time with laceration to right knee and a small bump to her right hip, with no lack of mobility or reported pain by the patient. She clearly has no other complaints however she is somewhat of a poor historian. Under assessment/plan documents: fall, initial encounter, setting of multiple falls, now with small lacerations to right knee, but no lack of mobility to be concerned with fracture. Patient also with injury to right hip, mobile. Agree with need for imaging of the same, however as no immobility can tolerate non STAT imaging #Debility, setting of multiple falls, will need ongoing therapy as tolerated, or evaluation of the same. Under plan/ treatment notes will you have to sign verbal orders entered by the nurse? Yes, orders were given to be cosigned in EMR. Orders given / Nursing instructions right hip radiograph. The following statements are true I reviewed prior external documentation. I obtained history from an independent historian. I reviewed prior test/lab or other results. I ordered new test/labs and/or imaging. I advised tele presenter to request another telehealth visit for any acute changes in clinical condition or questions. Patient should be seen by primary team within 1-2 days (or as soon as possible based on primary team schedule). Was the patient sent to the ED? Patient not sent out. Did you place call to ED for initial handoff? Patient not sent out. Provider: [V17(MD)].R3's medical record and physician orders did not document an Xray to right hipR3's progress noted dated 12/22/2025 at 2:00 PM (14:00) documents: Received resident in bed no signs or symptoms of distress noted. family to see resident with concerns and requesting resident to be sent to hospital. Nurse practitioner and Assistant Director of Nursing made aware. Progress note dated 12/22/2025 at 2:55 PM (14:55) shows local ambulance arrived at 2:40pm . All necessary documents are given in hand. Resident left the facility via stretcher, stable with no signs and symptoms of apparent distress. dressed appropriately for the weather. accompanied by two men crew. escorted to local hospital.R3's hospital record dated 12/22/26 documents: R3 coming to the hospital for confusion and generalized weakness. R3 complaining of right hip pain. Under musculoskeletal it documents there is tenderness to palpation of the right hip and tenderness with any range of motion of the right hip. Right hip x-ray dated 12/22/25 documents: superolateral displaced right femoral neck fracture. Under HPI: R3 states she may have fallen two weeks ago, Daughter was called who states the last time she saw R3 walking was four weeks ago. Right femoral neck fracture may have been due to a fall 2 weeks prior to presentation and was contributed to by osteoporosis.On 5/27/26 at 10:45AM, V2 (Director of nursing, DON) said she expects all staff to follow physician orders. V2 said all staff are responsible for reviewing progress notes and orders. V2 said the team will review the resident's record following a fall as part of the fall review. V2 said when R3 returned from the hospital she reviewed the chart and saw the progress note on 11/26/25 with hip XRAY order. V2 said she did speak to V3 (nurse), and the nurse was terminated due to the not ordering the x-ray.On 5/27/26 at 3:09PM, V16(NP) said she expects staff nurses to follow any physician recommendations for their residents if they are not available and report to them the following day any changes or orders received by on call physician or tele health.Employee report dated 12/30/25 showed that V3 failed to carry out provider order given on 11/26/2025 approximately 1:38 AM via tele health visit. R3 had fallen. V3 was given orders to obtain X-ray to right hip. V3 did not order nor obtain x-ray for R3. V3 also charted no new orders given.Facility policy Physician orders reviewed 9/2024 documents: Physician orders may be written by the provider or received by telephone by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so. Verbal orders are those given to the nurse by the physician in person or by telephone, however, they are not written by the physician in the medical record. Policy Explanation and Compliance Guidelines: Physician orders are followed as written; if there is a question about the order, contact the physician for clarification. For verbal orders, repeat any prescribed orders back to the physician or health care provider. Use clarification questions to avoid misunderstandings. Enter the order into the medical record manually or electronically; complete the order and indicate the name of the physician or health care provider giving the order. The nurse transcribes the order. The physician should sign the order on his/her next visit to the facility or within the time frame required by the facility. Follow through with orders by making appropriate contact or notification (e.g., lab or pharmacy).

Based on interview and record review, the facility failed to follow its pain management policy by failing to adequately assess, monitor, and manage pain for one of three (R3) reviewed for pain management. This failure resulted in R3 following a fall, experiencing ongoing right lower extremity pain that was not comprehensively evaluated or effectively managed. This resulted in R3 experiencing unmanaged pain, an inability to fully participate in therapy services.Findings include:R3 was admitted to the facility on [DATE] with diagnoses of history of malignant neoplasm of breast, weakness, mixed hyperlipidemia, unspecified fall, hypotension, anxiety disorder, insomnia, unspecified severe protein calorie malnutrition, major depressive disorder, constipation, alcohol abuse, gastroesophageal reflux disease, cognitive communication deficit, metabolic encephalopathy, difficulty walking. R3's Brief Interview for Mental Status (BIMS) assessment revealed a score of four/ fifteen on her Minimum Data Set (MDS) dated indicating severe impairment.R3's incident report dated 11/26/2025 documents: resident was observed to be lying on the floor on her right side next to her bed, following a loud noise noted from her room. The resident denied hitting her head. Lacerations and redness noted on right and left knee. Laceration noted on right ankle. Redness noted on the right hip. Resident reports no pain. R3's Occupational therapy (OT) notes dated 12/1/2025 documents: R3 verbalized a pain level of 5 out of 10 to RLE (right lower extremity) described as aching, limiting lower body ADL's (activities of daily living) and functional mobility tasks. It also documents what relieves pain are prescribed medications and remaining still. What exacerbates pain is sitting, standing, and bending. On 12/8/2025, OT (Occupational therapy) R3 verbalized a pain level of 5 out of 10 to RLE (right lower extremity) described as aching, limiting lower body ADL's (activities of daily living) and functional mobility tasks. It also documents what relieves pain are prescribed medications and remaining still. What exacerbates pain is sitting, standing, and bending. R3's physical therapy (PT) notes dated 11/26/2025 documents: intermittent pain level of 3 out of 10 at rest to right hip and 8 out of 10. What relieves pain are prescribed medications and remaining still. What exacerbates pain is sitting and bending. On 11/28/2025, PT (physical therapy) notes document an intermittent pain level of 4 out of 10 at rest to right hip and a constant pain level of 8 out of 10 with movement to right thigh verbalized by R3. It also documents that R3 performed sit to stand 3 times with walker support and took 2-3 small steps max assist secondary to pain on the right lower extremity.On 11/29/2025, PT (physical therapy) notes document an intermittent pain level of 3 out of 10 to right hip and thigh verbalized by R3. On 12/3/2025, PT notes document an intermittent pain level of 4/10 at rest to right hip and an intermittent pain level of 8/10 with movement to right thigh and hip. Patient unable to ambulate at this time secondary to severe pain on the right lower extremity.On 12/5/2025, PT (physical therapy) notes document an intermittent pain level of 4 out of 10 to the right hip at rest and a pain level of 8/10 with movement to right hip and thigh verbalized by R3. Patient presents with severe pain to the right lower extremity and unable to put weight on that leg and has difficulty standing.On 12/7/2025, PT notes document that right lower extremity range of motion is decreased due to contracture. On 12/8/2025, PT notes document an intermittent pain level of 7/10 at rest to right hip and an intermittent pain level of 7/10 with movement to right thigh and hip. On 12/12/2025, PT notes document an intermittent pain level of 3/10 at rest to right hip and an intermittent pain level of 8/10 with movement to right thigh and hip. Patients present with right lower extremity severe pain on the anterior thigh area and tightness on the right knee flexion tightness. R3's progress noted dated 12/22/2025 at 2:00 PM (14:00) documents: Received resident in bed no signs or symptoms of distress noted. family to see resident with concerns and requesting resident to be sent to hospital. Nurse practitioner and Assistant Director of Nursing made aware. Progress note dated 12/22/2025 at 2:55 PM (14:55) shows local ambulance arrived at 2:40pm . All necessary documents are given in hand. Resident left the facility via stretcher, stable with no signs and symptoms of apparent distress. dressed appropriately for the weather. accompanied by two men crew. escorted to local hospital.R3's hospital record dated 12/22/26 documents: R3 coming to the hospital for confusion and generalized weakness. R3 complaining of right hip pain. Under musculoskeletal it documents there is tenderness to palpation of the right hip and tenderness with any range of motion of the right hip. Right hip x-ray dated 12/22/25 documents: superolateral displaced right femoral neck fracture. Under HPI: R3 states she may have fallen two weeks ago, Daughter was called who states the last time she saw R3 walking was four weeks ago. Right femoral neck fracture may have been due to a fall 2 weeks prior to presentation and was contributed to by osteoporosis.On 5/27/26 at 11:53Am, V8 (physical therapist assistant, PTA) said if a resident complains of pain during therapy, they will report it to the nurse and document it in their therapy note. Depending on the patient or pain they may try to do other exercises, may hold off on therapy or try medication for pain. V8 said he worked with R3 and recalled R3 complaining of pain to her right leg and would not walk or put weight on her right leg. V8 said he reported the pain to the nurses but was unable to recall which nurses.On 5/27/26 at 1:06PM, V11 (APRN) said he saw R3 during her stay at the facility. V11 said staff will usually verbally report to him any changes to the residents. V11 said he does not recall ever being notified of any pain in R3's right leg or inability to ambulate. V11 said if he was notified of the pain or changes to her leg, he would have done a thorough assessment of R3's leg and probably would have ordered an x-ray. V11 said R3 did not have complaints of constant pain at time of his visits. He recalls R3 having intermittent pain but never appeared to have any signs of a fracture. V11 said most people, even if confused, who have sustained a fracture would be showing some signs of pain. V11 recalls during his visit on 12/12/26 family was present, and he ordered Tylenol scheduled due to concerns of the R3 being restless not for pain. V11 was asked if restlessness could be a sign of pain and he said R3 did not show any concern related to a fracture. V11 said R3 history of drinking and encephalopathy may have contributed to her not experiencing pain or showing signs of pain as would be expected with a fracture.On 5/27/26 at 10:45AM, V2 (Director of nursing, DON) said if a resident has complaints of pain the doctor or nurse practitioner should be notified of the pain. Staff should offer pain medication if available. If pain medication is given staff are expected to follow up to see if pain improved. If pain did not improve or medication was not effective, they would inform the doctor. Pain can be documented in progress notes or a pain assessment. Pain is monitored every shift and documented on medication administration record. If resident experiences pain during therapy, its expected the therapist should notify the nurse. Nurses should then report to the doctor and document any interventions provided. V2 does not recall any concerns related to R3 pain or changes in condition. V2 did not present any pain assessments or investigation of R3's complaints of pain during the survey.R3's medication administration record for November and December do not document any pain medication given to R3 from 11/24/25-12/12/25.R3's medical record did not document any assessments of pain after documentation of pain in therapy notes.Facility policy pain management review date 10/2025 documents 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 resident's the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The pain management program is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following observing for the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the residents pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions; and modifying approaches as necessary. It is important to recognize cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain. For example, some cultures value stoicism and a high threshold for pain which may influence a resident's willingness to report pain or accept pain-relieving interventions. It also documents that pain is assessed using the comprehensive pain assessment form with significant change, following a fall, when new pain is identified. Licensed nursing may notify the health care provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors.

Based on interview and record review, the facility failed to follow their death of a resident policy by not having a registered nurse verify and timely pronounce the death for one resident. This affected one of one residents (R11) reviewed for death. This failure resulted in R11 being left on the ventilator and waiting almost two hours until police and emergencies services arrived to pronounce R11 death.Findings Include:R11 was admitted to the facility on [DATE] with a diagnosis of respiratory failure dependence on ventilator, tracheostomy status, seizures, and pneumonia.R11'a practitioner order for life sustaining treatment form (POLST) dated [DATE] documents: Do Not attempt Cardiopulmonary Resuscitation (CPR).R11's progress notes dated [DATE] at 10:25PM (22:25) documents: Upon making rounds around 1950, writer noticed resident unresponsive to name/touch, vital signs absent, no Vent alarms sounding. Resident was last seen alert to baseline by writer around 1745 when tube feeding was started post dialysis. Resident with DNR code status, Primary Physician notified. Emergency contact made aware. Police non-emergency called. Officer arrived with Emergency medical team (EMT). Resident pronounced 2137 by local hospital doctor.On [DATE] at 3:18PM, V42 (nurse, LPN) said she was the assigned nurse to R11 at time of death. V42 said she found R11 unresponsive during rounds around 7:50PM. V42 said she informed V47 (evening supervisor) about R1. V42 said she was not sure what to do because R11 was a DNR and not on hospice services. V42 said she confirmed R11's unresponsiveness with V47 (nurse Supervisor, LPN), V49 (RT) and V50 (RT). V42 said R11 eyes were closed and not responding. No vital signs were able to be obtained. V42 said she notified the doctor, family and non-emergency police about the death. V42 said she left a message with on-call doctor and was unable to recall if they called back. V42 said the police and emergency services arrived later and the hospital doctor pronounced the death.On [DATE] at 3:56P m, V47(nurse supervisor) said he was unable to recall if he was in the building at time of R11's death and did not participate in any care or assessment of R11 that he can recall.On [DATE] at 2:16PM, V49 (RT) said he does not recall R11's death or any care provided to R11 on [DATE].On [DATE] 3:47PM V50 (RT) said he was working the day R11 was found unresponsive. V50 said he was not assigned to R11 but recalled going to R11's room. Staff said he was a DNR and V50 returned to his rounds. V50 said he did not provide any care to R11.On [DATE] at 2:47PM, V2 (director of nursing, DON) said if a resident is found unresponsive and has a do not resuscitate order, two staff nurses which one has to be a registered nurse can pronounce the death and document the signs of death (mottling, absence of vital signs, loss of bowel and bladder) in the progress notes. V2 said staff V42 and V47 were educated on what to do for a resident's death after R11's death. V2 said staff do not need to call 911 to pronounce a death at the facility if the resident is a has do not resuscitate order.On [DATE] at 11:34AM, V3 (Assistant director of nursing, ADON) said staff are expected to call a registered nurse to pronounce a resident death that is a do not resuscitate (DNR). They should document time of death and notify family and physician. V3 said she received a call from V47 unsure what time about R11's death. V3 said while on the phone with V47 emergency services arrived at the facility. V3 said V47 was in-serviced on protocol for death after this incident for not following the policy. V3 said R11 should not have been left on the ventilator after finding him unresponsive because it was dignity issue.R11's emergency services report dated [DATE] documents: Dispatched for dead on arrival with police. Crew found R11 in bed unresponsive and cold to touch. R11's nurse stated she noticed R11 absence of vital signs two hours prior to EMS arrival. The crew noted R11 was still attached to the ventilator and being provided ventilations. R11's respiratory therapist said that he did not want to disconnect R11 from the ventilator until the patient was pronounced dead. Crew called local hospital and MD confirmed death at 9:37 PM.R11's death certificate dated [DATE] documents time of death at 9:37 PMFacility death of a resident policy reviewed 12/25 documents: Appropriate documentation shall be made in the clinical record concerning death of a resident. A resident may be declared dead by a licensed physician or a registered nurse with physician accordance to state law. All information pertaining to a resident's death may be recorded in the nursing notes as applicable: pupils fixed and dilated, mottled discoloration of the body, absence of reflexes, loss of bowel and bladder, absence of vital signs, date and time. Document name and time of the person pronouncing the death. Attending MD will be notified. The attending physician must record cause of death in the medical record notes.V42 (nurse) nursing license documents licensed practical nurse.V47 (nurse) nursing license documents licensed practical nurse.Resident rights for people in long term care facilities undated documents: You have right to be treated with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on interviews and record reviews, the facility failed to follow its discharges policy and notify the family/emergency contact that R5 was being transferred to the hospital and the reason for the transfer. This affected one of three residents (R5) reviewed for notification of a change and Hospitalization.Findings include:On 4/22/26 at 3:10 PM, V2 DON (director of nursing) stated that upon transfer to the hospital staff should notify the resident's emergency contact or power of attorney. V2 stated a voicemail should be left asking the contact to return a call to the facility. V2 stated a follow-up call should occur within 15-20 minutes after the initial voicemail has been left. V2 stated the nurse should follow-up with the hospital for resident's diagnosis and/or if the resident was transferred/diverted to another hospital. R5's medical record, dated 12/7/25 at 8:36 PM, V5 (agency nurse) entered room and observed R5 shaking. V5 obtained vital signs blood pressure 159/132, pulse 86, temperature 100.6, respirations 20, and oxygen saturation level 97% on room air. V5 notified supervisor on duty of the change in condition. V5 contacted telehealth physician and was given order to send R5 out 911 for sepsis. V5 called family to notify them of transfer to hospital, no answer V5 left voice mail.There is no documentation in R5's medical record noting staff followed up with the hospital for admitting diagnosis or that R5 was transferred to another hospital. An attempt to contact V5 (agency nurse) was made on 4/21/2026 at 3:35 PM 4/24/2026 at 9:48 AM. V5 did not answer phone, and this surveyor was unable to leave a voicemail message.R5's hospital record, dated 12/8/25, notes R5 was transported from the facility to another hospital on [DATE]. R5 presented to the emergency room on 12/7 due to exhibiting shaking, fever and altered mental status. While there, R5 developed new onset atrial fibrillation with rapid ventricular response and was transferred to the second hospital on 12/8 at 1:43 AM.The facility's discharge guideline policy, reviewed 09/2025, notes in part to inform the resident/patient and the resident's/patient's responsible party of the transfer. Hospital transfers: document in the progress notes the condition of the resident/Patient, who was notified of transfer, where the resident/patient is going, mode of transportation, disposition of resident/patient belongings and medications, notification to all parties of the discharge.

Based on interview and record review, the facility failed to follow its Rapid Response Policy and hospital discharge orders for one resident (R13) who experienced seizure-like activity by failing to initiate a rapid response, obtain a blood glucose reading, remain with the resident until emergency medical services (EMS) arrived, and monitor blood glucose levels following a hypoglycemic event. These failures affected 1 of 3 residents reviewed for quality of care.Findings include:R13 was admitted to the facility on [DATE] with a diagnosis of hemiplegia, aphasia, anemia, end stage renal disease, and adult failure to thrive.R13's progress note dated 4/12/26 documents: Resident appears alert to name call and usually nonverbal due to history of stroke. Involuntary movement of eyes and seizure-like activity. No history of seizure with Involuntary movement. Spouse adamant about further evaluation to the nearest Emergency room. Weekend NP in during in-house rounds with a new order to send to emergency room via 911.R13's eInteract note dated 4/12/26 documents the following: At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 168/85 - 4/12/2026 06:21 Position: Lying l/arm, Pulse: P 78 - 4/11/2026 20:55 Pulse Type: Regular, Respiratory Rate: R 18.0 - 4/11/2026 20:55, Temperature: T 98.0 - 4/11/2026 20:55 Route: Tympanic, Pulse Oximetry: O2 98.0 % - 4/11/2026 20:55 Method: Room Air and Blood Glucose: BS 119.0 - 3/8/2025 19:54.On 4/29/26 at 1:34 Pm, V15 (nurse) said she was assigned to R13 on day of hospital transfer. V15 said R13 was experiencing abnormal eye movements and family was present in the room. V15 said she called for the V60 (NP) who was in the building and assessed R13. V15 said she took R13 vital signs but not her blood sugar according to the documentation. V15 said R3's blood glucose was not checked because she was not a diabetic. V15 said she did not call a rapid response because there were two people in the room (V15 and V60), and they did not need assistance. V15 said she called 911 from her cellphone. V15 said she stayed with the resident until paramedics arrived. V15 said she only left the room to get the paperwork for the paramedics.R13's run report dated 4/12/26 documents; call received at 1:11PM, primary impression: Hypoglycemia. Under narrative: Crew dispatched for person having a seizure. Upon arrival crew found patient in bed with no staff on the scene in the room. Family on scene said R13 has not been acting normal. Blood glucose obtained reading 28.On 4/30/26 at 2:47PM, V2 (Director of nursing, DON) said if a resident was experiencing a change in condition or seizure like activity, she would expect staff to call a rapid response to have help to ensure an appropriate determination of the residents change in condition is made. During any change in condition, staff should check vital signs including blood sugar. One staff is expected to stay with the resident until emergency services arrive.On 4/29/26 at 11:34AM, V3 (Assistant director of nursing, ADON) said staff are expected to stay with the residents during a change in condition. V3 said staff would be expected to check the residents' blood sugar during a change in condition.On 4/30/26 at 2:06PM, V61 (MD) said during a change in condition he would expect staff to stay with the resident and check blood sugar with other vital signs.R13's hospital discharged paperwork dated 4/12/26 documents: Altered mental status with diagnosis of low blood sugar and chronic kidney disease. Under instructions: Continue monitoring her blood sugar.On 4/30/26 at 2:06PM, V61 (MD) said he was not aware of any orders to check R13's blood sugars and would expect staff to follow discharge recommendations.On 4/29/26 at 12:19PM, V12 (Nurse Practitioner, NP) said she did not review R13 readmission paperwork but would expect staff to have followed the discharge recommendations. V12 (NP) said she would expect glucagon and blood glucose checks to be ordered following an episode of hypoglycemia.R13's medical record did not document any blood sugar reading or orders after 3/8/25 in the medical record until new orders received on 4/30/26.R13's progress note dated 4/12/26 documents: Resident returned to the facility from (local) Hospital. No new orders. ED ordered blood sugars monitoring. Writer notified MD.Facility policy titled Rapid response dated 12/25 documents: to ensure early recognition and rapid clinical intervention for residents experiencing acute changes in condition, preventing avoidable hospital transfers and improving resident outcomes. Triggers for rapid response documents altered mental status or somethings Is not right. Under procedure documents: obtain full vital signs, stay with the resident.Facility policy admission/readmission reviewed date 4/2025 documents: All medications should be reconciled with the resident/resident representative and verified with the primary physician or nurse practitioner; Physician order sheet should reflect any standing orders specific to the resident as well as medications and treatments that are ordered throughout the stay. All necessary admission information discussed above will be documented in the resident's clinical record.

Based on interviews and record reviews, the facility failed to follow its medication administration policy and check the administration record prior to administering a discontinued medication (Keppra - antiseizure medication) to one resident (R1) out of three reviewed for medication administration in a sample of 19.Findings include:On 4/22/26 at 11:00 AM, V12 NP (nurse practitioner) stated that V12 would expect the nurses to identify the resident with at least two resident identifiers prior to administering any medications. V12 stated that V12 would expect the nurse to call her or V19 (attending physician) immediately for any medication errors.On 4/22/26 at 3:10 PM, V2 DON (director of nursing) stated that on 4/1, R1's family expressed a medication concern that occurred prior to R1 leaving the facility for an outside physician appointment. V2 stated that V22 (nurse) administered a medication which had been discontinued. V2 stated that V2 went to R1's room immediately to assess R1. V2 stated that V22 administered Keppra 250mg (milligrams) to R1. V2 stated that V19 (attending physician) was notified, and V12 NP (nurse practitioner) assessed R1. V19 gave orders to monitor R1 and obtain a Keppra level. V2 stated that Keppra should have been removed from the medication cart as soon as it was discontinued. On 4/23/26 at 2:59 PM, V22 (nurse) stated that she does recall a medication error involving R1. V22 stated R1 was going out for an appointment and V22 was rushing to administer R1's medications before R1 left. V22 stated that because she was rushing and did not notice Keppra was not on R1's MAR (medication administration record). V22 stated she realized after R1 took the Keppra tablet that the Keppra had been discontinued. V22 stated that discontinued medications are not supposed to be kept in the medication cart. V22 stated that R1's Keppra medication had been discontinued and should have been removed by the nurse receiving the discontinuation order. V22 stated the nurse is supposed to do the five rights check to ensure right resident, right medication, right dose, right time, and right route. V22 stated she notified V2 DON and V19 (attending physician). V22 stated that most of the time she will let the resident know what medications resident is receiving prior to administering medications. V22 stated the physician instructed her to monitor R1 for any signs of drowsiness, disorientation, and lethargy. V22 stated V19 ordered for the outside laboratory service to obtain a Keppra level the following morning.On 4/24/26 at 9:58 AM, V19 (attending physician) stated he spoke with V22 (nurse) involved in administering the Keppra on 4/1 to R1. V19 stated he does not know reason V22 gave the Keppra because it had been discontinued. V19 stated R1 did not have any issues or side effects from receiving Keppra on 4/1.R1's POS (physician order sheet), dated 2/26/26, notes an order for levetiracetam (Keppra) 250mg by mouth every 12 hours for seizures. Keppra was discontinued on 3/12/26.R1's medical record, dated 4/1/26 at 9:30 AM, V22 noted administered medication pass at approximately 9:30 AM. R1 prepared for transportation to medical appointment. Post medication pass assessed R1 immediately. Notified physician and all other parties. R1 alert and oriented x 4, no signs of drowsiness, no acute distress, or signs/symptoms of seizures, weakness or any adverse reactions. R1's vital signs stable, blood pressure 120/89, temperature 97.8, heart rate 85, respirations 17, and oxygen saturation level 98% on room air. R1's family at bedside. V22 spoke with V19 prior to R1 leaving for appointment. V19 requested to draw laboratory testing and continue to monitor R1.R1's medical record, dated 4/1/26, V12 NP noted R1 seen due to nursing reports R1 was given Keppra today which is not currently ordered on profile. R1 is alert, reports no concerns or discomfort at this time. R1 is smiling and eating while in room. R1's family at bedside. V12 did spend significant time talking about current medications on profile, showed on computer current orders as they are written. Answered all questions regarding medications and management of care. R1's family is expressing ongoing concerns for prevention of any medication being given in future to R1. V12 did escalate to V2 DON and had discussion about medication safety with current nurse on duty. Laboratory testing has been ordered and is pending, continue to monitor for any adverse effect from Keppra. Please notify if any adverse effects occur.The facility's investigation of this medication error notes failure to verify active physician orders in the eMAR (electronic medication administration record).The facility's medication administration policy, dated 04/2025, notes in part an order is required for administration of all medication. Check the medication administration record prior to administering medication for the right medication, dose, route, resident and time.

Based on interviews and record review, the facility failed to supervise R1 who was diagnosed with Mild Dementia with moderate cognitive impairment, who was identified as incapable of unsupervised outside pass privileges, scored as high risk for elopement with exit-seeking behavior from leaving the facility unauthorized via an unknown exit/egress door, crossing a busy intersection, getting lost on a pace bus traveling approximately twelve miles to 95th and the [NAME] which is a high-traffic, multi-lane intersection with significant vehicle volume that includes access points to a major expressway (The [NAME] Expressway (I-90/I-94) is a11.47-mile, 8-to-16 lane, heavily traveled artery in Chicago, carrying over 300,000 vehicles daily from downtown to the South Side) for 1 of 3 residents reviewed for elopement in a total sample size of six.The Immediate Jeopardy began on 03/20/2026 when R1 left the building without staff acknowledge. R1 traveling approximately twelve miles to 95th and the [NAME] which is a high-traffic, multi-lane intersection with significant vehicle volume that includes access points to a major expressway. V1(Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 03/26/26 at 1:38PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 04/03/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the interventions implemented.Findings Include:R1 was admitted with the diagnosis of unspecified Mild Dementia with other behavioral disturbance, bipolar disorder, current episode manic severe with psychotic features. Minimal Data Set (MDS) dated [DATE] documents: Brief interview for mental status (BIMS) score of twelve which indicate moderate cognitive impairment. Section GG (functional abilities): R1 requires supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) Assistance may be provided throughout the activity or intermittently) with walking ten (10) feet-once standing, the ability to walk at least ten feet in a room, corridor, or similar space. Walk fifty (50) feet with two turns and walk one-hundred fifty (150) feet. Nurse Practitioner note dated 2/11/26 documents: Cognitive: Alert and Oriented time two (2), mild deficits in short and long-term memory, mildly impaired attention, mildly impaired concentration. R1's community survival skills evaluation dated 2/13/26 documents: The resident is able to move/negotiate safety on community streets (crosses safely maintain a safe distance around cars uses sidewalk, if in wheelchair propels safely/carefully, etc. No; The resident knows the facility address, location and how to contact the facility in an emergency. No; The resident appears able to refrain from self-harm and/or socially inappropriate behavior while in the community (including abstaining from alcohol and illicit drugs, avoiding person who constitute a bad influence and is able to practice harm reduction strategies. No; The resident knows how to ask for/seek help in help in an emergent or problematic situation. No; The resident has knowledge of potentially dangerous situations, such as walking alone after dark, straying into an alley, accepting rides from strangers, carrying valuables where they are seen. No; The residents appear to be capable of unsupervised outside pass privileges at this time. No; Comments: No community pass. Nurse Practitioner note dated 2/26/26 documents: Late entry: Neuro - Alert plus orientation times two -three (A+O x 2-3.) Forgetful.Facility Elopement Risk undated documents: R1's name. R1's elopement evaluation dated 2/26/26 documents: Category: High Risk. The resident has demonstrated or present with: Hanging around facility exits and/or stairways or wanders between floors. Yes. The physical ability to leave the building. Yes. Becoming easily agitated, confused and/or disoriented or shows poor judgement (i.e., would not be able to safely care for him/herself outside of the facility). Yes. Engaging in theme behavior (i.e., belief that he/she has specific responsibilities in another setting, such as going to work, returning home to care for children, driving to church, preparing dinner). Yes. Observing environmental cues (i.e., seeing staff prepare to leave, putting coats on) or time of the year cues, (i.e., needing to prepare for Thanksgiving or Christmas and/or becoming increasingly restless, distressed about a significant/historical time, place or person) AND/OR any known triggers/warning signs that might indicate potential elopement risk? Yes. Comments (explain why the person is or is not considered at risk for unauthorized departure/flight risk) Resident is an elopement risk. Social Service Note dated 3/4/36 documents: Late Entry: Resident (R1) assessed for elopement risk this shift. Resident is alert and oriented to person/place/time (modify as appropriate) with noted history of confusion/wandering/cognitive impairment. Resident ambulating independently throughout the unit and intermittently attempting to access exit doors without appropriate authorization. Resident demonstrates [poor safety awareness/impaired judgement/memory deficits], increasing risk for potential elopement. No successful elopement attempts noted at this time. R1's elopement evaluation dated 3/4/26 documents: Category: High Risk. The resident has demonstrated or present with: A history of unauthorized departure from health care setting and/or verbalizing a serious intent to leave the facility and/or has a history of unauthorized departure (s). Yes. Hanging around facility exits and/or stairways or wanders between floors. Yes. The physical ability to leave the building. Yes. Becoming easily agitated, confused and/or disoriented or shows poor judgement (i.e., would not be able to safely care for him/herself outside of the facility). Yes. Engaging in theme behavior (i.e., belief that he/she has specific responsibilities in another setting, such as going to work, returning home to care for children, driving to church, preparing dinner). Yes. Observing environmental cues (i.e., seeing staff prepare to leave, putting coats on) or time of the year cues, (i.e., needing to prepare for Thanksgiving or Christmas and/or becoming increasingly restless, distressed about a significant/historical time, place or person) AND/OR any known triggers/warning signs that might indicate potential elopement risk? Yes. Comments (explain why the person is or is not considered at risk for unauthorized departure/flight risk) Resident is an elopement risk. Resident assessed for elopement risk this shift. Resident is alert and oriented to person/place/time (modify as appropriate) with noted history of [confusion/wandering/cognitive impairment if applicable]. Resident observed ambulating independently throughout the unit and intermittently attempting to access exit doors without appropriate authorization. Resident demonstrates [poor safety awareness/impaired judgement/memory deficits], increasing risk for potential elopement. No successful elopement attempts noted at this time Elopement risk.On 3/24/26 at 1:03PM, V5 (nurse) said, R1 was confused and wandered the hallways on her unit (the long-term care unit) when R1 was trying to leave. V5 said R1 was able to ambulate without assistant or a device. V5 said R1 had her bags packed a couple times before and tried to leave out of the facility's front door. R1 would say her son was coming to pick her up when she was trying to leave. V5 said R1 took pictures of the exit door on her phone and showed them to staff. R1 reported she worked for the Central Intelligence Agency (CIA) while at the facility. V5 said she was not sure what R1 did with the pictures of the exit doors other than keeping them on her phone. R1 would sundown (get confused) in the evening time, pack her bags and state she was leaving. Progress note dated 3/18/26 documents: Writer (V5) observed resident (R1) with packed bags, headed to front entrance, in attempt to leave. Resident was escorted back to room and educated about why she couldn't leave and that this was her home. Resident became very angry and began to scream.On 3/24/26 at 1:11PM, V12 (nurse supervisor) said, R1 was on her unit walking around on 3/20/26. V12 said he gave R1 her prescribed six o'clock (6:00pm) medication. V12 said he preceded to administer medication for the rest of the residents on R1's unit. V12 said he got back to R1's room at nine o'clock (9:00pm). R1 was not in her room. V12 said, he asked V15 (agency certified nursing assistant/CNA) if she saw R1. V12 said, V15 replied she saw R1 with her items packed and sitting on R1's bed at eight o'clock (8:00pm). V12 said, V15 stated, R1 reported she wanted to leave at 8pm. V12 said, he called a code yellow and notified V1 (administrator) and V3 (director of nursing) that R1 was missing. V12 said he and other staff searched the entire building, checked the egress/exit doors looking for R1. V12 said the exit door between the long-term care unit and the respiratory unit is constantly used for staff to enter/exit the building. V12 said, residents like to hang around that door. V12 said he was not sure which door R1 exited when she left the building. V12 said R1 was not given permittion to leave the facility by any staff members. V12 said R1 was packing her clothes a few days prior to her leaving the facility on 3/20/26. V12 said, when R1 was packing she said, she wanted to go/leave. Progress note dated 3/20/25 documents: Late Entry: Writer (V12) was at resident (R1) room at early (evening) PM; to give resident med, resident took the meds. At about 9:30 PM, writer went to give the resident her remaining med, but resident was not in her room. Writer called CNA assigned to resident to inquire about resident, CNA verbalized that resident packed her things and told her she was leaving the facility, resident left facility against medical advice/AMA. On 3/24/26 at 1:23PM, V13 (R1's family) said, R1 called him at '7ish' (7:00PM). R1 reported she did not know where she was, but she was trying to get to V13. V13 said he instructed R1 to go back to the facility at which time R1 became upset and disconnected their call. V13 said R1 was calling his daughter, and he was trying to call R1 back. V13 said he tried to call R1 back for three (3) hours with no response. V13 said around 10:15PM - 10:30PM, he received a call from a bus driver off R1's phone who reported R1 was at 95Th and the [NAME]. V13 said he did not recall the bus driver's name. V13 said he instructed the bus driver to put R1 on the 352 and tell that bus driver not to let R1 off the 352 bus until R1 made it to downtown [NAME] where he would pick R1 up. V13 said it was 11:00pm when R1 reached [NAME]. V13 said he did not receive a call from the facility until midnight when the police called about R1 leaving the facility. V13 said he asked R1 how she got to 95th street to which R1 replied she walked until she found a ride and the bus did not charge her any money. V13 said R1 was not alert enough to be outside at night walking and catching a bus. V13 said R1 has memory issues. R1 will take what she sees on television and applies it to her life. V13 said R1 has reported she works for the CIA. V13 said he does not know how R1 walked out the facility unnoticed. R1 was not available for a phone interview. On 3/24/26 at 1:53PM, during a tour with V14 (maintenance) the double door down from the dialysis unit were able to be pushed open with no alarm/delay. A keypad was observed on both sides of the door located on the wall. V14 said the facility just recently installed a new code for the door down from the dialysis unit. Once through those doors there was another set of double doors to the left near the time clock that also opened when pushed without an alarm/delay that led directly outside to the alley behind the facility. On 3/24/26 at 2:25PM, V4 (social service) said R1 would pack her bags once a week to leave. V4 said R1 liked fresh air. V4 said when she worked and R1 packed her bags, she would take R1 outside for some fresh air. V4 said R1 left on Friday 3/20/26. R1 had a diagnosis of Dementia. R1 was an elopement risk because she had exit seeking behaviors. On 3/24/26 at 4:09PM, V11 said the last time she worked with R1. R1 was trying to leave the facility. On 3/25/26 at 8:57AM, V3 (DON) said she could not determine which door R1 exited the building. On 3/25/26 at 3:56pm, V12 (nurse) said R1's unit was locked and required a code to get off the unit. V12 said he does not know how R1 got off her unit. V12 said once off R1's unit, the respiratory unit has an exit door. V12 said, R1 could have exited through the double doors near dialysis unit and then out of the next set of double doors by the time clock that lead directly to the alley behind the facility. V12 said the doors down by the dialysis unit and the double doors by the time clock did not require a code to open and did not have an audible alarm that was activated once opened. Those doors are left unarmed/opened for staff to enter and leave the building when getting off or reporting to work. V12 said the only code needed is to enter the building from the alley. On 3/25/26 at 4:44PM, during the tour with V12 (nurse), the exit doors that led from the stive hallway, near the public restroom to the service hallway, was able to be opened without an alarm sounding or delay. Once through those doors, down the service hallway near the time clock was another set of two double doors that could be pushed open with no alarm/delay which exited directly outside to the alley behind the building. V16 (maintenance director) said that doors leading from the facility hallway, near the public restroom to the service hallway were not supposed to open without a delay/alarm. V12 said that exit is for employees only but there are a few family members who are aware if they are in the building after eight (8:00pm)/visiting hour they can exit through the employee only door, walk to the second set of double doors by the time clock and exit the building. V12 said, after 8:00pm the front lobby doors are locked.On 3/26/26 at 9:43AM, V1 (administrator) said he does not know which door R1 used to leave/exit the building. V1 said R1 coordinated with her family for her to go to [NAME] bus station. V1 said he called V13 twice with no response. V1 said R1 was alert. R1 only needed minimal verbal cueing after five (5) minutes to repeat the three words for the BIMS test. R1 was able to remember the words, sock, blue after some verbal cueing. V1 said R1 needed one more point to be cognitively intact. V1 presented a BIMS Score from Cleveland Clinic last updated on 09/09/2025 which documents: provides use score ranges to help explain what your BIMS score means: eight to twelve (8-12) moderate problems with thinking and memory. On 4/1/26 at 5:47PM, V23 (agency CNA) said she was R1's assigned CNA the night she left the building. V23 said she last saw R1 sitting in her room, putting clothes in and taking clothes out of a plastic bag. V23 said she did not get a report that R1 was an elopement risk. V23 said the last time she saw R1 was around 8:30pm/9pm before she went on break. V23 said V12 wanted to give R1 medication at 9pm when he noticed R1 was missing. V23 said she heard an alarm but didn't know if R1 triggered that alarm or if the alarm was a door alarm. V23 said when she ended her shift and left the building via the alley, she walked around the front of the facility and saw the facility patio gait open. V23 said the gait was near the exit door across from the main elevator on the 'Strive' unit. V23 said she does not know with the gate was opened by R1 or a staff member. R1's police report date 3/20/26 documents: Responding office responded to a missing person at 10:44pm. V12 was made aware by staff that patient, later identified as R1 was possibly missing. R1 was last seen in her room by her nurse, later identified as V23 (nurse) at approximately 8:00pm and was noticed missing at approximately 10:00pm. V12 initially stated that a search was conducted to look for R1 but later retracted that statement. A search was then conducted with officers with negative results. V12 explained that he was not sure where R1 could have gone but he was aware that R1 stated that she did not want to be there. During the investigation, V23 relayed the following in summary: The last time V23 saw R1 was approximately 8:00pm and she advised that R1 was sitting in her room on a chair while packing a big plastic bag with her personal items. R1 was observed putting items in the bag and taking items out of the bag. V23 advised that she had not seen R1 since. Responding officer asked V12 if they had security cameras in the hallways and V12 advised that they did but it was then discovered that they do not record. Responding office then asked what ways out were there from this section of the building. V12 advised the front door, which is locked, and all other doors require a pass code to exit. V12 advised that some of the patients have knowledge of the pass code. Responding office asked if that's something they are allowed to have and V12 advised that they (residents) are not and he was not sure how they got the codes. Responding officer contacted V13 (R1's family) who advised R1 was safe with him at his residence. V13 was informed that R1 was at a bus stop at 95th Street and the [NAME] Expressway by a friend. Responding office advised V12 that R1 was safe with V13 and that it is not good that they lost a patient with no knowledge of them leaving the facility. On 4/2/26 at 12:19PM, V16 (maintenance director) said the door from the strive unit the is listed as employee's only which leads to the service hallway, keypad was changed on both sides, and an audible alarm was added. The exit doors down from the dialysis unit had a keypad that was disarmed. V16 said those keypads were reactivated. V16 said nothing was done for the double doors that lead directly to the alley. Those doors can be pushed open. V16 said since the other two doors that lead to the hallway was activated with an alarm that should cover the double door that lead to a direct exit behind the building and to the alley. Invoice #5229 dated 3/26/26 document: Service on double exit/entrance door between strive and rear service corridor. Installed latching alarm system controlled by wall mount digital keypad on each side. Trace reran cables, installed and trim keypads, door contact switches, sounder. Trim to power supply tied to emergency power electric circuit.On 4/2/26 at 3:44pm, R7 who was assessed to be alert and oriented to person, place and time said, the code to exit the long-term care unit (R1's unit) was 9876* but to get back in its 9876. That code entered on the key pad, the door locks released allowing the door to be pulled open by surveyor.On 4/3/26 at 10:15am, V1 (administrator) said, the residents should not have the code to the exit doors, and he would have them change today.On 4/3/26 at 2:12pm, R7 said the code was changed. R7 said she was informed she is no longer allowed to have the code to exit off the long-term care wing. R7 said if she wants to exit the wing she has to be escorted by staff. On 4/3/26 at 2:38pm, V38 (electrician) was observed on a ladder in the service hallway working in the ceiling, with thick white wire hanging down. V38 said he was working on the alarm to increase the sound. V38 said the wires are already ran to the respiratory nursing station and he would be putting an audible alarm that will sound when the strive employee exit doors are opened without a code. Invoice #2122 dated 4/3/26 documents: The employee exit only double door are having their alarms tied to the alarm at the nurse's station on the Vent unit. Every time these exit doors are opened without the code an audible alarm will go off at the nursing station. The double door down from the dialysis unit that connect to the service hall will be wired together with the alarms on the vent nursing station. When complete every time either alarm goes off it will also go off at the nursing station to notifying staff. On 4/3/26 at 4:04pm, the employee only exit that leads to the service hall alarm was triggered by staff and heard on the respiratory unit. V16 said, the double doors by the dialysis still has to be connected. Elopement Policy dated 6/2015 document: Elopement occurs when a resident leaves the premises or safe area with authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. This does not include alert and orient resident who resident who handle themselves outside the facility and choose to leave the facility, even if against medical advice and sometimes, common sense. The Immediate Jeopardy that began on 03.20.26 was removed on 04.03.26 when the facility took the following actions to remove the immediacy. Affected Resident corrective actions: 03/20/2026 R1 was identified to have eloped from the facility at between the hours of 8pm and 9:30pm. She was received by her family in safe custody. She is no longer residing at the facility. No further corrective action can be taken. Immediate Actions and Actions to Prevent Occurrence/Recurrence. (Initiated on 3/26/2026 at 4:30PM and will continue until all staff are in-serviced and trained prior to the start of their shift) A Resident head count of the whole facility was completed by the DON/clinical managers on 03/26/2026. There was no concern identified, and all residents are accounted for. The facility has instituted an ongoing headcount that is done during shift change as part of the nurse-to-nurse shift reporting. This will include discussion of new or worsening elopement risk resident behaviors that may need additional support. All exit alarms were affirmed to be functional by testing and confirmation of power supply. They were found in proper working conditions by the maintenance director. This was completed by 03/26/2026. All alarms will be tested and verified in proper working fashion weekly thereafter by the maintenance director. Any instance of alarm found to be non-functional will be repaired immediately. If unable to be immediately repaired, the facility will assign a 24/7 monitor of the exit until it can be replaced or repaired. The doorway leading from the 1st floor STRIVE unit to the employee exit was adjusted to sound louder at point of service. An additional remote horn and signage alerting the source was configured to sound by the nearest nursing station on the Ventilator unit that is 24 hours manned. This was completed by a contracted electrician on 04/03/2026. All nurses and CNA's on their assigned units are responsible for monitoring and response to sounding alarms on their unit for all shifts. If an alarm is sounding, staff are required to immediately respond. Any instance of non-compliance of nurses and/ or CNA not responding to a sounding alarm will be provided with further training and human resources will be consulted for progressive disciplinary action if warranted. Residents are to be escorted by facility staff members between secured doorways if wanting to go to another unit of the facility. If a resident is identified as elopement risk and wants to visit another unit, they will be escorted and supervised by a clinical staff member that can include but is not limited to Nurse, CNA, activities, and or Interdisciplinary team until they return to their unit. The current doorway access code leading between Longterm care and the ventilator unit will be changed by the maintenance director, so no residents have code access. All facility doorway codes are changed monthly thereafter. This was completed on 04/03/2026. The access codes will not be shared with the residents. All residents are educated to use assistance and escort if needing access through secured unit doorways. They are not allowed to have access codes. This was completed on 04/03/2026. All staff are educated to escort residents in between secured doorways, and they are not to share passcodes with residents or visitors. This was completed on 04/03/2026. Elopement assessment, BIMS and community survival skills assessment was completed for all residents. The Social Service Department completed the assessments. After the completion of all resident assessment, Nexus at [NAME] has identified 4 residents remaining as risk for elopement. During waking hours, the residents are involved in daily activity routines that have direct supervision. If the resident leaves a supervised activity or prefers to have leisure time outside of structured routines, the outgoing staff will report to clinical staff, social service and/or activities to help supervise their current activity of choice on a 1:1. The social service department completed care plan reviews that include interventions such as frequent monitoring checks, keeping the residents in communal areas that allow for visual supervision during waking hours, redirecting residents to activities of choice. Other interventions, include staff members are to report any themed activity or suspicious behavior to supervisors for support. This was completed on 03/26/2026. Any resident who was identified as an elopement risk have care plans developed with interventions addressing their behavior. This was reviewed and completed by the social service department 03/26/2026. The elopement binders were reviewed and updated. The elopement binders were placed by all nursing stations, front desks, and department head offices. The elopement binders include Face pictures, name, location, Facesheet information and pertinent information regarding elopement risk behavior for staff to observe for and report to supervisors and clinical coordinators for support and management. If an elopement risk resident is displaying elopement risk behaviors. 1st available direct staff will stay with the resident until managerial support is provided, and the resident is redirected to their normal baseline. Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/ exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD (manager on duty)/charge nurse, DON will also conduct weekend clinical meetings to review new or worsening exit seeking/wandering behaviors and ensure interventions are in place to prevent elopement. The elopement binders is not a new system, but it will be updated when a resident is newly identified as a high-risk elopement. The Administrator provided training to the Social Service Department regarding development of care plans to address residents who are identified as an elopement risk. The training was completed on 03/26/2026. The DON/Administrator/Social Services Director provided education to all staff that were in the facility on 03/26/2026. The education items include but not limited to: Code yellow proceduresUse of the elopement bindersExit-seeking behaviors and interventionsElopement risk interventionsResponding to alarms Resident safety and supervisionReporting to the Administrator/Maintenance Director any concerns related to alarms. The training was completed on 03/26/2026. Any staff who were not in the facility, on vacation, or on leave of absence will have training completed at the start of their shift upon return to work. To measure knowledge retention, post tests will also be started on 03/27/2026. The Administrator/Director of Nursing/Social Services Director will conduct posttests of five (5) random staff per week for four (4) weeks to evaluate knowledge retention starting on 03/27/26. The acceptable score of the post-test is 100%. Any staff who will not meet the acceptable score will receive additional training. The Administrator/Director of Nursing/Social Services Director will provide the staff with training on specific areas based on the results of the post tests. The facility will conduct the same training quarterly for four (4) quarters, and then annually thereafter. The training will also be included in the orientation of new employees. The facility currently uses agency, the DON/Social Services Director/Administrator, will provide the same training to the agency staff at the start of their first shifts. Ad-Hoc QAPI meeting was completed on 03/26/2026 which were participated by the leadership team. The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events.Elopement drill was completed on 03/26/2026 by the Social Service Director and Administrator. This will also be completed daily, for the seven (7) days, and will be done at different shifts. After seven (7) days, the elopement drills will be done weekly for three (3) months, then monthly thereafter. The elopement drills will be completed per policy, as indicated above. For effective staff recognition and response, the elopement drills will also include evaluation of responding to alarms sounding for identified triggers and/or unknown source. New referrals will be reviewed by the DON and clinical managers to screen for elopement risk precautions prior to placement. Any new /return resident identified as being at risk will be updated into the facility elopement binders upon admission. The QAPI team will discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors at their next monthly meeting. The QAPI team will determine if additional corrective actions are necessary based on concerns identified. The Administrator/Social Services Director/DON will conduct audits of the elopement binder three (3) times a week for one (1) month to ensure that identified elopement risk are included in the binder. Additionally, the Administrator/Social Services Director/DON will also review five (5) residents weekly for one (1) month to ensure that residents are assessed appropriately, and who are identified with new and/or worsening exit-seeking behaviors have proper interventions in place. After three (3) months, the QAPI team will determine if additional monitoring or corrective actions are necessary. To evaluate the effectiveness of the removal plan, QAPI team will review results of the audits, posttests and alarmed doors. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 03/26/2026

Based on interview and record review the facility failed to follow their abuse policy by not reporting alleged allegations of abuse for 1 of 1 (R4) residents within 2 hours reviewed for abuse reporting.Findings include: On 3/22/2026 at 2:46 pm, R4 who was assessed to be alerted and oriented to person, place and time said he reported physical abuse by V11 (Certified Nursing Assistant/CNA) to V17 (Nurse). R4 said he was hit with an open hand on his right posterior upper arm and verbally abused/cursed out by V11. R4 said he reported the allegations to V17 the night it happened around midnight on 3/22/2026 and V1 on Monday 3/23/2026 to V1. On 3/27/2026 at 2:40 pm, Regional office was called and reported there was no facility reportable abuse allegation for R4 dated 3/23/2026.On 3/27/2026 at 2:43 pm, V1 (Administrator) said V17 called and reported the incident when it happened, but he missed the call due to being asleep, when he called back, it was already passed noncompliance, so he did not report the initial abuse allegation for R4. V1 said he was going to send the initial report with the final report.Nursing note dated 3/23/2026 (1:09 am) Resident (R4) stated, 'She hit me and I'm calling the Police.' DON and Administrator notified.Facility provided Initial report dated 3/24/2026 at 1 am. R4 had an allegation of physical abuse.Abuse Policy and Prevention Program dated 10/2022 documents: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on observation, interview and record review, the facility failed to provide a dignified dining environment for one resident (R3) in a sample of 10 residents reviewed for resident rights.Findings include: R3 is a [AGE] year-old female, admitted to facility 1/2/2026 and has diagnoses to include: Neuromyelitis Optica, Difficulty in Walking, Specified Disorders of Muscle, Lack of Coordination, Cognitive Communication, Need For Assistance with Personal, Depression, Nonspecific Abnormal Finding of Lung Field, Spinal Stenosis, Cervical Region, Anemia,Localized Edema, Hyperlipidemia, Tremor, Unspecified Aphasia, Anxiety Disorder, Unspecified, Dysthymic Disorder, Disorder of Kidney and Ureter, Unspecified R3's BIMS (Brief Interview for Mental Status) dated 3/4/2026 - 12 indicating moderate cognitive impairment On 3/7/2026 at 11:46am R3 observed lying in bed wearing gown, watching TV, call light within reach. R3 alert, oriented, groomed with missing teeth and was able to make needs known. R3 stated in part, I needed to be changed, and I have been pressing the call light, and no one has come. See I am pressing the call light, and nothing is happening. Surveyor observed R3 pressing call light. The light at the call light panel did not come on, there was no audible sound, and the light above the door did not come on. R3 stated, When I press the call light they do not come, this happens all the time. The CNA said she would come back and she never came back. I need someone to change me. On 3/7/2026 at 12:08pm V18 (Certified Nursing Assistant) entered R3's room to do incontinence care. After providing incontinence care to R3, V18 proceeded to adjust R3 in bed and prepared to feed R3. R3 was served meal using Styrofoam plate and plastic fork and V18 stood the entire time she fed R3 her meal. On 3/7/2026 at 12:38pm V18 stated, When feeding residents, I am supposed to sit, but I like to stand sometimes so I don't get tired. V18 did not know why R3 was being fed with plastic fork and served food on Styrofoam plate.On 3/7/2026 at ~1:50PM V2, Director of Nursing/DON RN stated staff should be sitting during feeding and residents should be treated with dignity.On 3/7/2026 at 2:22pm V17, Assistant Director of Nursing/ADON RN stated V17 is familiar with R3. R3 is fed by staff. V17 stated, When feeding residents, staff should sit. Staff should be sitting down when feeding residents. It is a dignity issue, and you do not want the residents to feel rushed and need to be at eye level with residents. I am not sure why (R3) was served on paper products. She does not have a restriction. Facility Policy:Certified Nurses Aide job description dated 01/01/2026 documents in part: Basic Function To provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, state and federal guidelines, and as directed by your supervisor. 20. Prepare residents for meals, assist serving food trays or feed as necessary and record/or report residents intake or acceptance of food. 31. Treat all residents, families and visitors with kindness, dignity and respect. 33. Create and maintain an atmosphere of warmth, personal interest, and positive regard as well as a calm environment throughout the unit and shift. 34. Adhere to all facility and department policies and procedures.Resident's Rights documents in part: You Have Rights! To be treated with care, dignity and respect.

Based on observation, interview and review record, the facility failed to ensure one resident (R3) was provided with a working call light in a sample of 10 residents reviewed for accommodations of needs.Findings include: R3 is a [AGE] year-old female, admitted to facility 1/2/2026 and has diagnoses to include: Neuromyelitis Optica, Difficulty in Walking, Specified Disorders of Muscle, Lack Of Coordination, Cognitive Communication, Need For Assistance with Personal, Depression, Nonspecific Abnormal Finding of Lung Field, Spinal Stenosis, Cervical Region, Anemia, Localized Edema, Hyperlipidemia, Tremor, Unspecified Aphasia, Anxiety Disorder, Unspecified, Dysthymic Disorder, Disorder of Kidney and Ureter, Unspecified R3's BIMS (Brief Interview for Mental Status) dated 3/4/2026 - 12 indicating moderate cognitive impairment R3's room census documents she was admitted to the current room on 01/02/2026. R3's care plan documents in part:CHECK AND CHANGE: R3 is at risk for complications r/t incontinence.Date Initiated: 01/04/2026 Revision on: 01/04/2026 Goal: Will remain free of complications r/t incontinence throughout next review. Target Date: 03/27/2026 Interventions: Encourage to notify staff if feeling the urge to use the restroom.Date Initiated: 01/04/2026 FALL: R3 is at high risk for falls r/t Decreased balance and Lack of Coordination Date Initiated: 01/04/2026 Revision on: 01/04/2026 Goal: Will remain free of falls causing hospitalizations r/t injury through next review. Date Initiated: 01/04/2026 Target Date: 03/27/2026 Interventions: Promote placement of call light within reach and assess residents' ability to use.Date Initiated: 01/04/2026 ADL: R3 requires extensive staff assist with daily care needs r/t lack of coordination, muscle weakness and decreased balance. Date Initiated: 01/04/2026 Revision on: 01/04/2026 Goal: Staff will anticipate and meet all of residents' needs on a daily basis through next review ie: clean, dry, groomed, turned and positioned Date Initiated: 01/04/2026 Created on: 01/04/2026 Interventions: Keep clean and dry after each incontinent episode. Date Initiated: 01/04/2026 Communication Problem r/t Aphasia Created on: 03/06/2026 Revision on: 03/06/2026 Goal: R3 will improve communication function by (how, with what assistance i.e. making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, writing messages) through the review date. Date Initiated: 03/06/2026 Interventions: Ensure/provide a safe environment: Call light in reach Date Initiated: 03/06/2026 Created on: 03/06/2026 On 3/7/2026 at 11:46am R3 observed lying in bed wearing gown, watching TV, call light within reach. R3 alert, oriented, groomed with missing teeth and was able to make needs known. R3 stated in part, I needed to be changed, and I have been pressing the call light, and no one has come. See I am pressing the call light, and nothing is happening. Surveyor observed R3 pressing call light. The light at the call light panel did not come on, there was no audible sound, and the light above the door did not come on. R3 stated, When I press the call light they do not come, this happens all the time. The CNA said she would come back and she never came back. I need someone to change me. On 3/7/2026 at 12:02pm R3 stated to V18 (Certified Nursing Assistant), My call light is not working. I have been pushing the call light, and it is not working. Call light within reach of the resident. I have been pushing the call light (R3 demonstrated how she was using the call light), and the call light is not working. I am wet and need to be changed. I am wet. V18 pushed the cable at the panel and asked R3 to push the call light and stated, The call light is not working I will let maintenance know. On 3/7/2026 at 12:38pm V18 stated, The call light should turn red on the panel when the button is pushed. If something is wrong with the call light, we tell maintenance. I usually check to make sure the call light is working, but I did not check it this morning. I came in and checked on her and checked on my people. On 3/7/2026 at 12:47pm V19, Maintenance Director stated, Call lights are checked every morning. Have managers that do room rounds, and we depend on the CNA and nurses to ensure call lights are working. If there is a problem with the call light or equipment, a work order in TELS is put in or they will call the receptionist or myself. I try to catch any problem before they call. V18 just told me R3's call light is not working. I have to reset the system. If the call light is not working, someone should be making rounds. I changed light bulb in another room, and the call light did not come on, so my first assumption is the system needs to be reset. I will go and hit button to reset and call light should work. If the call light does not light up above the room, the light should come on at the panel in the room and you should hear the call light. At 12:53pm surveyor and V19 entered R3's room. V19 pushed cord and pushed call light button and red light at panel came on but there was no audible sound and the light did not come on above the door. V19 left to reset system and returned to R3's room at 12:55pm and pressed call light button. There was no audible sound, and the light did not come on above the door. V19 rechecked the cord and the call light did not work. V19 left room at 12:57pm to reset system. At 12:59pm V19 entered R3's room and pressed call light. Call light did not work. V19 checked bathroom call light and call light worked appropriately. V19 stated, I will figure out problem. V19 checked call light for bed space 1 and call light worked appropriately. V19 stated, I will give (R3) the call light for bed space 1 while I figure out why (R3's) call light is not working. On 3/7/2026 at approximately 1:50PM V2, Director of Nursing/DON RN stated, Rresidents are to use their call light if they need help from staff. We test call lights and maintenance does rounds and tests the call light and during room readiness we check. At least every shift we check the call light to make sure it is working. If call light does not work, we notify maintenance right away and may move to a room that has a functioning call light. We have done bells just for the interim. For maintenance we just instituted TELS system and receptionist takes the concern from staff and relays to maintenance. If they see him on the floor staff will let him know too. On 3/7/2026 at 2:22pm V17, Assistant Director of Nursing/ADON RN stated, Call lights are checked every shift to ensure call lights are working by staff. If call light does not work, we call maintenance to fix it and will use bells or do room change to a room where the light is working. (R3) will call to get our attention. She should have a call light she knows how to use the call light. On 3/7/2026 at 3:10pm V17 stated, Call lights are checking every shift to ensure the call light is working. They are checking to make sure the light comes on at the panel, they should step out to make sure the light is working above the door, and the sound is going off. On 3/7/2026 at 3:22pm V19 stated, I check call lights periodically daily every day is different ones (rooms). We check to make sure lights come on in the room and outside the room and bathroom, overhead light, bedside and displayed on the computer at the nurses' station and make sure we can hear the call light. Facility Policy: General Resident Rights review date 9/2024 documents in part: General: 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. Responsible Party: All Staff Policy: 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. Procedure: 1. The facility will assess and interview resident for the need to make reasonable accommodations such as: Resident equipment to be maintained in proper working order Guideline: CALL LIGHT RESPONSE revision date 9/2025 documents in part: GENERAL: To provide the staff with guidance on responding to resident's request and needs. RESPONSIBLE PARTY: IDT PROTOCOL: 5. Report all defective call lights to the nurse supervisor or maintenance director promptly.Registered Nurse/Licensed Practical Nurse job description dated 6/30/2013 documents in part: Basic Function Under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Essential Duties 4. Assist in maintaining a physical, social and psychological environment, which is conducive to the overall welfare of the resident. 5. Participate in resident and family teaching. 6. Monitor performance of team members and become involved in staff development, evaluation and discipline when indicated. 7. Assign nursing care duties to team members and ensure such duties are completed in an appropriate manner. 12. Adhere to all facility and department safety policies and procedures. Certified Nurses Aide job description dated 01/01/2026 documents in part: Basic FunctionTo provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, state and federal guidelines, and as directed by your supervisor. 24. Report all hazardous conditions and equipment to the nurse immediately. 25. Follow established safety precautions in performance of all duties.

Based on interview and record review the facility failed to administer medications as ordered by the physician for one resident (R3) in a sample of 10 residents reviewed for quality of care. Findings include: R3 is a [AGE] year-old female, admitted to facility 1/2/2026 and has diagnoses to include: Neuromyelitis Optica, Difficulty in Walking, Specified Disorders of Muscle, Lack Of Coordination, Cognitive Communication, Need For Assistance with Personal, Depression, Nonspecific Abnormal Finding of Lung Field, Spinal Stenosis, Cervical Region, Anemia, Localized Edema, Hyperlipidemia, Tremor, Unspecified Aphasia, Anxiety Disorder, Unspecified, Dysthymic Disorder, Disorder of Kidney and Ureter, Unspecified R3's BIMS (Brief Interview for Mental Status) dated 3/4/2026 - 12 indicating moderate cognitive impairment On 3/6/2026 at 3:42pm R3 with fall mats next to bed on either side. R3 stated she was not wet and got changed twice earlier. R3 lying in bed wearing gown and watching TV. R3 having tremors and stated, she was having more tremors because she had not received her medicine and the nurse said she would be back to give her medicine, and she did not come back. R3 alert and oriented and able to make needs known. R3 stated staff feed her and she was getting therapy. On 3/7/2026 at 11:46am R3 observed lying in bed wearing gown, watching TV, call light within reach. R3 alert, oriented, groomed and was able to make needs known. R3 stated she received her medicine today, but she did not get it yesterday (3/6/2026) morning like she was supposed to get. On 3/7/26 at 12:01 pm V2 (Director of Nursing) said, ordered medications are given 1 hour before and 1 hour after. If for some reason not given, nurse is to notify the provider and family or the resident if they are their own power of attorney and oriented. V2 said if the medication is not available or covered by insurance the doctor will give an order how to proceed as they can order some alternative medication. V2 said nurses when they give medications, they are to sign it out in the electronic health record (mar) at the time when its given, boxes left empty on the mar means the medications were not given. On 3/9/26 at 11:53 am V22 (LPN) she was the nurse on duty and assigned to R3 on Friday (3/6/26) she worked from 7:00 am to 3:30 pm. V22 said she gave her 9:00am and 12:00 pm medications. V22 said, regarding the documentation, she probably forgot to do it due to the fact she got busy. V22 is not sure if she documented it. V22 said, in general, she is to document medications as given after she gave it and she is fully aware she should have clicked them but R3 was serviced. On 3/7/26 at 9:30 am V24 (LPN) said, medications can be given 1 hour before and 1 hour after the scheduled time. V24 said, if the medication administration record is blank for that time, that means the medication was not given. Review of R3's Medication Administration Record (MAR) for 3/7/26 documents in part the following missed medications. 3/7/26 at 9:00 am Famotidine Oral Tablet 20 MG, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), Nystatin Powder 100000 UNIT/GM, Primidone Oral Tablet 50 MG, Buspirone HCl Oral Tablet 15 MG 3/7/26 at 12:00 pm Vitamin D3 Oral Tablet 25 MCG. Review of R3's (3/6/26-3/7/26) progress notes and mar does not include the reason the above medications were not administered. Facility's Registered Nurse/Licensed Practical Nurse job description documents in part: Essential duties: Participate in the development and implementation of an individualized patient care plan for the resident with allied health team members. Implement total nursing care plan through assessment, planning and evaluation. Administer prescribed medications and treatments according to policy and procedures; evaluate treatment effectiveness on a continuing basis. Facility's (rev. 4/25) Medication Administration policy documents in part: 18. Document as each medication is prepared on the MAR. 22. If the medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required.

Based on observation, interview and record review, the facility failed to change soiled gloves and failed to perform hand hygiene after providing incontinence care for one resident (R3) in a sample of 10 residents reviewed for incontinence care. Findings include: R3 is a [AGE] year-old female, admitted to facility 1/2/2026 and has diagnoses to include: Neuromyelitis Optica, Difficulty in Walking, Specified Disorders of Muscle, Lack of Coordination, Cognitive Communication, Need for Assistance with Personal, Depression, Nonspecific Abnormal Finding of Lung Field, Spinal Stenosis, Cervical Region, Anemia,Localized Edema, Hyperlipidemia, Tremor, Unspecified Aphasia, Anxiety Disorder, Unspecified, Dysthymic Disorder, Disorder of Kidney and Ureter, Unspecified R3's BIMS (Brief Interview for Mental Status) dated 3/4/2026 - 12 indicating moderate cognitive impairment On 3/7/2026 at 11:46am R3 observed lying in bed wearing gown, watching TV, call light within reach. R3 alert, oriented, groomed with missing teeth and was able to make needs known. R3 stated, I needed to be changed, and I have been pressing the call light, and no one has come. The CNA said she would come back and she never came back. I need someone to change me. On 3/7/2026 at 12:08pm V18, Certified Nursing Assistant/CNA entered R3's room to do incontinent care. V18 donned gloves. V18 stated she last changed R3 around 9:00am. R3 stated she was wet and V18 proceeded to change R3. After V18 completed incontinence care, V18 proceeded to put incontinence brief in plastic bag, moved bedside table over R3, adjusted R3's clothing and bed without changing gloves and completing hand hygiene. V18 then went to glove box, removed soiled gloves and put on clean gloves, but did not do any hand hygiene. V18 proceeded to adjust R3 in bed and prepared to feed R3 without completing any hand hygiene. On 3/7/2026 at 12:38pm V18 completed feeding for R3. V18 stated she should have removed gloves and washed her hands after doing incontinence care and she should not have touched anything with dirty gloves. V18 said, During orientation, we were told about infection control, and the infection control nurse tells us and tells us information about the resident. On 3/7/2026 at 2:11pm V16, Infection Prevention Nurse/LPN stated, When providing incontinence care need to wear gloves. After incontinence care is done wash hand prior to and after care for residents and get rid of garbage. After completing incontinence care, you should do hand hygiene hand washing with soap and water or use hand sanitizer. You should not touch resident items/food until hand hygiene is complete. Hand hygiene is done to make sure they are not contaminating residents and help prevent infection and cross contamination.On 3/7/2026 at 2:22pm V17, Assistant Director of Nursing/ADON RN stated, When doing incontinence care gloves on, have bag to discard dirty diaper, wash hand before and after doing care. You should not use dirty gloves to touch resident items or equipment with soiled gloves.Facility Policy:Guideline Incontinence Care dated 9/2025 documents in part: General: Incontinence care is provided to keep residents dry, comfortable and odor free as possible. Guideline: 2. Perform hand hygiene and don gloves. 11. Perform hand hygieneCDC Clinical Safety: Hand Hygiene for Healthcare Workers dated February 27, 2024, documents in part: Know when to wear (and change) gloves. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves. Remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil hands. When to wear gloves When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment)Certified Nurses Aide job description dated 01/01/2026 documents in part: Basic Function To provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, state and federal guidelines, and as directed by your supervisor 25. Follow established safety precautions in performance of all duties. 26. Wash hands before and after performing any service for the resident and follow infection control guidelines and universal precautions. 32. Perform all assigned tasks in accordance with policy and procedure and instruction of your supervisor. 34. Adhere to all facility and department policies and procedures.

Based on interview and record review the facility failed to prevent resident to employee sexual abuse for one of one resident (R11) reviewed for abuse. This failure resulted in R11 not feeling safe. Findings include:On 2/24/2026 at 9:15am V20 (Family of R11) said that R11 was kissed on the cheek by V21 (Certified Nursing Assistant-CNA) and the facility make her feel like it was okay, and she felt unsafe after that. On 2/24/2026 at 10:45am V1 (Administrator) said that R11 complained of V21 walking up behind her and kissing her on the cheek. R11 wanted to call the police and we did. She made out a police report and it was unfounded. V21 denied it, he was sent home and later terminated. On 2/26/2026 at 2:45pm V13 (Assistant Director of Nursing-ADON) said that V19 informed her of what R11 said she then assessed R11, called the administrator who is the abuse coordinator, and she also wanted to call the police. On 2/26/2026 at 2:58pm V19 (Nurse) said that R11 complained of V21 walking up behind her kissing her on the cheek saying that was not the first time. V21 made this attempt before, and she feels uncomfortable. V19 said V19 called V13 (Assistant Director of Nursing-ADON) and informed V13 of what R11 said. On 2/26/2026 at 3:00pm V2 (Director of Nursing-DON) said, I was not in the facility at the time of the complaint. I expect all nursing staff to follow the abuse guidelines and that everyone has abuse training upon hiring. (V21) is no longer employed at the facility. An admission record indicates R11 has a cognitive communication deficit and depression. An abuse care plan, a progress notes dated with discharge, a witness statement on 1/2/2026, an incident report dated 1/2/2026.Facility Policy: 3/2022 Abuse Policy and Prevention Program 2022Abuse Policy This facility affirms the right of our residents to be free form abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident 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 abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by:Conducting pre-employment screening of employees and pre-admissions screening of residents:Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation and misappropriation of property.Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property.

Based on interview, and record review the facility failed to provide a safe and orderly discharge for one of one resident (R9) reviewed for discharge. This failure resulted in R9 having to visit the local emergency room hospital for Dialysis treatment. Findings include:On 2/24/2026 at 10:40am V1 (Administrator) said R9 did not want to stay in the facility to ensure that a dialysis date and time was set up and confirmed R9 and family was aware that dialysis was not confirmed and proceeded to discharge home anyway. On 2/25/2026 at 2:28pm V10 (Director of Social Services) said he was made aware of this incident upon R9 transferring to the facility and that he immediately wrote a new discharge plan for the social workers to follow stating that if a resident does not want to stay for home supplies and confirmation of dialysis set up of date and time, then they would have to sign out AMA (against medical advice). On 2/24/2026 at 4:00pm, V22 (Family of R9) said on 11/23/2025, R9 was discharged home without a confirmed hemodialysis chair date or time. V22 said the social worker said they would call and inform them of the date and time as soon as possible and that all the paperwork was in. V22 said V22 never received a phone call. On 11/24/2025 the following morning R9 was taken to the local hospital emergency room to receive dialysis.On 2/26/2026 at 11:41am V2 (Director of Nursing-DON) said, I expect the social service staff to set up all home health care services including a confirmed dialysis date and time and if the resident insists on leaving, then they should notify the physician.An admission record indicated R9 has a diagnosis of end stage renal disease and dependence of renal dialysis. Records show an order summary report dated 2/24/2026 with a discharge home order on 11/21/2025; a care plan dated 11/11/2025 showing to assist with discharge planning and dialysis on Monday, Wednesday and Friday; and a progress note dated 11/23/2025 at 11:13 by social service stating dialysis time was pending and that the family chose to discharge home at 1pm stating they have a wheelchair available at home and that the assistant administrator and administrator had been notified.Facility Policy: 9/2025 DischargesGeneral: To establish a plan of how to discharge a resident from the facility to home, another facility, or the hospital. Responsible Party: RN, LPN and Social Services Discharge potential is assessed by the Social Services on admission.Social Services will meet with the resident/patient and/or family to set up outside services and equipment.15. The Social Service Department will enter a Discharge summary progress note into the patients EMR upon planned discharge from the facility.

Based on interview and record review the facility failed to ensure that a safe discharge and transfer, was provided and the resident receive the correct medication for one of one resident (R9) reviewed for discharge. Findings include:On 2/24/2025 at 4:20pm V22 said the facility called her cell phone and ask them to bring the medications back to the facility. V22 said, It was not my family's. We returned the medication. It was not used. On 2/25/2026 at 2:57pm V18 (Licensed Practical Nurse-LPN) said that on 11/23/2025 she discharged and educated V22 (Family of R9) on medications and that they expressed understanding. The family was discharged home with the medications. Then about an hour later V18 said she noticed R9 medications and immediately called the family and asked them to return with the medications and pick up the correct medications. The family expressed understanding and returned the medications and retrieved the correct ones. On 2/26/2026 at 11:41am V2 (Director of Nursing-DON) said, I expect the nurses to discharge resident's using the two nurse system to verify the correct medication and dosage. When (V18) said she discharged (R9) with the wrong medications, the family was immediately called and ask to bring the medication back to the facility and pick up the correct medications. They did return them immediately and never used any of the medications. An admission record indicated R9 has a diagnosis of end stage renal disease and dependence of renal dialysis. Records show an order summary report dated 2/24/2026 with a discharge home order on 11/21/2025; an order summary with R9 medications; a care plan to administer medications as ordered; a discharge summary progress note dated 11/23/2025 of medication education and discharge teaching; and an incident report dated 11/23/2025 for discharge of wrong medications. Facility Policy: 1/2024 Resident Discharge-not to HospitalGeneral:To provide direction for residents discharge other than the hospitalProcedure:Complete Nursing section of Discharge instructions form in PCC (this form is opened by ss and completed nu nursing prior to discharge.)Once completed, instructions should be printed along with a medication list and reviewed with the resident /resident representative.All appropriate medications should be given to the resident at the time of discharge per physician orders.

Based on interview and record review, the facility failed to follow physician order for Bilevel Positive Airway Pressure (Bipap) machine usage affecting one (R2) of three residents reviewed for physician orders. Findings include:On 2/26/26 at 11:55AM, V7 (Licensed Practical Nurse Unit Manager), stated she confirmed physician order for R2 Bipap machine. V7 said V7 was unsure if R2 received it.On 2/26/26 at 12:15PM, V2 (Director of Nursing) stated R2 did have a physician order for Bipap to be used at night. V2 indicated that on Medication Administration Record a 9 recorded indicates not given/not administered. R2 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: Displaced comminuted fracture of shaft of right tibia, chronic obstructive pulmonary disease with acute exacerbation, unspecified asthma, hyperlipidemia, essential hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, dependence on supplemental oxygen, syncope and collapse, prediabetes. Physician order dated 2/12/26 for Bipap: 20/7 with oxygen blend in 25-30% FiO2 to maintain pulse oximetry of 92-94%-full face mask. To be used every night. Staff to assist patient to put on at night. Progress note dated 2/12/26 - Nurse Practitioner note indicating R2 did not receive his Bipap machine. Medication Administration Record (MAR) dated 2/2026: order for Bipap: 20/7 with oxygen blend in 25-30% FiO2 to maintain pulse oximetry of 92-94%-full face mask. To be used every night. Staff to assist patient to put on at night. Indicates No administration/Not given from 2/12/26, 2/13/26, 2/14/26 and 2/15/26. Facility is unable to provide Policy on Following Physician orders. Facility Policy on Bilevel Positive Airway Pressure (Bipap)Purpose: Bi-Level Positive Airway Pressure (Bipap) provides non-invasive positive pressure at different levels during exhalation and may be appropriate for persons who require high pressure CPAP. Policy: Respiratory Therapy/ Nurses oversee the initiation and delivery of Bipap to residents who require Bipap.Procedure:Verify Physician order.6. Document appropriately.

Based on observation, interview, and record review the facility failed to ensure facility's daily nurse staffing information form posted at the front desk. This failure has the potential to affect 164 residents receiving care in the facility. Findings include:On 2/25/26 at 11:00AM, Observed that no daily staffing post is available or visible in the front desk.On 2/25/26 at 11:30AM, V1 (Administrator) said daily staff posting should be in the receptionist area, staffing coordinator does it. If daily staff posting not found at receptionist area, then it has not been posted.On 2/25/26 at 12:45PM, V2 (Director of Nursing) said daily staff posting should be posted at the receptionist desk at main lobby daily.On 2/25/26 at 1:04PM, V1 said there is no facility policy for daily staff posting, but it is a requirement to have it daily. Facility unable to provide policy.

Based on observation, interview, and record review, the facility failed to implement fall care plan interventions for residents at risk of falls. This applies to 2 of 2 residents (R3 and R6) reviewed for fall in a sample of 9.The findings include:1. R3 is an [AGE] year-old female admitted on [DATE], with intact cognition as per the Minimum Data Set (MDS) dated [DATE].A review of the facility's provided fall log documented that R3 had a fall on 12/25/25.A review of R3's fall care plan includes interventions, including to keep bed in the lowest position and call light within reach.On 2/21/26 at 11:55 AM, R3 was observed on her elevated bed, all the way to the top, with the call light on the floor.On 2/21/26 at 12:00 PM, V9 (Licensed Practical Nurse / LPN) lowered the bed to the lowest position and brought the call light from the floor to the residents within reach.On 2/21/26 at 12:00 PM, V9 stated the bed should be in the lowest position to prevent injury, and the call light should be accessible to residents. 2. R6 is a [AGE] year-old male admitted with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE].A review of R6's fall risk assessment dated [DATE] documents that R6 is at high risk for falls.A review of the facility presented a falls log document that R6 had two falls on 1/19/26 and 1/20/26.A review of R6's fall care plan includes interventions with the floor mats at the bedside.On 2/21/26 at 11:00 AM and 2/23/26 at 8:57 AM, observed R6's room with no floor mat in use or available to use for R6.On 2/23/26 at 9:05 AM, V11 (Certified Nursing Assistant/CNA) stated, I don't think R6 ever had floor mats as fall interventions. I don't see any floor mats in his room.On 2/23/26 at 9:10 AM, V10 (Unit Manager) stated that the floor mat should be available for the residents as the care was planned.The facility presented a fall prevention and management policy reviewed in the 01/2026 document: Guidelines: 2. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP (individualized service plan) with interventions implemented to minimize fall risk.

Based on observations, interviews, and record review, the facility failed to provide an inner canula to the tracheostomy for one resident (R6) during tracheostomy care. This failure affected one (R6) of three residents reviewed for tracheostomy care.Findings include:R6 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to cardiac arrest with anoxic brain injury, chronic respiratory failure with hypoxia, tracheostomy and gastrostomy tube, and heart failure. On the (MDS) Minimal Data Set assessment of section C on 01/18/2026, the BIMS (Brief Interviewed Mental Status) section C1000, Cognitive Skills for Daily Decision Making, shows R6 is severely impaired. MDS section GG of 1/18/2026 GG, R6 is dependent care - Helper does all the effort. Residents do none of the effort to complete the activity. The assistance of 2 or more helpers is required for the residents to complete the activity. R6's physician order dated 1/16/2026 reads in part, change inner cannula twice daily every day and night shift, and Trach: Shiley- Size: 8 FLEXES. On 2/3/2026 at 09:40 AM, the surveyor observed the tracheostomy without the inner canula and requested V7 (Respiratory Therapist) remove the tracheostomy mask and check the tracheostomy. V7 said, I do not see an inner canula inside the tracheostomy and (R6) is supposed to have one. I will call another respiratory therapist to help me. When questioned, V7 said, I rounded on (R6) around 8:00-8:30 AM when I gave her breathing treatment earlier today. V7 could not say why the inner canula was not there. At 10:07 AM V6 (Respiratory Therapist) came into the room to assess the tracheostomy and checked for the inner canula and said, I do not see one and (R6) should have an inner cannula with the trach. I usually assess the resident first thing in the morning by auscultating, checking lung sounds, oxygen saturation, heart rate and swap dressing, ties twice a week or as needed and the inner canula should be changed twice a day. The inner cannula is a safe feature that allows the quick removal of a mucus plug and removes any obstruction. If a mucus plug occurs without an inner cannula, the whole trach needs to be removed and replaced. 2/3/2026 at 12:33 PM, V12 (Respiratory Therapist Director) said, I expect the staff to change the inner cannula during tracheostomy care every shift or as needed. (R6) is expected to have an inner cannula in place, and the respiratory therapist is expected to assess during initial rounds and make sure it is in place. The inner cannula helps to avoid a mucus plug, and when there is one, just pick it up and remove the cannula and remove the plug. We can do lavage if there is a mucus plug, and we use aerosol, which prevents it. On 2/3/2026 at 4:37 PM, V3 (Director of Nursing) provided facility policy Title Tracheostomy Care Policy revised 10/2024. Which reads in part (but not limited to):PURPOSE: To provide guidelines for maintaining an unobstructed airway and preventing infection in residents with a tracheostomy.POLICY: It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway, that aseptic technique is used during dressing changes until the tracheostomy is healed, and a physician's order is obtained for tracheostomy care.EQUIPMENT: Tracheostomy care kit, Sterile water (if not in kit), Inner cannula if disposable, Suction kit or closed suction catheter, Tracheostomy tube holder.G. With clean hand, remove the inner cannula1. For disposable cannula, insert new inner cannula and lock it into place; maintain sterility2. For reusable cannula, reapply tracheostomy collar over outer cannula to provide oxygenation during cleaning; cleanse secretions from outside and inside of inner cannula and rinse in sterile saline; gently reinsert cannula and lock into place; maintain sterility (may use solution supplied in the tracheostomy care kit)

Based on interview and record review the facility failed to ensure two staff member were at bedside during incontinence care for one resident who was high risk for falls and required two person assistance with turning and repositioning. This affected one of three residents (R4). This resulted in R4 sustaining a fall, being transferred to the local hospital with a diagnosis of scalp hematoma. Findings include:R4 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease, weakness, and difficulty walking. R4 fall risk evaluation dated 7/29/25 documents a score of 10. Facility fall prevention policy dated 8/2024 documents a score of 10 or greater indicates resident is at high risk for falls. R4'sR4's incident report dated 8/7/25 documents while receiving Activities of daily living (ADL) care patient slid out of bed.R4's functional ability and goals assessment dated [DATE] documents under toileting: Hygiene and roll left to right substantial/maximal assistance which indicates helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.R4's task list date 7/30/25 documents turn and reposition resident two person assist at all times.On 9/4/25 4:49pm V2 (DON) said she was present during the fall for R4. V2 said she was assisting V19 (CNA) with R4's care. V2 was on one side of the bed and V19 (CNA) was on the other side of the bed. V2 said she stepped away from the resident to move or get the garbage can at the same time V19 (CNA) wiped R4 causing her to jerk and start to slide off the bed. V2 said she was unable to stop R4 from falling. On 9/5/25 at 3:43PM, V19 (CNA, Certified nursing assistant) said she was assisting V2 (DON) with incontinence care for R4. V19 said R4 is total care and requires two people for all care. V19 said R4 was on her side and was cleaning her buttocks. V2 (DON) was on the other side and went to get the garbage can by the door when R4 starting to go forward because she could hold her weight. R4 fell to the ground.On 9/4/25 at 4:30PM, V16 (restorative nurse) said R4 requires two staff members be present during care for safety. V16 said staff should never leave the bedside when providing care and all items should be at bedside prior. V16 said staff should have never left the resident bedside during care. V16 said she provided reeducation to staff about ensuring all items are at bedside prior to starting care. R4's progress note dated 8/7/25 documents: While receiving ADL care patient slid to floor, head to toe and ROM assessed without deformities or complaints of pain, patient positioned back to bed with 2 person assist using a mechanical lift, lump to left frontal lobe noted, pain medication administered by mouth for pain, ice pack applied to head. Doctor and nurse notified, new order: send to hospital for evaluation and treat. R4's hospital discharge paperwork dated 8/7/25 indicates fall with scalp hematoma.

Based on interview and record review, the facility failed to implement respiratory care interventions including ensuring the application of hand mitten restraint as ordered, and to maintain patency of trach tubes due to resident history of chronic pulling of tracheostomy tube according to the plan of care for 1 of 3 (R4) residents reviewed for tracheostomy care. As a result of the facility's noncompliance with mittens not being applied and monitored by staff, R4 was able to reach her tracheostomy tubing and self-decannulated which led to her expiring. Findings Include:Based on interview and record review, the facility failed to implement respiratory care interventions including ensuring the application of hand mitten restraint as ordered, and to maintain patency of trach tubes due to resident history of chronic pulling of tracheostomy tube according to the plan of care for 1 of 3 (R4) residents reviewed for tracheostomy care. As a result of the facility's noncompliance with mittens not being applied and monitored by staff, R4 was able to reach her tracheostomy tubing and self-decannulated which led to her expiring.The Immediate Jeopardy began on [DATE]. V1 (Administrator) was notified on [DATE] at 2:31 PM of the Immediate Jeopardy. The facility presented an initial removal plan of [DATE]. The plan was accepted, and on [DATE] the surveyor conducted an onsite record reviews and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on [DATE].Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation.R4 is a [AGE] year-old with the following diagnosis: aphasia following cerebral infarction, acute respiratory failure with hypercapnia, tracheostomy status, dependence on supplemental oxygen. R4 admitted on [DATE] and expired in the facility on [DATE].On [DATE], R4 was found unresponsive with the tracheostomy pulled out and later pronounced expired in facility by paramedics. On [DATE] at 9:44 AM, V1 (Administrator) and V2 (Assistant Director of Nursing) informed surveyor that their electronic medical records (EMR) were down from [DATE] until the morning of [DATE]. All clinical documents were produced manually during this time. However, a completed progress note was not provided because it was not done as confirmed by V2. There was also no documented incident report of [DATE] provided to the surveyor.A police report from [NAME] Hills Police Department was obtained pertaining to the death incident of R4 on [DATE]. Report indicate V17 (Agency Nurse) informed V3 ([NAME] Hills Police) that she was the nurse for R4. According to report on [DATE], between the times of 5:55AM and 6:05AM, V17 was in the room assisting another resident when V17 observed R4's trach tube not in place and R4 was unresponsive. Police interview of V11 (Respiratory Therapist/RT) indicated that he was the respiratory therapist of R4 and approximately at 4:45 AM of [DATE], V11 was in the room of R4 assisting with trach care. V11 stated R4 is supposed to wear glove restraints (identified as mittens) to prevent her from removing her trach tube as she has history of removing her trach tube. Report indicated that V11 stated he did not observe R4 wearing glove restraints while in the room. Report indicated an interview with V16 (Nursing Supervisor) was also completed. V16 stated R4 was supposed to always wear the glove restraints according care plan. V17 stated that it was her first time working with R4 and was unaware that glove restraints were to be in place. Additionally, V17 reported that the facility online medical records database of R4 for physician orders and plan of care were inaccessible and V17 was not provided with updates, information or paperwork pertaining to R4 by the prior shift nurse. V16 informed V3 that there should be a binder at nurse station with R4's plan of care information. Report indicated V3 checked the binder and did not appear to be properly filled out.On [DATE] at 10:25AM, V3 ([NAME] Hills Police Department) stated he arrived at facility with R4 unresponsive and 911 paramedics working on her. Staff were interviewed and nurse on duty/ Agency nurse told V3 at approximately 5:55A - 6:05A R4 was observed with trach not in place (pulled out). V3 said while in the facility he did not observe R4's mittens in placed. V3 said employee informed him that electronic access to chart was down from a week to a week and half. V17 stated she did not get report from outgoing nurse regarding R4's mitten needs to be in placed at all times and V17 has no knowledge of facility restraint policy. V3 stated he believed there was neglect on facility as staff do not know their restraint policy and there was no hand off report from nurse to nurse according to his interview with agency nurse who was on duty.On [DATE] at 11AM, in separate interviews, V2 and V4 (Restorative Nurse) both stated R4 should have mittens on at all times to maintain trach patency because R4 has a history of pulling on trach tubes.On [DATE] at 10:28AM, V7 (Attending Physician/AP), stated he is the AP in facility only and not R4's community doctor. V7 said the last time R4 was seen was Friday, [DATE]. R4 was stable. He was aware that R4 has history of pulling on trach tube and the plan was to apply restraint (mitten) to prevent R4 from pulling trach. There was an order for mittens to be on at all times, staff to monitor, and may remove only when there is staff present and working with resident. V7 signed off on the Death certificate with cause of death, Respiratory Failure (not complete list). V7 stated the immediate cause of death was possibly R4's trach being pulled out since there was no oxygen being received by R4.On [DATE] at 11:34 AM, V8 (Certified Nursing Assistant/CNA) stated she work 11-7 shift on 8/23 thru 8/24 and was assigned to R4. V8 said she rounded on R4 every 2 hours and at 5:00AM she provided incontinence care. V8 said she did not visibly saw the mittens being on during her entire shift. V8 said no one communicated to her about R4's need of mittens. V8 stated she do not know the facility restraint policy and only received education today in the morning. V8 further state that during police investigation and interview with staff she was present and heard the nurse did not know anything about R4 needing mittens. V8 said there is no CNA to CNA shift to shift report or endorsement.On [DATE] at 1:42 PM, V11 (Respiratory Therapist/RT) stated he was the RT working with R4 on 8/23 -[DATE]. V11's shift is 7p - 7a. On [DATE] at 6:15AM nurse called stated R4 trach was out. When he went to the room V11 said R4 did not look like she was breathing and there was no pulse. V11 stated he do not re-call seeing R4's mittens on. V11 said there was an order for mittens as R4 have the history of self-decannulating behavior. V11 rounded 6X on R4 during his shift and at one point he reported to the nurse that mitten needs to be applied, however, V11 said he was unsure if nurse went to the room to check after acknowledging he was heard.On [DATE] at 10:25 AM, V14 (R14's Daughter) stated the incident of her mother pulling on tracheostomy tube occurred 3x since admission to facility. Stated facility was aware before admission that her mother was on restraints from another facility because of behavior. Requested for restraint but was told initially by V13 (Regional Nurse Consultant/ Interim DON) that facility is restraint free and that they do not use restraint in the building, but later it was decided that R4 needed it after the 2nd attempt and upon return from hospital. During this investigation, multiple call attempts to V17 (Agency Nurse) for an interview was done with no success of a call back.Review of R4's medical records indicate an admission date of [DATE] with diagnosis information of aphasia following cerebral infarction, tracheostomy status and dependence on supplemental oxygen (not a complete list). Comprehensive assessment of MDS Section O, dated [DATE], indicated R4 with tracheostomy care, Section C, [DATE], indicated Brief Interview for Mental Status (BIMS) was not conducted. Order Summary Report, start date [DATE], read: Monitor left hand mitt for circulation, motion, sensation, PAIN, ROM. Every 2 hours for monitoring remove mitt for 10-15 period, CMS/ADL/ROM. Care Plan Report, date initiated [DATE] read: Focus- Physical Restraints: Requires physical restraint r/t pulling on mechanical equipment. Interventions include Check and remove restraints as per policy. Keep resident close to areas that are supervised. Provide hazard free environment. Special Instructions read: Apply MITT to LEFT hand to maintain patency of trach tubes due to patient chronic pulling of tubing. Ventilator/Aerosol Flowsheet indicated Trach care was done by V11 on [DATE] at 8:30 PM where trach inner cannula was changed. Consent for Use of Restraint/Device, effective date [DATE] read: 2. Benefits, a. Based on the resident's individual needs, restraints may be beneficial for the following. 2. Prevention of injury to self or other. Progress Notes, Effective Date: [DATE] 15:39 Type: Nurses Notes: Note Text: @ 0910 Pt., was observed by this nurse with her trach out, immediately RT was called to pt's room by CNA. 2 RT put the trach back in and SPO2 97 HR 66. Progress Notes, Effective Date: [DATE] 23:59 Type: Nurses Notes: Note Text: A Shiley 5XLTD decannulation occurred. Nurse notified the RT. Despite multiple attempts, the trach wouldn't reinsert. DON was notified. RT applied a 4x4 gauze over the stoma and a non-rebreather mask. R4 was stable at 95% oxygen saturation and 82 b/m HR. Ambulance left with her not in distress. Progress Note, Effective date [DATE] 20:08 Type: Nurses Notes: Note Text: Writer called resident daughter to inquire / inform of the use of hand restrain, daughter verbalized that she is aware of such order from the hospital and gave verbal Consent for the use of the hand mitten to restrain resident from pulling out her trach again. Nurse on Duty made aware. Facility did not provide progress note or completed incident report for [DATE] self-decannulation incident. Review of Illinois Certificate of Death read Cause of Death, Immediate Cause a. Nontraumatic Intracerebral Hemorrhage, b. Acute Respiratory Failure, c. Type 2 Diabetes. Certificate was signed and certified by the Attending Physician/Physician in Charge on [DATE]. Policy and ProcedureGuideline: Physical Restraint/Device, Review date 10/2021General: To provide guidance on the assessment for the use and documentation of physical devices including, but not limited to, position change alarms, bed rails, furniture positioning, concave mattress, reclining chairs, cushions such as wedge shaped, hand mitts, abdominal binders, etc. A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff.Guideline:2. If is determined that the physical device is a restraint: a. A physician order will be obtained. b. Education will be provided to the resident/resident representative regarding the risks and benefits of the physical device. c. Informed consent will obtain from the resident/resident representative using the Consent for use of Restraint/Device Form3. If a resident or resident representative request the use of a restraint, then the facility will evaluate the appropriateness of the request and consult with the physician/NP to determine if resident has a medically necessary reason for the restraint.6. the effectiveness of physical device in treating the medical symptoms or as a therapeutic intervention and any negative impact on the resident shall be assessed by the facility throughout the period of time the physical device is being used and documented in the progress note.7. The behavior incident that prompted the use of the physical device will be documented in the progress note.8. The date and time the physical device was applied and released will be documented in the progress note.9. the name and title of the person responsible for the application and supervision of the physical device will be documented in the progress note. On [DATE] the surveyor verified by interview and record review that the facility implemented the following to remove the immediacy:Immediate Actions:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. All residents with tracheostomies were reviewed by DON/Unit managers. Completed on [DATE]. The review was done to ensure special instructions which includes mittens or other physical restraints were in place per physician orders and resident care plans. There was one resident to was identified with a physical restraint. No other concern was identified related to use of physical restraints during the review.The DON/Unit Managers provided education to nursing staff (nurses and nursing assistants), RT's (respiratory therapists) including Agency staff on special instructions such as use/application of mittens and other physical restraints for residents with Tracheostomy, following care plans and physician orders. Completion date: [DATE].The DON/Nurse Managers provided education to the nurses, including nurse agency staff, on change of shift reporting. The training also included notifying nursing assistants of any new special instructions at the start of the shifts. Completion date: [DATE].All nursing staff (nurses and nursing assistants) and RT's (respiratory therapists), including agency staff, who are not available and/or currently on vacation will also receive the same education upon their return to work. The DON/Unit Managers will provide the same training. Ongoing. Additional Interventions:The DON/Unit Managers will continue to audit new admissions with Tracheostomy to ensure that orders for physical restraints are care planned and are communicated with the nursing staff and RT's. Initiated on [DATE].The DON, Administrator, Unit Managers reviewed the policies and procedures related to physical restraints, tracheostomy, nursing rounds, care plan and following physician orders. There is no revision necessary. Completion date: [DATE].The QAPI committee held an Ad-Hoc QAPI meeting to discuss R4, and action actions described in this plan of removal. Completion date: [DATE].The DON/Unit Managers will conduct audit and observation of all residents with tracheostomy weekly for four (4) weeks to ensure compliance with special instructions, such use if mittens and physical restraints are being implemented, physician orders and care plan interventions are followed. Ongoing.The results of the audit/observation will be reviewed by the QAPI committee weekly for four (4) weeks. The QAPI committee will determine if additional corrective actions are necessary to maintain compliance. Ongoing.The facility asserts the likelihood for serious harm no longer exists on [DATE].

Based on interview and record review, the facility neglected to follow their policy and procedure to ensure staff provided incontinence care at least every two hours for a resident identified as dependent on staff for toileting. This affected one of three (R131) residents reviewed for neglectful care and services. This failure resulted in R131 being exposed, soiled with feces, crying, verbally distraught, begging for help and feeling uncomfortable. Findings Include: R131 was diagnosis with mixed/urinary incontinence, rash and other nonspecific skin eruption, malignant neoplasm of vulva and obesity. Minimal Data Set (MDS) section C (cognitive patterns) dated 5/8/25 brief interview for mental status documents a score of thirteen which indicates cognitively intact. Section GG (functional abilities) documents R131 was dependent with toilet hygiene (helper does all of the effort). Resident does none of the effort to complete the activity or the assistance of two (2) or more helpers is required for the resident to complete the activity. Care Plan initiated on 1/31/25 and 5/8/25 documents: R131 has a self-care deficit in bed mobility related to decrease ability to position or reposition self in bed and turn from side to side without staff assist. At risk for abuse and neglect. On 5/13/25 at 4:53pm, R131 who was assessed to be alert to person, place and time said, she was left in her feces from 2am until the police arrived. R131 said, she called V37 to report staff was not answering her call light and she needed to be cleaned up after a bowel movement. R131 said, her vaginal area was exposed and there was so much diarrhea. R131 said, she felt bad and just wanted some help while starting to tear up. R131 said, she was falling in and out of sleep due to her nightly medication and was not provided incontinence care until the police arrived. Facility provide statement for R131 dated 5/14/25 documents: I woke up. I had a mess on my hands because I was in diarrhea. I pressed the call light to be changed. No one was coming so I called my son and V37. I just remember being uncomfortable and needing to be changed. On 5/15/25 at 10:03am, V37 (family) said, R131 called him crying, upset, verbally distraught begging for help early Monday morning at 2am complaining of staff not answering her call light on the night shift. Not changing her after she had a bowel movement. R131 has a wound from radiation in her groin. V37 said, R131 called him back multiple time between 3am -5am to report staff still hadn't come to her change/provide incontinence care. V37 said, he called the facility with no answer. V37 said, after the multiple calls from R131 due to her not receiving care, he called the police for a well check. R131 was left soiled and saturated in urine and feces for four hours. The facility tried to say R131 tore of her adult brief. R131 does not have any behaviors. Facility provided concern form dated 5/12/25 (9:37am) documents: V37 stated he had concerns regarding care. Wasn't able to reach anyone. Stated he called police. All parties notified. Facility provide statement for V37 dated 5/14/25 (2:41pm and 4:08pm): V37 said, that he received a phone call from R131 early Monday morning and that she mentioned she was waiting for someone to come and change her. V37 also mentioned that he called the police because he said he [NAME] like R131 was being mistreated. Police Report dated/time report 5/12/25 at 6:31am documents: Last known secure 5/12/25 at 3:00am. On 5/12/25 at 6:52am, police responded to nursing home in reference to a citizen assist complaint. V37 informed them that he was requesting a well-being check on his wife, R131. V37 stated that he tried calling the facility several times and no one was answering. Additionally, V37 informed Southwest Central Dispatch (S.W.C.D) that he spoke with R131 who stated she was sitting in her own feces and had open wound. V37 explained that he was unhappy with the care R131 was getting. Upon police arrival, police observed a female subject standing behind a nurse's cart, dressed in scrubs. In the hallway for two hundred rooms. Police inquired, if she was the nurse for the wing, at which point she informed police she was and assisted police with the location of R131's room. Upon entering R131's room, police could smell the strong odor of feces. Police then observed a female subject, later identified as R131, lying on the bed closest to the entry door of the room. R131 did not have any undergarments on, was lying on her back, and her vaginal area and groin area appeared to have a large amount of feces on it. R131 was holding a bed sheet that also appeared to have feces on it. Police spoke with R131, who explained the following in summary but not verbatim: She/R131 had been lying in that condition since May 12 2025 between the hours of 2:00am -3:00am. R131 further advised that she called her husband to report the condition and also her son. Police asked, R131 if she had a call button located near her, to contact staff. R131 informed police there was call button beside her bed, but no one had come to assist her. Police relocated back into the hallway and spoke with the female subject standing behind the nurse cart, dressed in scrubs. Police informed her of R131's condition, at which time the female subject standing behind a nursing cart, dressed in scrubs advised that she was not a CNA (certified nurse's assistant). Police relocated to the administrative area and knocked on the doors. Police was met by a male subject, dressed in what appears to be a doctor coat. Police informed him of R131 condition and what the female subject standing behind a nurse cart, dressed in scrubs explained to police. The male subject dressed in what appears to be a doctor's coat immediately relocated to R131 room and then contacted another individual. Upon the arrival of a second female staff member, she did not enter R131's room and began working on her schedule paperwork. Police inquired with the female staff member if she needed police assistance getting another staff member to assist her, due to R131 sitting in her feces since 2:00am. After some time had passed a third female staff member arrived at the location where the second female staff member was. The third female staff member explained that she was gathering an undergarment adult brief for R131. Police inquired with the third female staff why R131 did not have an undergarment on at this moment. The second female staff member answered and advised that it was due to R131 having behavioral problems. Upon the second/third female staff entering R131's room, the second female staff member began question R131 about her notifying the police and who she contacted about her condition. Police advised R131 that she did not have to answer the questions, at which time the second female staff member became agitated and informed police that R131 was obligated to answer her questions, due to the second female staff member being in charge of the floor. Police advised the second staff member that R131 had been lying in her feces for some time and that assisting R131, prior to question R131, would be her best interest. On 5/15/2025 at 11:27am, V28 (social service) said R131 did not have any behaviors related to refusing incontinence care nor is any charted in the care plan with seventeen pages. V28 said, she would assume R131 would want to be changed after a bowel movement like anyone else. On 5/15/2025 at 3:15pm V35 (nurse) said, she was assigned to R131's unit on the night shift (11pm -7am) for 5/11/25. V35 said, she was an agency nurse and had never worked with R131 before. V35 said, there wasn't an evening (3pm -11pm) nurse on R131's unit to get report from. V35 said, when she started her shift at 11pm, there were two certified nursing aides that introduced themselves to her. V35 said, she thought those two aids were assigned to her unit. V35 said, two hours into her shift she realized a lot of call light were going off. V35 assumed the aides were in other resident's room providing care. V35 said, R131's family called to complaint that R131 was soiled. V35 said, she went into R131's room at 1:00am. V35 said, R131 was soiled with feces and needed to be changed. V35 said, she needs another staff member to assist with R131 due to her size. V35 said, she did not have any staff to assist her with R131 incontinence care. V35 said, there wasn't any aides on her unit. V35 said, she started to check all of her assigned resident to make sure they were alive. V35 said, she called V10 (manager on duty/nurse) and informed her that there was no CNAs on her shift and only one nurse on the opposite unit. V35 said, residents were soiled and neglected. V35 said, the facility put her licensed and the residents at risk. On 5/15/25 at 5:06pm, V10 (IP Nurse) said, she worked upstairs on the second floor on the 3-11 shift. V10 said, she was the manager on call from Sunday night (5/11/25). V10 said, she was short staff on the night shift of 5/11/25 going into the early morning of 5/12/25 on R131's unit. V10 said, on R131's unit there was only one nurse and one certified nursing assistant working on the 11-7am for the long term care unit/R131's unit. V10 said, two (2) nurse and (4) four CNA are needed for the long term care unit. One nurse and two CNA should have been on R131's unit. On 5/16/25 at 1:16pm, V48 (CNA) said, she was short staffed on the night shift on (5/11/25) Sunday night. V48 said, she worked with V47 (CNA), and they provided incontinence care for R131 two to three times that night with the last time being around 4:30am- 5:00am. V48 said, she did not see the police. V48 said, she did not chart the care provide to R131. Facility provided witness statement from V47 dated 5/14/25 documents: V47 was a CNA on the night 5/11/25. V47 was not assigned to R131. V47 did not take care of R131 on 5/11 night shift. Statement given by V47 via phone on 5/15/25 at 11:20am. On 5/16/25 at 4:20pm, V9 (nurse) said, she was the nurse on the south unit. V9 said she worked the day and evening shift on 5/11/25. V9 said, she was in the facility charting until 1:30am -1:45am because she sent a resident to the hospital. V9 said, at the end of her double shift she was not providing any patient care. On 5/16/25 at 12:13pm, V2 (Administrator) said, if staff was aware that R131 needed incontinence care and failed to provide it, that failure is neglect. V2 said, residents should be changed every two hours and as needed. V2 said, she did not view the camera to determine if staff responded to R131's call light. Surveyor requested to view the video footage of staff entering and exiting R131's room. V2 did not present any video footage for review during the survey. On 5/16/25 at 1:47pm, V4 (ADON) said, she came into the facility on [DATE] at 2:00am, that morning. V4 said she was informed around 11:45pm that a nurse was needed on the south unit on long term care side. V4 said, she spoke agency nurse, who informed her that the south unit nurse had just left. The nurses are not supposed to leave without being relived or giving report to another nurse. The long term care unit had two nurses when she reported for work, ideally it should be three nurses assigned to the long term care unit. V4 said, she did not interact with the police. Abuse policy dated 9/2017 documents: This facility affirms the right of our resident to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Neglect means the failure of the facility, it employees or service providers to provide goods and service to a resident that are necessary to avoid physical harm, pain or mental anguish or emotional distress. Further, neglect means a facility's failure to provide or willful withholding of adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident.

Based on interview and record review, the facility failed to prevent one resident with a tracheostomy, who was identified as high risk for skin breakdown and dependent on staff for care, from acquiring a wound, and failed to follow their policy to develop and implement interventions individualized based on the resident's condition for one resident at high risk for skin breakdown with 18 impaired skin areas. This affected two of three residents (R111, R122) reviewed for pressure sore. This failure resulted in R122 sustaining an open wound to the left side of the neck measuring 7 cm x 1cm x 0.5 cm at the tracheostomy collar. Findings include: 1. R122 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, type II diabetes, abnormal posture and tracheostomy status. R122's Minimum Data Set, dated dated dated [DATE] documents R122 is dependent on staff for rolling left to right and for all activities of daily living. R122's Braden scale for predicting pressure sore risk documents score of 8. A score of 9 or below indicates very high risk for skin breakdown. On 5/15/25 and 5/16/25 at 10:46 AM, R122 was observed in bed with head leaning to left side. R122 had tracheostomy collar in place. A tracheostomy collar is a soft, clear mask that fits over the tracheostomy tube to deliver oxygen that has a green thin strap that goes around the neck. R122's skin and wound evaluation dated 5/4/25 documents in house acquired laceration to left side of neck measuring length 6.5 (centimeters, CM) x 0.7 CM). R122's wound assessment report dated 5/6/25 documents: Resident was in bed for wound evaluation. Resident has Respiratory Failure, and Cerebral Infarction. Resident is status trach/vent, incontinent, and poor bed mobility. Resident has laceration injury to the neck due to trach collar. Injury was picked up and is being treated. Primary Etiology: Skin Tear/Laceration. Stage/Severity: Stage 3. Size: 7 cm x 1 cm x 0.5 cm R122's wound note dated 5/13/25 documents: Resident has laceration injury to the neck due to trach collar. Injury was picked up and is being treated. Primary Etiology: Skin Tear/Laceration Stage/Severity: chronic On 5/16/25 at 12:27PM, V43(Wound NP) said R122's wound was classified as a laceration due to the shape of wound being straight and linear. The opening was caused from resident moisture causing the skin to became softer and easier for foreign force to cause breakdown. R122 trach collar was determined to be the cause of opening along with moisture. V43 said it was classified as laceration and skin tear which are the one in the same and can be used interchangeable. V43 said the wound stage three on initial note was done in error. On 5/16/25 at 10:59AM, V3 8(Respiratory Manager) said R122's had a wound to left neck which could have been caused by friction from the trach collar. V38 said staff are supposed to ensure the strap is placed on pad the to ensure it does not irritate the skin. On 5/15/25 at 2:20 PM, V30 (wound nurse) said R122's wound is a laceration from the tracheostomy collar. Laceration is a cut in the skin from trauma like friction from the tracheostomy collar. Facility policy reviewed 9/23 Pressure injuries documents: to prevent or reduce the incidence of pressure injuries, standards of practice should be implemented. A pressure injury may be defined as any lesion caused by unrelieved pressure that results in damage to the underlying tissue, although friction and shear are not primary causes of pressure injuries, friction and shear are important contributing injuries to pressure Injuries. A pressure injury is localized damage to the skin and or underlying tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. [NAME] l device related pressure injury. Use staging system to stage. This describes the etiology of the injury. Medical device related pressure injuries result from the sue of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. 40066 2. R111 diagnoses include but are not limited to fracture of lumbar vertebra, diabetes, protein calorie malnutrition, and attention to gastrostomy. R111 is not verbally or physically responsive when spoken to or while staff providing care. On 05/14/25 at 10:35 AM V15, CNA, said, I check and change R111 every 2 hours. We check and change everyone every 2 hours. On 05/14/25 at 12:53 PM V30, wound nurse, accompanied surveyor to see R111. R111 in his bed laying mostly on his right side. R111's right ear was resting on his shoulder and pillow. A visible 4x4 foam dressing was over his left ear. V30 said R111 has deep tissue injuries to his left ear, elbows, sacrum, ischium, feet, and left lateral neck/head areas, skin tears and lacerations over his right hand. V30 said interventions for pressure relief include a horse shoe shaped neck pillow, heel boots, and an air mattress set to his weight. The neck pillow was not on R111 neck and was at the top of the mattress. V30 said interventions include turn every 2 hours for all residents who can't reposition themselves. V30 did not make any movement or response during observations and conversations at this time. On 5/15/25 at 1:55PM V30, Wound care, said R111's right ear wound was identified on 5/1/25 and present on readmission. V30 said the wound was unstageable. On 5/12/25 the right ear measured 0.7 x 1.0 x 0.1 deep, and at stage 3. V30 was asked specifically what intervention were put in place for V30's ear pressure ulcer. V30 said interventions include turn and reposition, every 2 hours, wedges in his room help him be elevated off his sides and bottom, and an air mattress, protein supplements were added. V30 said these wounds were present since before his readmission. V30 said R111 has always had an air mattress originally delivered on 12/26/24. V30 said interventions are appropriate for R111. V30 said they are repositioning R111 enough. The surveyor asked if the facility completed a tissue tolerance test for R111. V30 said a tissue tolerance test has not been done to V30's knowledge. The surveyor asked V30 if R111's care plan includes the use of his neck pillow. V30 said it's not on there. V30 was asked if bolsters are on the care plan and V30 said they are not on there. V30 said they have heel boots and turn and reposition every 2 hours on the care plan. V30 said R111 has about 18 skin impairments (without counting). V30 said we complete unavoidable documents we fill them out and the nurse practitioner reviews and signs them. V30 said R111 has unavoidable documentation for his sacrum and left ear but not the right ear because it did not develop in the facility. On 5/16/25 at 11:42 AM V32, MDS Nurse, said the purpose of the care plan is how they know what care and services to provide to the residents. V32 said the action part of the care plan is the interventions, what we are doing. V32 said the care plan is individualized based on resident needs and preferences. V32 said anyone providing care to the resident has access to the care plan. On 5/16/25 at 11:52AM V44, Doctor, said R111's prognosis is poor. R111 is a bedbound patient. R111 said interventions for pressure relief should be followed. The surveyor discussed the unavoidable assessment completed by the facility for R111's ear with the intervention for heel protectors. R111 said, I don't see that applying to an ear wound. V30 provided a list with R111 skin impairments including left ear unstageable pressure ulcer acquired in house and right ear stage 3 pressure ulcer. There are 18 impairments on the list for R111. On 5/16/25 at 11:46AM V30 said we use Braden scale for everyone. V30 said R111 is at high risk for pressure ulcers. Review of R111 wound progress notes date 5/12/25 identify sacrum pressure ulcer, right knee, right hand, right lateral foot, and left leg vary from pressure to venous. Wounds on bilateral ears and left side of head and breakdown on various sites of body. Right ear pressure ulcer stage 3 size 0.7 x 1 x0.1, peri wound skin is fragile. Left ear pressure unstageable size 2.8 x 1.9 x 0.1 granulation and eschar present. Peri wound fragile. Pictures include in document of left ear. Care plan provided to the surveyor by the facility for R111 reviewed and does not include use of wedge/bolster, neck pillow. There is no intervention for turning or repositioning or frequency. There is no intervention specific to R111 left and right ear to relieve pressures, except for treatment. An Unavoidability/Avoidability Determination for R111 ulcer site left ear, unstageable onset 4/21/25. Diagnosis identified Severe PVD, Urinary and Bowel incontinence, and history of pressure ulcers. Interventions include moisture barrier after each incontinent episode, pressure relief mattress, low air loss, turn and reposition every 2 hours, supplements, and tube feeding. The policy for Skin Management: Treatment/General Wound Treatment dated 4/2024 states, in part, treatment guidelines have been developed to serve as a general protocol for selecting the type of treatment or dressing to be used. The facility recognizes that the selection of treatment protocol is individualized based on the resident condition and practice patterns .implement prevention protocol according to resident needs. Mobility: turn and reposition as needed using a person centered approach.

Based on interview and record review the facility failed to provide effective supervision for a resident with a diagnosis of right-side hemiplegia, lack of coordination, abnormal posture, displaying agitation while in dining room, and failed to ensure effective interventions to include supervision and monitoring were implemented to prevent a resident from falling out of bed. This affected two of three residents (R59, R65) reviewed for safety, supervision, and falls. This resulted in R65 falling from the wheelchair, R65 was sent to the local hospital for treatment of a clavicle fracture, and resulted in R59 sustaining a closed head injury, abrasion to the top of the scalp and left upper extremity (arm) with diffuse swelling. Findings include: 1. R65 face sheet shows diagnosis of hemiplegia and hemiparesis following non traumatic subarachnoid, type 2 diabetes, aphasia, lack of coordination, abnormal posture, unspecified dementia. R65 incident report dated 3/13/2025 denotes in-part fall, date of incident 3/13/25, location dining room, during lunch resident was in the dining room while his room was being cleaned. Resident became agitated and he reached for the door and fell . Resident unable to give description. Was this incident with incident witnessed, N documented. Description took vital signs, informed Doctor, and family. Neuro check initiated with normal findings. The resident initially denied pain, but after 30 minutes c/o (complain of) pain to left arm. MD was updated and ordered Xray of left shoulder, arm, and elbow. Pain level -one. Mental status- confused/ fearful, orientated to person. Non complaint to safety guidance. Resident had a misunderstanding with his sister who was visiting and was agitated and hard to redirect. On 5/14/25 at 2:17pm V21 (LPN) said she was the Nurse for R65 on 3/13/25 when R65 fell in the dining room. V21 said on this day, R65 room was being deep cleaned and R65 had to get up from bed and come to the dining room until the room was finished being cleaned. V21 said R65 was in a manual wheelchair. V21 said R65 usually stays in his room and watch his movies. V21 said R65's sister did visit that day, and during that visit R65 was agitated because he wanted to go back to his room. V21 said R65 sister was upset that R65 was agitated. V21 said R65 sister was not in the dining room when R65 fell , she was lingering in the hallway. V21 said she asked several times if she could put R65 back in his bed because of the agitation. V21 said R65 reached for the door in the dining room, to open the door and that's when he fell from the wheelchair. V21 said the Director of Nursing at that time allowed her to watch the video and she observed what happened on the video. V21 said she watched the video, but she can't recall if someone was in the dining room when R65 fell . V21 said she does recall that she observed two aides in the hallway. V21 said staff are supposed to monitor the dining room. Facility presented assignment sheet for 3/13/25 (day of R65's fall). V52 (CNA) was identified as one of the aides that was standing in the hallway. On 5/14/25 V52 said herself and V54 were in the hallway, and the other aides were setting up for lunch services. V52 said she thinks a nurse was in the dining room when R65 fell , but she doesn't recall. V52 said R65 was having behaviors because he wanted to go back to his room. V52 said you could hear R65 banging on the door. V52 said herself and the other aide were planning to put R65 back to the bed, but he had the fall prior to them putting back to bed. V52 said R65 does not usually get out of bed, he prefers to be in his room and watch his movies. V52 said staff are supposed to monitor the dining room when residents are in there. 5/16/25 at 1:42pm V53 (CNA) said she was not in the dining room when R65 fell , she was taking her 15 minute break. V53 said the dining room supposed to be monitored, she thought it was. V53 said she doesn't know who was monitoring the dining room. 5/16/25 at 2:14pm V9 (LPN) said she was not in the dining room when R65 fell , she was passing medications. R65's emergency room after visit summary dated 3/14/25 denotes you was seen diagnosis clavicle fracture. Upon exit of this survey the facility failed to identify who was monitoring the dining room when R65 fell from the wheelchair. Facility fall policy prevention management policy with last review date 8/2024 denotes in-part this facility is committed to maximizing each resident 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 prevention strategies, and facilitate as safe an environment as possible. All falls shall be reviewed, and the residents existing plan of care shall be modified as needed. 41758 2. R59 has diagnoses with Dementia, history of falling and unspecified fracture of left humerus shaft with routine healing. Brief interview for mental status dated 3/6/25 documents a score of eight which indicates moderate cognitive impairment. Fall risk evaluation 2/27/25 documents score of twelve. Scoring a ten of higher makes resident high risk for falls. Minimal data set dated [DATE] documents: roll to left and right; R59 requires substantial/maximal assistance (helper does more than half the effort), lying to sitting on side of bed: R59 is dependent. On 5/14/25 at 3:15pm, R59 who was alert to self only said, she fell out of bed but could not elaborate on the events prior to the fall. On 5/14/25 at 3:22pm, V22 (nurse) said R59 had two unwitnessed falls from the bed. R59 was observed on the floor face down both times. V22 said she was not sure how R59 fell . V22 said she got report that R59 did not move. V22 said R59 did not have any injuries the first fall. The second fall R59 complained of arm pain. V22 said R59 was sent to the hospital both times. On 5-15-25 at 1:54pm, V46 (restorative directive) said R59 was high risk for falls. R59 was dependent on staff for repositioning in bed. R59 was unable to turn and reposition herself. V46 said she is not sure how R59 fell since she was unable to reposition self without staff assistance. V46 said R59's fall intervention was ineffective to prevent her from falling out of the bed. R59 was given a fall mat after the first fall which was an ineffective because R59 had a second fall from the bed. Fall mats do not prevent falls from the bed. Fall mats decrease the chance for injuries if the resident falls onto the floor. V46 said R59 sustained abrasion to the scalp and left toe with the second fall. V46 said she does not know what R59 hit to obtain the abrasions nor is it documented. Nursing note dated 4/8/25 document: Resident (R59) observed laying in a prone position (flat on their stomach, with their face downward or turned to one side), on the floor next to the bed. Resident states, I fell out the bed. Left upper extremity edema, no visible injures, bed was at the lowest position and call light still attached to the resident. Fall incident dated 4/8/25 documents: R59 has poor bed mobility, positioning and requires assistance from staff. R59 has old left arm fracture with routine healing. Will maintain be in the lowest position. Floor mat given. Round at a minimum of every two hours and prompt or assist for change in position, toilet, offer fluids and ensure resident is warm and dry. Hospital after visit summary dated 4/8/25 documents: fall from bed. Nursing Note dated 5/5/2025 documents: Resident (R59) observed laying prone position on the floor near bed. R59 states, I rolled out bed. Left upper extremity edema, abrasion to left top of head. Complains of pain 8/10. Fall event dated 5/5/25 documents: During rounds, the nurse on duty observed the resident laying prone position on the floor on the floor mat. Injury: Abrasion top of scalp and left third toe. Hospital paperwork dated 5/25 documents: Resident presented to the emergency department at this time for evaluation after experiencing a fall out of her bed. According to the patient, the patient was sitting on the edge of the bed and fell off of the bed. R59 has a history of dementia. Physical Exam Finding: Left upper extremity with diffuse swelling, contracted, sling. Closed head injury, Abrasion of scalp. Fall Prevention and Management Policy dated 5/2015 documents: The facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible.

Based on observation, interview and record review, the facility failed to monitor and implement effective interventions for one resident at risk for malnutrition. This affected one of three residents (R113) reviewed for weight loss. This failure resulted in R113 sustaining a 34.8 percent unplanned weight loss in less than 6 months. Findings include: R113 was admitted to the facility on [DATE] with a diagnosis of diabetes, muscle wasting, dysphagia, seizures and gastrostomy status. R113 's Minimum Data Set, dated dated dated [DATE] documents substantial/maximal assistance with eating. On 5/15/25 at 2:00PM, R113 weight was taken via mechanical weight lift by staff. Weight scale was set to 0 prior to weighing. Resident weight was 133 pounds. R113's weight on 12 /25/24 documents 201 pounds; 2/5/25 documents weight of 199 pounds, 2/19/25 documents 132.2 pounds; 3/5/25 documents 132.8 pounds, 3/7/25 document 132.8 pounds; 4/1/25 documents 131.6 pounds; 5/6/25 document 129 pounds, 5/14/25 documents 129 pounds R113's 12/20/24 dietary note documents: R113 receiving continuous feeding with nothing by mouth status. R113's eternal feed order dated 1/16/25 documents eternal feeding 1.2 bolus 250 ml two times a day. (900 calories, 40 grams of protein) R113's dietary note dated 2/23/25 documents: enteral feeding 250 ml bid bolus (nutrient content 900 calories, 40.5 gm protein, 363 ml free water and water flush 250 ml four times a day. (total water 1363 ml) excluding oral intake. has puree 1:1 pleasure feeding order intake 50-75%. Weight history: 2.5.25 199, 12.9.24 201, 11.6.24= 199, 10.9.24 = 200 Height 59 Body Max Index 40.2 estimated Kcals needs: 1420-1704 adjusted BW (25-30); estimated protein needs: 54-65 (1.0-1.2); estimated fluid needs: 1420-1704 (25-30 ml); Skin: intact; Plan: Continue Enteral Nutrition and water flush as ordered. Monitor tolerance to Tube Feeding and follow up as needed. R113 dietary evaluation documents high risk for malnutrition. Question accuracy of 199 weight on 2/5/25. Estimated caloric needs 1510-1812 calories. Under intake variable intake 50- 75 % is fed by staff. Under comments: significant change continues, artificial nutrition with no new orders or interventions documented. R113's dietary note dated 4/26/25 documents: EN: feeding 250 ml bid bolus (nutrient content 900 calories, 40.5 gm protein, 363 ml free water and water flush 250 ml Four times a day. (total water 1363 ml) excluding oral intake. has puree 1:1 pleasure feeding order intake 50-75%. Weight t history: 4.1.25= 131.6, 2.7.25= 132.8, 2.5.25 199, 12.9.24 201, 11.6.24= 199, 10.9.24 = 200 Height 59 inches Body Max Index 29.6. Weight loss 34% in 180 days discussed in Nutrition at Risk meeting 4.9.25 and 3.12.25 and secondary to acute kidney failure estimated. Kcals needs: 1495-1794 kcal; estimated protein needs: 54-65 gm (1.0-1.2); estimated fluid needs: 1495-1794 cc; Skin: intact; Plan: Continue Enteral Nutrition and water flush as ordered. monitor tolerance to Tube Feeding and follow up as needed. On 5/16/25 at 10:09 AM, V45 (dietician) said R113 had a significant weight loss of 34 percent based on weight of 199 pounds to 131 pounds. V45 said R113 was on continuous artificial feeding and orders was changed in January to receive feeding twice a day which is about half of her caloric intake due to R113 eating by mouth. V45 said in February she questioned the weight and asked for reweight which indicate same weight. V45 said she begin to question the accuracy of all R113 weight from august 2024 through January 2025 saying she was unsure if R113 ever weighed 200 pounds and was always around 130. After a significant weight change depending on resident, we will monitor weights weekly, implement supplements or caloric counts. V45 was unable to provide any additional information related to any interventions or monitoring down for R113 weight and requesting to review her notes. At 11:29AM, V45 was not able to present any new information related to R113, except that she reviewed her hospital weights which did not match but said they do not use hospital weights calculate weight changes. V45 said R113's weight was stable at 130 pounds and no further interventions were placed. On 5/16/25 at 1:09PM, V50 (Nurse Practitioner) said he was not able to recall any concerns related to R113 having a significant weight loss. V50 recalls receiving reports of R113 not eating good possible to mood. V50 was shown R113 weights and was unable to explain the change or any interventions put in place. Facility weight management policy reviewed 6/24 documents: to establish a policy for the consistent, timely monitoring and reporting of resident's weights. Weekly weights will also be done with a significant change of condition, food intake decline or with physician order. The director of nursing will forward dietary recommendations to the physician or nurse practitioner will follow up with recommendations within 24- 48 hours.

Based on interview and record review, the facility failed to prevent one resident (R3) who was admitted to the facility with healed scar tissue to sacrum and identified as moderate risk for skin breakdown from developing a facility acquired pressure ulcer measuring 2 centimeters (cm) length X 1.5cm width x 0.3cm depth within three days after admission for one of three residents reviewed for wounds. Findings Include: R3 diagnoses include paraplegia, moderate protein-calorie malnutrition, diabetes and osteomyelitis in the left foot. Brief interview for mental status dated 9/13/24 documents a score of fourteen which indicates cognitively intact. R3's face sheet documents: admitted [DATE]. On 12/03/24 at 11:16am, R3, who was assessed to be alert and oriented to person place and time, said she was left soiled with stool on the overnight shift twice when she was admitted which caused her to have an open wound on her buttock. R3 said she did not have an open wound on her buttock upon admission. R3 said she was devastated. She said she never thought she would be left soiled in feces. Wound care note dated 9/7/24 documents: Admission: R3 was admitted to facility with admitting diagnosis of rehabilitation related to Osteomyelitis. Head to toe skin assessment completed by wound team: Resident noted with healed scar tissue to sacrum. Barrier cream applied/initiated. Resident is incontinent of bowel and bladder, needing assistance with turning and repositioning. Resident may have a chair cushion, heel boots and will be turned/repositioned. Although interventions will be in place resident will continue to be at risk for further skin breakdowns due to unidentified factors. Pulmonary initial evaluation dated 9/10/24 documents: R3 was also found to have osteomyelitis of her foot. On 12/06/24 at 11:11am, V35 (treatment nurse) said she completed R3's skin assessment on 9/7/24. R3 had a healed scar tissue on her sacrum area. R3 was given barrier cream at that time. R3 did not have an unavoidability charting upon admission. Unavoidability charting is completed when the resident has a change in condition or worsened wound. R3 did not acquired unavoidability charting because she did not have any issues with her sacrum wound. R3 was found to have a facility acquired wound during rounds on 9/9/24 by V36 (treatment nurse) and V37 (wound doctor). Skilled Wound Expert Skin and Wound Note date of service 9/9/24 documents: Wound: 2, Location: sacrum, Primary Etiology: Pressure, Stage/Severity: Stage 3 Wound Status: Present on Admission, Odor Post Cleansing: None, Size: 2 cm x 1.5 cm x 0.3 cm. calculated area is 3 sq cm. Wound Base: 75-99% granulation, 25-49% slough Wound Edges: Attached, Peri wound: Intact, Fragile, Exudate: None amount of None. On 12/06/24 at 1:30pm, V36 (treatment nurse) said, R3 had a facility acquired a wound that was notice during round on 9/9/24 with V37. R3 was at moderate risk for skin breakdown to being very moist and incontinent of bowel and bladder. R3 was alert and able to report if she had any issues or concerns. Braden Scale for predicting pressure sore risk dated 9/6/24 documents a score of thirteen with indicates: Moderate risk related to very moist: Skin is often, but not always moist. Unavoidability/ Avoidability Determination dated 9/19/24 document: R3's wounds were unavoidable. Unavoidability/Avoidability Determination dated 10/28/24 document: R3's wound were avoidable. Facility policy Skin Care Prevention revised 9/2023 documents: Resident will receive appropriate care to decrease the risk of skin breakdown. Clean skin at time of soiling and at routine intervals.

1. Based on observation, interview, and record review, the facility failed to find appropriate roommates for R1, appropriately notify R1 of room change and consider room preferences and follow up with R1's discharge planning. This resulted in R1 being placed in a room with two residents (R11 and R12) that have behaviors and are severely cognitively impaired causing R1 to lose sleep and experience mental distress. Findings include: R1 is a [AGE] year-old female who originally admitted to the facility on [DATE] and moved to the long-term care side of the facility on [DATE]. R1 continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: surgical amputation, type II DM, need for assistance with personal care, HTN, heart failure, CKD V, and left BKA. Per Minimum Data Set (MDS) dated [DATE] shows R1 has a Brief Interview for Mental Status (BIMS) score of 12 meaning resident is cognitively intact. On [DATE] at 12:50PM, R1 was interviewed regarding roommates and discharge planning. R1 said the facility staff moved her to the long-term care side of the facility without getting her consent or being acclimated to the room or roommates. R1 said she did not want to come to this side of the building and would have rather transferred to another facility instead. R1 said, I told the staff I did not want to move rooms, but they transferred me here anyway. I have not spoken with a social worker since moving to the long term care side of the building, and even before that I barely saw any social workers. R1 said, I have two roommates that are severely cognitively impaired. R1 said R11 will talk all night saying things like 'do not touch me', 'give me my whiskey', and 'where is my food stamp card'. R1 said R11 is constantly saying things that does not make sense and sounds as if she is hallucinating. R1 said R12 will constantly yell out all day and night and scream bloody murder. R1 said, The staff will move (R12) into the dining room during the day, so I try and sleep during the day when she is out of the room. R1 said both of these residents prevent R1 from sleeping. R1 said, The staff is aware that I do not want to be in the room with (R11) and (R12). The staff does not care, they get to go home at night, but I am stuck in this room with (R11) and (R12) that scream all night. It is to be noted that during observation on [DATE], resident's eyes were puffy. R1 was in bed cuddled up with blanket at 12:50PM and was sleeping when this surveyor entered the room. On [DATE] at 12:17PM, R1 was observed to be sleeping in bed. R1's name was called twice but was in a deep sleep and did not respond back to surveyor. At 12:40PM, R1 was interviewed again. R1 said she is not getting any sleep because of R11 and R12 screaming all night. R1 was observed to have puffy eyes and to be upset about loss of sleep. On [DATE] at 1:15PM, R1 told this surveyor that on [DATE] R1 had a care plan meeting with the interdisciplinary team where R1 let them know R1's concerns with R1 roommates and discharge planning. R1 observed to have wet eyes talking to this surveyor about having a hard time sleeping. R1 said R1 met V6 (Social Worker) for the first time on [DATE] after speaking with this surveyor. It is to be noted that during the course of this survey, [DATE]-[DATE], R1 was visited on four different occasions and each time R1 expressed that she cannot sleep due to R11 and R12 yelling all night. R1 was observed to look tired and distraught on all visits from surveyors. On [DATE] at 2:10PM, V1 (Administrator) and V2 (Director of Nursing) were interviewed regarding social services. V1 said, We recently had a lot of changes in the social service department. All the social service workers are very new. On [DATE] at 3:30PM, V6 (Social Service Worker) was interviewed regarding R1. V6 said, I have not spoken with (R1) since I started working here and I am unaware of her discharge goals and plans. Per social service progress notes, it is to be noted that prior to [DATE], the last time discharge planning was discussed with R1 was on [DATE]. R1's care plan states in part but not limited to the following: R1's tentative plan is for the resident to return home upon completion of skilled services. As necessary, meet with the R1 on a regular basis to help with preparation for discharge. It is to be noted that at no point in R1's care plan does it show R1's plan of care is to move to long-term care within the facility. It is also to be noted that on [DATE], R1 was observed to still be in room with R11 and R12. Room change notification form shows R1 was notified of the room change on [DATE] at 11:30AM, which is the same day R1 moved to the long-term care side of the facility. Resident Rights policy dated [DATE] with revision date of ,d+[DATE] states in part but not limited to the following: 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 residents own needs and preference. Room Change/Transfer within Facility policy dated ,d+[DATE] with review date of ,d+[DATE] states in part but not limited to the following: To assure that residents are appropriately notified of room transfers. When a resident is being moved to a new room at the request of the facility, the resident shall receive an explanation in writing of why the move is required. The resident will be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. 44570 2. Based on interview and record review, the facility failed to ensure timely signing of a Certificate of Death. This failure applies to one resident (R7) who expired in the facility [DATE] and resulted in mental anguish to R7's family and delay of funeral services for R7. Findings include: R7 admitted to the facility [DATE] and had diagnoses that included pneumonia, severe protein-calorie malnutrition, and multiple pressure ulcers. According to progress notes, on [DATE] R7 went into cardiac arrest while participating in resident activities. Emergency Medical Services were called to the facility to provide advanced life saving measures, however R7 was unable to be revived and was pronounced deceased without transfer. On [DATE] at 1:58pm, V33 (Funeral Home Staff) said when R7 expired in the nursing facility, the funeral home recovery team reported to the facility and requested R7's face sheet that included R7's demographics such as name, birthdate and physician's contact information. The funeral home reached out to R7's Primary care Physician (V29) to have the Death Certificate signed within 24 to 72 hours of V7's transfer. V33 said when the Funeral home called V29, V29 refused to sign the Death Certificate because V29 said they were not the primary physician. V33 called V34 Pulmonology Consultant as listed on the face sheet and V34 said they could not sign the Death Certificate because they were not the primary physician for R7. V33 mentioned notifying R7's family and made several calls to the facility regarding the issue. On [DATE] at 9:52am V34 said a few weeks ago, the Funeral Home contacted V34 to sign the death certificate, however V34 explained that because V34 only saw V7 in the facility under pulmonology consultation, it was not appropriate to sign the death certificate. V34 said V33 was angry and offered to assist with reaching out to V29 (primary physician) however V33 mentioned that they had previously reached out to V29 but refused to sign. During the interview, V33 said they called the facility several times since R7 was transferred leaving several messages for the administrative staff and did not get any response. Finally, V33 called the facility on [DATE] and spoke with the receptionist (V35) and informed V35 that the Funeral Home had been attempting to get a physician to get the death certificate signed. V33 notified V35 that the family would be filing a formal complaint. Later that day, the signed death certificate was received dated [DATE]. V33 said that the delay in signing the death certificate also delayed proceeding with funeral arrangements for R7's family. On [DATE] at 11:13am, V36 (Family Member of R7) said that when V33 informed them of the delay in getting the death certificate signed, several messages were left with administrative staff, however no one returned their calls. V36 said regarding this issue, It took a mental toll on all of us because it was like we couldn't even get the process of grieving, or the funeral arrangements made without the death certificate. On [DATE] at 2:23pm V35 (Receptionist) said they received a call from a family member of R7 who was upset and mentioned suing the facility for refusing to sign the death certificate. V35 transferred the call to an administrative staff member but could not recall who. V35 said later, the funeral home called the facility, relaying the same concern and then V35 notified V2 Director of Nursing directly. On [DATE] at 2:23pm V2 Director of Nursing said, the funeral home reached out to the facility a few weeks ago, saying V29 had been refusing to sign the death certificate. V2 spoke with V29 and got it signed later that day. On [DATE] at 10:30am V29 said they were notified at the time V7 expired in the facility and signed the death certificate when the facility called. The death certificate was reviewed and was noted to be signed by V29 on [DATE], 30 days after V7 expired in the facility. V29 provided a fax confirmation that the signed death certificate was sent to the funeral home on [DATE].

A. Based on interview and record review the facility 1.) failed to implement effective interventions to prevent accidental removal of tracheostomy cannula and accidental extubation for a ventilator dependent resident; 2.) failed to follow their Hypoglycemia Policy and procedure by not initiating intravenous access to provide intravenous fluids and failed to call 911 immediately upon determining that intervention for hypoglycemia was not effective. These failures applied to one (R3) of three residents reviewed for nursing care and resulted in R3 being found decannulated and in cardiac arrest on [DATE] and on [DATE] when R3 was assessed as deceased and in rigor mortis (irreversible sign of death) by paramedics. Findings include: 1.) Respiratory progress notes dated [DATE] at 2:04am showed that R3 was found decannulated and without pulse. On [DATE] at 11:24pm V24 Respiratory Therapist said they worked the night shift [DATE] from 7pm to 7am. V24 said towards the beginning their shift, V24 received in report that R3 was fidgeting and pulling the tubing attaching the tracheostomy to the ventilator machine. Because of this, the ventilator alarmed many times during the previous shift. V24 said this behavior was noted to start at least a week prior. V24 said when this was noted and the ventilator alarm sounded, V24 would go into R3's room, try to calm R3 and notified the nurse of the behavior. On [DATE], V24 responded to an alarm at approximately 1:45am and found R3 with the tracheostomy cannula removed from R3's neck. V24 explained that the cannula is the tubing that is placed in the neck of an individual who is unable to breathe independently, and the ventilator mechanically provides breathing support. Since the cannula was completely removed, R3 was not getting any oxygen or assisted breathing support. When V24 replaced the cannula, R3 was noted to be without a pulse. V24 said this assessment took about 30 seconds. V24 said there were no nurses on the unit at the time, as both nurses were on break. V24 said it took about two minutes to leave the room, called code blue (medical emergency) to the overhead speaker and grab the emergency cart to bring into the room. V24 said when going back into the room, V24 attached the automated defibrillator pads, started compressions, and waited for help to arrive. V24 said there was one nurse who responded from the next unit over. V24 and the nurse (V30) performed cardiopulmonary resuscitation until the paramedics arrived. On [DATE] at 11:40am V10 Respiratory Therapist and Respiratory Manager said R3 was known to occasionally pull on the tracheostomy and ventilator tubing. V10 said when residents display this behavior, interventions to address this may include using a 1:1 sitter or a psych consult for agitation and adding medications to treat the agitation. V10 could not recall any of these interventions being placed for R3. R3 received care in the facility on the dialysis/ventilator unit. Interviews from nursing staff on duty at the time R3 was found unresponsive revealed that both nurses (V31 and V32) assigned to the unit had left the facility for break between 1am and 2am. According to the working schedule for night shift [DATE] 11pm to 7am, seven nurses were on duty. Only one nurse (from long-term care) responded to the emergency and provided CPR (cardiopulmonary resuscitation) with V24 prior to paramedic arrival. When the paramedics arrived, the nurse assigned to R3 (V31) was outside of the facility on break and did not return until after paramedics transferred R3 out of the facility. Ventilator flow sheets document R3 pulling and disconnecting ventilator tubing on [DATE], [DATE] and [DATE]. On [DATE] at 10:27pm V24 wrote patient disconnected couple of times, vitals stable. On [DATE] at 7:11pm R24' note included, (R3) frequently disconnected his ventilator circuit over 10 times the first hour. (R3) calmed down with (as needed) nursing meds and has desisted. On [DATE] at 1:08AM V24 wrote, (R3) had a major reduction of self-circuit disconnection. Just one incident tonight in the ,d+[DATE] interval where 15 incidents occurred in recent shifts from ,d+[DATE]. (Respiratory Therapist) noted no new distress presentation. On [DATE] at 4:01pm V2 Director of Nursing said, V2 was unaware of R3 exhibiting behaviors that included removal of tracheostomy cannula or ventilator tubing and R3 did not have any care plans for these behaviors. V2 said for R3 and other residents that exhibit this behavior, the facility is able to initiate the use of soft restraints, medications and more frequent observation which is prompted by an increased frequency of ventilator alarms. V2 said if they had known that R3 had these behaviors, interventions would have been ordered and documented on the care plan. V2 was also unaware that the unit was left without nursing supervision at the time R3 was found unresponsive. Provider and Nursing progress notes were reviewed for R3 from [DATE] to [DATE], and did not include assessments by providers or nurses that addressed Respiratory Therapy's observations of R3 disconnecting tubing and removing the tracheostomy cannula. An interview was attempted on [DATE] at 2:34pm to V37 (R3's Primary Physician). V37 refused to answer questions related to R3 due to being out of the country. A care plan for R3 was initiated for ventilator dependence on [DATE]. Interventions included ([DATE]): Prevent accidental extubating by taping tube securely, checking every 2 hours and restraining/sedating as needed. Care Plan was also initiated [DATE] for trach (tracheostomy): at risk for complications (related to) tracheostomy placement secondary to respiratory failure. Interventions included replace trach immediately if removed. Physician Order sheet reviewed during R3's admission did not include any interventions for preventing accidental decannulation or extubation. 2.) R3 was admitted to the facility [DATE] with diagnoses that included but are not limited to cerebral infarction, type II diabetes mellitus, chronic obstructive pulmonary disease, tracheostomy, and dependence on ventilator. On admission and according to the MDS (Minimum Data Assessment) R3 had severe cognitive impairment, was non-verbal and unable to follow commands. According to the physician's order sheet and care plan, R3 was considered full code which indicates all life saving measures should be performed in the event of cardiac arrest. Fire Department run sheet dated [DATE] notes the facility called the fire department at 1:13am. Fire department crew reported to the bedside for assessment of R3 at 1:18am and noted R3 lying in bed on a ventilator, and unresponsive. Crew's assessment as stated in the report said R3 was deceased on arrival as evidenced by cold to touch, no palpable pulse, rigor mortis setting in, and asystole (no heart rhythm) on cardiac monitor. The Crew obtained report from the nurse as documented: 'Nurse stated that while doing rounds R3 was noticed to have low blood sugar. The nurse gave glucagon twice, but the blood sugar kept dropping to the 30's. Per the fire department run sheet, no resuscitation measures were performed by the facility staff or fire department crew, and fire department contacted the local hospital for orders. The hospital physician on-call pronounced R3's time of death at 1:30am. Facility Policy Hypoglycemia (,d+[DATE], no revision) states in part; 1. Hypoglycemia is defined as a blood glucose of less than 70. If the resident has any symptoms of hypoglycemia including pallor, clammy skin, restless sleep, hunger fatigue, headache confusion, irritability or sweatiness notify the physician. (3.) If semi-conscious, uncooperative, unable to swallow or is NPO (nothing by mouth): a. Administer 50 milliliters of D50W (Dextrose 50% in Water) (1 amp) slow IV (intravenous) push and start IV D5W (Dextrose IV solution) at 100 milliliters/hour. B. If NO IV access: Glucagon 1 milligram Subcutaneously or IM then establish an IV access and start IV D5W at 100 milliliters/hour. C. Repeat glucose check and treatment every 15 minutes until greater than 70. D. Once greater than 70, repeat blood glucose check every one hour for 3 hours to monitor for recurrence. According to R3's electronic health record, R3 did not have intravenous access prior to the incident. Progress notes do not indicate the nurse on duty called a Registered Nurse for assistance to start intravenous access at any time during this incident. On [DATE] at 2:37pm V38 LPN (Licensed Practical Nurse) said they were about 15 minutes late reporting for the 11pm to 7am shift on [DATE]. V38 said after getting report, V38 completed visual rounds on the unit and saw R3 in bed on the ventilator, noted rise and fall of the chest and R3 did not appear to be in distress. V38 did not perform any physical assessment during this initial round. V38 said they returned to R3's bedside at approximately 12:30am to give medications which included insulin. When V38 took R3's blood sugar, it was noted to be low. According to V38's progress note, R3's blood sugar was 52. V38 said they gave R3 a dose of glucagon injection to increase the blood sugar and took vital signs. Vital signs as written in the progress note: Blood Pressure: ,d+[DATE], Pulse: 78 (beats per minute), Respirations: 18 (breaths per minute) and Temperature 97.5F. V38 said R3 did not have an active order for glucagon at the time, however it was standard protocol that in the event of low blood sugar, the glucagon medication should be given and an order from the physician would be obtained after administration. V38 said R3's primary physician was called, but V38 did not receive an answer. V38 said they could have called the telemedicine service but didn't, because it often takes a long time for a provider to answer the call. V38 said after giving the glucagon injection, no additional interventions were initiated while waiting for R3's physician to respond. V38 also said they did not ask any staff for assistance and did not call any other providers for guidance. In the progress note, V38 wrote after about 15 minutes giving the glucagon injection, R3's blood sugar increased to 65, however, R3's pulse increased to 99 beats per minute, and R3 was noted to be diaphoretic (excessive sweating) and short of breath. During the interview, V38 said R3's physician didn't respond within the 15 minutes of reassessment, so V38 called 911. V38 did not stay at the bedside of R3 and was outside of the room with the paramedics arrived. V38 said when the paramedics arrived, they attached the heart monitor to R3. V38 was unaware R3 did not have a pulse until V38 was notified by the paramedics. [DATE] at 1:51pm, V2 Director of Nursing said, according to the progress notes, when V38 reassessed R3's condition had not improved after giving glucagon, 911 should have been called right away. According to the facility policy Hypoglycemia, glucagon should be given and then IV access should be established as to administer IV fluids to increase blood sugar. V2 said R3 did not have an IV access, and that considering R3 is a hard stick (difficult to establish IV access), 911 should have been notified immediately after giving glucagon. The facility's Medical Director (V26) was interviewed [DATE] at 5:42pm. V26 said when a nurse assesses the blood sugar of a patient to be significantly low (less than 70), it is expected that the nurses do their best to stabilize the patient by giving food, or intramuscular glucagon to immediately increase the blood sugar. V26 said at that time, the nurses should call 911 right away rather than wait because a continuous decrease in blood sugar could result in the resident going into a diabetic ketoacidosis, which could be potentially life threatening. 911 should be called immediately, because in the nursing facility, dextrose intravenous solution is not usually immediately on-hand. V26 was unsure if the nurses were experienced enough to provide this acute intervention. V26 said they had not been notified of this particular situation until this interview. V26 explained that in emergency cases such as this, if the primary physician was not available, V26 should be called as an alternate for immediate guidance, although V26 would prefer the nurses to use proper judgement in calling 911 during an emergency and then notifying the physician after. 46344 B. Based on interview and record review, the facility failed to appropriately transcribe an IV antibiotic order for one (R8) of three residents reviewed for medication administration. Findings include: R8 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. It is to be noted that R8 was transferred to the hospital on [DATE], [DATE], and [DATE]. R8 has multiple diagnoses including but not limited to the following: Cerebral infarction, type II DM, respiratory failure, ESRD and dependence on renal dialysis, right AKA, left BKA, pneumonia, and TIA. Per hospital after visit summary dated [DATE], R8 returned to the facility with a chief complaint of left arm swelling. Discharge medications list states in part but not limited to the following: Cefepime in dextrose 5% 2 gram/50 ml piggyback IVPB - 50 ml by IVPB route every other day. Given Monday, Wednesday, and Friday with dialysis, dose of 2000 mg. It is to be noted that the medication of Cefepime was never transcribed as a physician order upon facility admission of [DATE]. On [DATE] at 10:45AM, V5 (Nursing Unit Manager) was interviewed regarding admitting residents from the hospital. V5 said the nurses are made aware of any IV antibiotics in report from the nurse at the hospital and on the discharge paperwork when the resident arrives to the facility. At 2:22PM, V2 (Director of Nursing) was interviewed regarding R8 and transcribing medication orders. V2 said when we admit a new resident, we contact the physician to verify and reconcile the orders. The nurse that is admitting the resident then will put in the medications into the physician orders. The night nurse then checks double checks the orders and the nursing manager the following day triple checks them again. It is to be noted that R8 was never started on the IV antibiotic of cefepime during their stay in the facility from [DATE]-[DATE]. Per hospital records [DATE]-[DATE] shows that R8 only received part of his antibiotics in the nursing facility despite all IV antibiotics being on his discharge paperwork. R8 now has some drainage from his stump. Admission/Re-admission Policy dated [DATE] states in part but not limited to the following: Physician order sheet should reflect any standing orders specific to the resident as well as medications and treatments that are ordered throughout the stay. 50519 C. Based on interview and record review, the facility failed to immediately assess and call 911 for transfer of a resident with active seizures to the hospital. This failure affected one (R4) of three residents reviewed for change in condition and resulted in R4 having active seizure activity for three hours before 911 was called for resident to receive emergency treatment. Findings include: R4 is [AGE] years old who was admitted to the facility on [DATE] with the diagnoses history of seizures, atrial fibrillation status post [NAME] ,d+[DATE], cerebral vascular accident pulmonary embolism, hypertension, respiratory failure and dependent on ventilator and required tracheostomy, tube feeding placement, pneumonia, and proctitis. On [DATE] at 09:56AM V18 (Agency Registered Nurse) said that she worked on [DATE] and started at 3:00PM and provided care to R4. V18 said that R4 started having seizures at 05:30PM; a respiratory therapist called her and notified that R4 was having jerky movement. When V18 got to the room, R4 was having head jerking movement initially and then hand movements. R4 was having seizures continuously but V18 did not recall why she did not chart when it started, duration, and vital signs during seizures. V18 said, she notified the charge nurse V23 (Assistant Director of Nursing) and gave R4's scheduled medication and called Telehealth physician with V23's assistance. After scheduled medication was given to R4, he was still having seizures and was sent to the hospital via 911. On [DATE] at 3:31PM V23 (ADON/Assistant Director of Nursing) said, on [DATE] she was doing her rounds on the long-term unit when V18 (Agency Registered Nurse) called for assistance and R4 was having seizures. When V23 got to the unit V18 was at the door of R4's preparing his scheduled medication. When V23 went to the room with V18, R4 was having head jerking movements, and V23 assisted the nurse with calling Telehealth physician. V23 used her computer to communicate with the physician. After 7:00PM the facility uses Telehealth answering service for the primary physicians. V23 observed V18 giving R4's scheduled medication and waited 30 minutes after medication given. R4 continued to have seizures on and off. V23 called 911 and sent the resident the local hospital. V23 said If V18 had notified her sooner that resident was having continuous seizures longer than 30 minutes, V23 would have called 911 right away. V23 said she instructed V18 to monitor resident's seizures, vital signs, and complete documentation on R4's condition. V23 called report to the hospital and completed the discharge paperwork for V18. V23 said she expects staff to follow instructions and complete assessments, charting and report change of condition timely. On [DATE] at 11:24PM V24 (Respiratory therapist) was interviewed. V24 said, on [DATE], during the 7:00PM to 7:00AM shift, R4 exhibited signs of seizure activity. V24 communicated this assessment to the nurse on duty. R4 was noted having shakes in the upper torso, face and head when V24 was obtaining vital signs and said the movements didn't appear to be a respiratory issue. V24 was unaware if the nurse on duty provided any interventions and noted R4 was not transferred out of the facility during the shift. V24 said, I asked the nurse a few times whether (R4) was going or staying, and the nurse said they were [waiting] to get the DON's (Director of Nursing) decision. R4's electronic health record was reviewed, and V24 completed Ventilator/Aerosol Flowsheet assessment on [DATE] at 10:10PM and included Ambu bag present bedside, resumption of convulsions unseen. Progress notes and Ventilator flowsheets available to review did not indicate when V24 initially assessed R4 to be noted with abnormal movements. No progress notes or physician notification was documented until [DATE] when V23 (ADON) and V18 (Registered Nurse) called telehealth and received orders to transfer R4 to the hospital for evaluation. Hospital records of [DATE] indicated R4 was admitted for seizures. R4's 911 emergency services records documents: chief complaint of seizures with three hours of duration. 911 was called at 8:54PM and Telehealth called at 8:42PM and nurse reported R4 having seizures since 6:30PM to telehealth physician and resident left the facility at 9:19PM. Medication administration audit report reviewed, and scheduled medication was signed out at 8:02 PM. On record review Ventilator/Aerosol Flowsheet assessment was not completed for [DATE] on the 07:00PM shift and Respiratory therapist was in the room assisting the 911 emergency services and disconnected R4 from the ventilator to be transferred to the hospital at 9:19PM. R4's hospitalization records reviewed and R4 was admitted for seizures and required Neurologist consultation and Electroencephalogram on from [DATE] to [DATE] under sedation and was also treated for pneumonia, urinary tract infection, and chronic sacrum wound osteomyelitis. On [DATE] at 11:54 AM V2 (Director Nursing) said she expects her nurses to assess resident, take vitals, chart, check laboratory test results, and call physician with change of condition such as check low blood sugar, low oxygen saturation, or low blood pressure or seizures. If a resident continues to have active seizures to call 911 and send the resident to the hospital. On [DATE] at 1:30PM V 26 (Medical Director) said he expects the facility to call 911 and send resident to the hospital when residents are having active seizures. The goal is to stabilize residents, obtain vital signs, blood glucose levels, and then transfer out to the hospital. There are medications that can only be given at the hospital. On [DATE] at 2:42PM V2 (Administrator) provided facility policy titled Change of Condition reviewed dated ,d+[DATE], Which reads: 1. Nursing will notify the resident's physician or nurse practitioner when: B-There is a significant change in the resident's physical, mental, or emotional status. E-It is deemed necessary or appropriate in the best interest of the resident.

Based on interview and record review, the facility failed to ensure a ventilator care unit had uninterrupted nursing supervision on [DATE]. Due to this failure, the unit was left in the care of unlicensed staff and (R3) experienced cardiac arrest while the two assigned nurses were on break outside of the facility. Findings include: R3 was admitted to the facility [DATE] with diagnoses that included but are not limited to cerebral infarction, type II diabetes mellitus, chronic obstructive pulmonary disease, tracheostomy, and dependence on ventilator. On admission and according to the MDS (Minimum Data Assessment) R3 had severe cognitive impairment, was non-verbal and unable to follow commands. Respiratory progress notes dated [DATE] at 2:04am said R3 was found decannulated and without pulse. On [DATE] at 11:24pm V24 Respiratory Therapist said they worked the night shift [DATE] from 7pm to 7am. On [DATE], V24 responded to an alarm at approximately 1:45am and found R3 with the tracheostomy cannula removed from R3's neck. V24 explained that the cannula is the tubing that is placed in the neck of an individual who is unable to breathe independently, and the ventilator mechanically assists with breathing. Since the cannula was completely removed, R3 was not getting any oxygen or assisted breathing support. When V24 replaced the cannula, R3 was noted to be without a pulse. V24 said this assessment took about 30 seconds. V24 said there were no nurses on the unit at the time, as both nurses were on break. V24 said it took about two minutes to leave the room, called code blue (medical emergency) to the overhead speaker and grab the emergency cart to bring into the room. V24 said when going back into the room, V24 attached the automated defibrillator pads, started compressions, and waited for help to arrive. V24 said there was one nurse who responded from the next unit over. V24 and the nurse (V30) performed cardiopulmonary resuscitation until the paramedics arrived. On [DATE] at 8:03am, V30 LPN (Licensed Practical Nurse) said on [DATE], V30 was charting at the nurse's station on the long term care unit, when an agency CNA (Certified Nursing Assistant) came to notify V30 of the active emergency regarding R3. V30 said that they had not heard a code blue called over the speaker prior to this notification. V30 said they announced the code overhead to get help to respond and called 911. V30 said the CNA only communicated the room number because they were from agency and did not know the name of the resident. V30 said after calling 911, V30 ran to the room which was right outside of the long term care unit and took over compressions with V24. V30 said there were two agency CNAs in the room and with V24, they took turns alternating the breathing bag and compressions. V30 said, they were getting tired from the exertion of compressions as they continued and no other staff from the building responded. V30 said the fire department paramedics arrived at the bedside, after letting themselves in the building. It wasn't until the paramedics took over that staff from other units reported to the room. On [DATE] at 11:56am V31 (agency nurse on duty) was asked about the emergency code blue for R3 and V31 said the RT (Respiratory Therapist) took care of it. V31 said they were outside taking a break in the car when a staff nurse came to inform V31 that R3 was coding in the building. V31 couldn't recall what time they left the building and did not know that they were required to tell any staff that they were leaving the unit or the building for break. V31 said they did not punch out or record any time leaving or re-entering the facility. V31 said they were aware the other nurse on the unit was on break at this time. During this interview, V31 repeatedly insisted they were unable to complete their break, due to being interrupted by staff because of the emergency with R3. When V31 said when they returned to the facility, the emergency had been cleared- meaning paramedics had already transported R3 to the hospital. V31 said, they couldn't recall when R3 was last assessed prior to going on break. On [DATE] at 2:10pm V32 LPN said, on [DATE], they notified the CNAs and V31 they would be leaving the building for break around 1am. V32 left their cell phone number to the CNAs and V31 because they were from agency and in case of emergencies. V32 said they did not punch out or record time leaving or re-entering the facility. V32 said once they arrived at the restaurant, an agency CNA called to notify V32 that an active emergency was taking place on the unit. V32 drove back to the facility and found that paramedics had already arrived. V24, V30 and CNAs were continuing CPR and other nurses were outside of the room. The paramedics were asking, 'who is the nurse' and no one responded. V32 then asked the staff where is the nurse? to no one in particular. According to the fire department run sheet, 911 was notified at 1:51am. Paramedics responded to the bedside of R3 at 1:57am. When paramedics arrived, they found V24 providing bag ventilation to R3's tracheostomy and another staff member doing CPR. Automated Defibrillator pads had been placed and advised no shock. R3 was assessed and was not breathing and did not have a pulse. The staff in the room did not know how long R3 had been unresponsive when asked by paramedics. R3 regained a pulse with resuscitative efforts from the paramedics, however, on transport to the hospital, R3 went into cardiac arrest again. Assessments maintain that R3 did not exhibit any eye movement or motor response. R3 was resuscitated in the emergency department and admitted to the Intensive Care Unit. On [DATE] at 4:01pm V2 Director of Nursing said, V2 was unaware that the unit was left without nursing supervision at the time R3 was found unresponsive. V2 said that when nurses go on break, they should communicate with one another to ensure the unit always has a nurse available in any event, but particularly during emergencies. Facility employee handbook (no revision) states in part; You are not permitted to leave the facility grounds during personal breaks. If you leave facility grounds at any time, you must punch out. Your supervisor will assign meal and break times. Meal and break times will be staggered among employees in order to provide adequate staffing at all times to meet resident needs. During emergencies it may not be possible to allow personal break periods.

Based on interview and record review, the facility failed to monitor one high risk for skin breakdown resident (R1) with a history of pressure sores who was admitted to the facility with skin intact for blanchable redness to sacrum. This affected one of three resident (R1) reviewed for pressure sores. This failure led to R1 developing an unstageable wound measuring 4 x 3cm within 12 days of being admitted to the facility. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of severe protein calorie malnutrition, atrial fibrillation, pressure ulcer of sacral area stage three (dated 2/2/24), adult failure to thrive, vascular dementia and Parkinson's. R1's Braden score dated 2/10/24 documents a score of 12 which indicates high risk for skin breakdown. R1's progress note dated 2/11/24 documents: Head to toe assessment was completed by wound team. Resident noted with red dark but blanchable discoloration to sacrum. Barrier cream applied/initiated. Resident noted with healed scratches to left and right rear thigh. Resident noted with healed surgical scar to left hip. Otherwise, skin intact. Resident is incontinent of bowel and bladder, has foley catheter in place, able to assist with turning and repositioning, Resident may have heel boots, chair cushion, treatment orders in place for redness and will be turned and repositioned. Although interventions will be in place, resident may continue to be at risk for further breakdowns due to unidentified factors. Wound care will continue the plan of care. R1's progress note dated 2/12/24 documents: Reason for visit: The resident is being evaluated today for a comprehensive skin assessment. SKIN: warm and dry, intact, no open wound. Blanchable redness to sacrum. The patient is at an increased risk of skin breakdown. Recommend good hygiene and skin care to prevent skin breakdown. Recommend continuing with moderate assistance with ADLs as needed. Recommend application of emollients daily. No open wounds on today's skin assessment; please keep the patient's skin clean and dry, apply barrier cream as necessary to prevent skin breakdown, and avoid pressure on any bony prominence by adhering to turning protocols and floating heels as applicable. R1's skin assessment dated [DATE] in progress documents: Moisture Associated Skin Damage (MASD) to sacrum inhouse acquired new. No measurements documented. No other documentation of this area. R1's skin assessment dated [DATE] in progress documents: Moisture Associated Skin Damage (MASD) to sacrum inhouse acquired new. Measuring 6.4 length and 2.1 width cm. R1's February medication and treatment records do not document any weekly skin assessments. R1's medical record did not document any skin assessments from 2/12/24 until 2/22/24. R1's care plan dated 2/12/24 documents R1 is at risk for skin complications related to bowel/bladder incontinence, impaired bed mobility, impaired nutrition, impaired circulation, impaired cognition, depression. Interventions dated 2/12/24 include: skin assessment weekly. R1's progress note dated 2/26/24 documents: SKIN: warm and dry, wound/skin condition noted. See wound assessment below. Wound: 1 Location: coccyx Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: New Odor Post Cleansing: None. Size: 4 cm x 3 cm x 0 cm. Calculated area is 12 sq cm. Wound Base: 0% epithelial, 0% granulation , 100% slough , 0% eschar Wound Edges: Unattached Peri wound: Fragile, Erythema Exudate: None amount of None Wound Pain at Rest: 0 Surgical Wound Debridement Location: coccyx Pre-Debridement Measurement: 4 x 3 x 0 cm . Calculated area is: 12 sq cm. Post-Debridement Measurement: 4 x 3 x 0 Percent of Wound Debrided: 100 Indications: Removal of necrotic tissue. On 8/28/24 at 10:47AM, V14 (wound care) said R1 was admitted to the facility with skin intact but had a dark red blanchable area to her sacrum. Floor nurses will do a weekly skin assessment on all residents without wounds and document in the medication or treatment record to monitor the area. On 8/28/24 at 1:06PM, V2 (DON) said facility monitors residents skin for breakdown by having assigned floor staff conduct weekly skin checks that is documented in the medication or treatment record for residents without wounds. Facility policy Skin Care Prevention revised 9/2023 documents: Resident will receive appropriate care to decrease the risk of skin breakdown.

Based on interview and record review, the facility failed to implement new and effective fall interventions after a fall for one high fall risk resident (R11) with a diagnosis of dementia and history of falls. This affected one of three residents (R11) reviewed for fall and fall prevention. This failure resulted in R11 sustaining another unwitnessed fall a week later that required a hospital stay with 6 staples to the left side of the head. Findings include: R11 was diagnosis with Dementia, Alzheimer, and repeated falls. Minimal data set section C (cognitive patterns) dated 8/9/24 documents a score of six which indicates severe cognitive impairment. Fall risk evaluation dated 8/2/24 documents a score of twenty-six. Scoring a ten or higher makes resident high risk for falls. Mentation: Impaired memory or judgement. History of fall in the past one to six months. Interim baseline care plan dated 8/2/24 documents: Impaired cognition related to a decline in cognitive functioning. Use task segmentation to support short-term memory deficits. Fall Interventions: Call light within reach, provide clutter-free environment, encourage use of assistive device and provide proper, well maintained footwear. Care plan dated 8/3/24 documents: resident is at risk for falls. Anticipate and meet the resident's care and safety needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Care plan dated 8/7/24 documents be sure residents call light is within reach and encourage to use it for assistance as needed. Nursing note dated 8/7/24 documents: Patient (R11) was found on the floor on the side of her bed. Bed was in lowest position with the rails up; call light was within reach, and table was within reach. Assessment was completed, skin check was completed. Vitals were completed when patient was on the floor, when the CNA and I transferred her to the bed and when we transferred her to her wheelchair. Skin is intact. No complaints of pain, vitals within normal limits. Neuro checks in progress. Fall report dated 8/7/24 documents: Mental status: confused/forgetful, not oriented. Predisposing Physiological factors: noncompliant with safety guidance, impaired memory, recent illness and weakness/fainted. Predisposing situation factors: Ambulating without assist. Notes: resident had a change in plane. Resident was observed sitting next to bed on buttocks. Resident stated she was okay she was just trying to get up. Encourage resident to keep call light within reach and use it for assistance. On 8/27/24 at 3:29pm, V36 (nurse) said, she was not given report that R11 was a fall risk. R11 would not remember to use the call light related to her cognition/Dementia. R11 was alert to self. R11 did not have any fall intervention in place. The bed was not low it was approximately a foot off the ground. V36 said, she went to give R11 her medication, and R11 was reaching over trying to get out of bed. R11 was repositioned and place in bed. V36 said she left the room to find the aide to help transfer R11 to wheelchair to bring to common. Aide went to get another resident to help transfer resident and that's when R11's roommate put on the call light. V36 said, when she entered R11's room. R11 was on the floor. On 8/27/24 at 1:54Pm, V2(DON) said R11 is alert to self and has periods of confusion. Intervention implemented after first fall was to be sure residents call light is within reach and encourage to use it for assistance as needed. Call light in reach was also documented in baseline care plan as well so the new intervention should have said to reeducate R11 on call light use. Nursing note dated 8/14/24 documents: At 5:50 pm-6pm, I (V36) gave the resident (R11) her scheduled medications. Call light was within reach; however, the resident did not utilize it and was attempting to exit the bed without assistance. Redirection and reorientation to surroundings was provided. At 6:45pm the resident was observed on the floor by the CNA. I was notified. The resident was conscious and alert. Gauze was applied to the site. Writer interviewed patient's roommate re: this incident. According to the roommate, she heard a loud thud that sounds like a chair that fell off. Roommate is uncertain about what time it happened, but roommate said she pressed the call light right away. Roommate did not hear anything else aside from the loud thud. Staff is able to answer the call light promptly per roommate's report and roommate only found out that the patient has fallen when she saw the nurse coming in immediately, and after a while, she heard the nurse saying, Let's put her back to bed. Fall report dated 8/14/24 documents: Injury type: Laceration, Injury Location: Back of head. Mental status: Confused/forgetful not oriented. Predisposing Physiological factors: Confused, noncompliant with safety guidance, impaired memory, recent illness and weakness/fainted. Predisposing situation factors: Ambulating without assist. Notes: R11 was alert to self only. R11 is mod assist times one with activities of daily living and transfers. It was determined that the fall was unavoidable. Root cause: unassisted transfer. Floor mats given and to be used when resident is in bed. After care visit dated 8/14/24 documents: revisit for visit: fall/ head laceration. Diagnosis head injury, Dementia Facility reportable dated 8/15/24 documents: R11 admitted on [DATE]. R11 is alert to self only. R11 sent to hospital and returned to six staples to left side of her head. Fall prevention and management policy dated 5/2015 documents: The facility will identify and evaluate those residents at risk for fall, plan for preventive strategies and facilitate as safe an environment as possible. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on interview and record review, the facility failed to properly assess a resident's change in condition after showing signs of respiratory distress, changes in oxygen saturation, and a low blood pressure. This affected one of three (R1) residents reviewed for quality of care and assessments. This failure resulted in R1 suffering a delay in being sent to the hospital, having a critically low blood pressure, and being tachycardic upon the paramedics' arrival. Findings Include: R1 is a [AGE] year old with the following diagnosis: hemiplegia affecting the right side following a cerebral infarction, type 2 diabetes, chronic respiratory failure with tracheostomy status, gastrostomy status, and dysphagia. A Nursing note dated 2/11/24 at 8:39AM documents upon arriving for the morning shift, R1 was very lethargic and weak. Vital were stable (no actual vital signs were charted at this time just that they were stable) but family was concerned R1 was not in a normal state. The physician was called and ordered to send R1 to the hospital. A Nursing note dated 2/11/24 at 9:36AM documents R1 had a change in condition per the family. R1 seems to be in distress with trying to breath and isn't talking to family. Oxygen saturations are at 93% on the trach. The physician was contacted again and ordered to send R1 to the hospital. There is no documentation a respiratory assessment or vital signs were completed at this time when a change of condition was noticed. There is also no documentation that respiratory therapists were not notified of R1's change in condition to assist. A Nursing note dated 2/11/24 at 7:27PM documents R1 was admitted to the intensive care unit for diabetic ketoacidosis. The Ambulance Run Sheet dated 2/11/24 documents the ambulance was called at 9:34AM for a resident having a breathing problem. Upon assessment, R1 was on 5L of humidified oxygen and the crew placed a non-rebreather at 15L oxygen to the trach site. Family reported R1 was not acknowledging their presence at today visit when R1 is usually alert to them. R1's blood pressure was low at 70/46 (normal is 120/80), pulse was 140 (normal is 60-100), and respirations were 26 (normal is 12-20). The oxygen level was 90% while on the 15L of oxygen. The Hospital Record dated 2/11/24 documents R1 was brought to the hospital for hypotension and hypoxia after the family noticed a change in mental status. R1 is toxic appearing and tachypneic. R1 is on 15L via nonrebreather mask at the trach site and there is an increased work of breath. Upon arrival the blood pressure was very low at 50/22 (normal is 120/80) and the temperature was 94.7 degrees Fahrenheit indicating hypothermia. R1 had a white blood cell count of 41.5 indicating infection in the body. Possible infection source was listed as urine vs, lungs vs abdomen. R1 was given 3L of IV fluid in the emergency room to increase the blood pressure. R1's blood sugar was 1196 mg/dL (normal is 60-100 mg/dL). R1 was in diabetic ketoacidosis likely caused by the septic shock. R1 was placed on an insulin drip for the elevated blood sugar, placed on Iv antibiotics for the septic shock, and continued with aggressive IV fluid resuscitation. R1 was admitted to the intensive care unit. On 5/29/24 at 1:07PM, V3 (Nurse) stated R1's family was in R1's room after V3 received report just after 7AM. V3 reported the family was thinking R1 was acting different so V3 took a set of vital signs and went back to the nurse's station to look at R1's medical record. V3 stated R1's oxygen level was at 93% on the trach collar. V3 denied calling a respiratory therapist to come assess R1. V3 reported the family then reported R1 had a difficult time breathing but V3 disagreed with the family and thought R1 was fine. V3 reported calling 911 based on what the family requested. V3 was not able to recall what R1's vital signs were when R1 was transported to the hospital. On 5/30/24 at 2:50PM, V13 (Agency CNA) stated V13 only peeked into R1's room that morning to check in R1. V13 reported the family was concerned and got the nurse. V13 stated R1 got sent out to the hospital for shortness of breath. On 5/31/24 at 11:48AM, V21 (Respiratory Therapist) stated residents get assessed twice a shift at 9PM and 3AM. V21 reported at the 9PM assessment R1 reported shortness of breath but the oxygen level was noted to be still above 90%. V21 stated if a resident is having shortness of breath, then the nurse should call the respiratory therapist into the room to assist. V21 reported rounding on R1 during the night but none of those assessments are documented to check in with R1 after R1 reported begin short of breath. On 5/31/24 at 12:43PM, V23 (Nurse) stated V23 has no recollection of R1 having any issues breathing the night before going out to the hospital. V23 reported R1 had no issues over night and was last seen around 5:30AM for the morning blood glucose check. On 5/31/24 at 12:57PM, V24 (CNA) stated during the second shift (3-11PM), V24 took R1's vital signs and R1's blood pressure was low and R1 felt cool to touch. V24 was unable to remember what the temperature or blood pressure were but remembers then being low. V24 reported R1 was also moaning. V24 noted this was different because R1 could normally talk even with a trach. V24 stated V24 told the V23 what was happening with R1 and V23 told V24 that R1 would be assessed. V24 reported V24 was pulled to a different unit so V24 could not check on R1 the remainder of the night. V23 was interviewed again at 1:11PM to confirm V23's previous interview and to ask questions regarding V24's interview. V23 did not deviated from the original statement of R1 being fine. V23 stated if something was wrong with R1 then V23 would have sent R1 out via 911. On 6/12/24 at 11:37AM, V59 (Nurse Practitioner) stated if a resident is having a change of condition, then staff should notify the physician or nurse practitioner immediately so new orders can be given. V59 reported when someone is septic, they tend to have a low blood pressure, a fever, and have tachycardic. V59 also noted there could also be some respiratory issues involved if that is the system that is infected. V59 stated if staff notice it changing condition with the resident or a family is saying that there has been a change then V59 would expect the nurse to get a set of accurate vital signs and assess the resident so V59 can know more of what is going on with the resident. V59 reported hypothermia would be a later stage of sepsis. V59 said, I can't really say exactly when it occurs, but I can say that blood pressure and fever along with tachycardia usually present first and then overtime the body will develop hypothermia in order to compensate for whatever infection. V59 reported telling the nurses to notify V59 immediately if something's going on and make sure they chart it so we can be getting a basis or a trend going and what's happening. V59 stated if an accurate set of vitals aren't obtained then staff can't accurately let anyone know what's going on. V59 reported, The patient might look OK on the outside, but if they're vital signs are showing something different than they need to be sent out immediately. V59 reported if a resident isn't sent out immediately when it changes are noticed then the sepsis is likely to get worse. V59 stated any indication of a resident being septic V59 would order at minimum a chest x-ray and urine with possible labs. V59 reported if the resident is in anyway unstable then call 911. On 6/12/24 at 1:43PM, V2 (DON) stated a resident needs to be assessed and the vitals should be done if there is a change in condition. V2 reported the next step is to call to notify the doctor and administer oxygen if needed. V2 stated if the resident is in the vent unit, then respiratory therapy is called for additional support. V2 reported if a resident is having respiratory issues, then 911 should be called immediately. The Ventilator Flowsheet dated 2/10/24 documents R1 was noted using accessory muscles with inspiratory breaths. R1 was suctioned with noted improvement. The oxygen level increased to 96% after suctioning. R1's breath sounds were diminished on both sides. There is no documentation what the oxygen level was before being suctioned. There is no documentation from the respiratory therapist that R1 was assessed again after experiencing labored breathing during the first assessment. The vital signs were reviewed for 02/2024. Vital signs (blood pressure and heart rate only) are charted for 2/11/24 at 11:10AM after R1 had left the facility. There is no documented respiratory rate or oxygen saturation level the morning of 2/11/24. The Care Plan that is not dated documents R1 has a potential for difficulty breathing related to COPD and acute respiratory failure. Interventions include: assess respiratory status to include rate, depth, pattern, and skin color; monitor vital signs and lung sounds; and observe for changes in breathing pattern. The policy titled, Emergency Management, dated 09/2017 documents, General: Emergency guidelines refer to actions given to residents with urgent and critical needs. When emergency situation arises, emergency procedures are initiated, which includes sending the resident to the closest emergency room . Policy: 1. The object of the emergency management of a resident is to administer necessary care until the paramedics arrive . 5. Monitor and treat as much as possible the following areas: f. Take vital signs and provide reassurance to the resident. Vital signs should be taken every 10-15 minutes based on resident need until the resident is stable or transferred . Guidelines for specific medical emergencies: 1. Acute respiratory distress . c. Take record, vital signs, including pulse oximetry . g. Document events in the medical record.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcer development for residents assessed at risk for alteration in skin integrity upon admission and failed to provide ongoing skin assessments for residents who are dependent on staff for care. This failure affected three (R1, R9 and R14) of four residents reviewed for pressure ulcers and resulted in R14 developing a facility-acquired stage 4 pressure ulcer to the right ear; R9's wound progressing to stage 4 on the sacrum, which required hospitalization for sepsis and an unstageable pressure ulcer to left hip; and R1 developing a stage 2 sacral pressure ulcer. Findings include: 1. R14 is a [AGE] year-old female admitted to the facility on [DATE] with past medical history of hemiplegia and hemiparesis following cerebrovascular disease affecting left non dominant side, dysphagia, difficulty walking, generalized weakness, essential primary hypertension, etc. Braden score assessment dated [DATE] scored R14 as a 9, MDS assessment dated [DATE] section G (functional) coded R14 as total dependence with two staff physical assist for bed mobility and transfers, and total dependence with one to two staff physical assist for all other ADLs. Section H of the same assessment coded R14 as always incontinent for bowel and bladder, review of physician orders shows an order for oxygen 2 liters via nasal canula, and weekly skin screen ordered 6/6/2023. ADL care plan initiated 6/19/2023 states that R14 requires assistance with daily care needs, interventions include but not limited to assist to turn and reposition every 2 hours, keep clean and dry after each incontinence episode, monitor skin integrity during routine care and report abnormal findings etc. 08/09/2023 10:41AM, R14 was observed in her room, awake but could not respond to interview questions. Floor mats were on each side of R14's bed. R14 was lying on her bed on her right side and was receiving oxygen via nasal canula. R14 had a bandage on her right ear. There was not an ear cushion between the oxygen tubing and R14's skin. V19 (Registered Nurse) stated R14 has a wound on her right ear. 08/14/2023 11:25 AM observed R14 lying in her bed on her right side. The assigned nurse was asked to remove the bandage on R14's ear. A large area of abrasion to R14's right ear was noted. R14 had oxygen via nasal canula. Oxygen tubing observed rubbing the skin, no ear cushion was in use. Wound assessment dated [DATE] documented a stage 4 pressure ulcer to the right ear measuring 2.2 x2.5 x 0.3cm, light serosanguineous exudate, less than 5 days, and an unstageable DTI to the left ear measuring 1.7 x 1.4 and unmeasurable depth. 08/14/2023 at 3:00PM, V39 (Wound Care Nurse/LPN) stated R14's pressure wound to her right ear was first reported to her 06/29/2023 and R14's wound is healing. Ear cushions were placed on R14 on 06/29/2023. R14 typically leans her head to the right side and is supposed to be repositioned from right to left to relieve some pressure off her ear. V39 stated if R14 was turned and repositioned every 2 hours it is possible the pressure wound on her ear could have been prevented. V39 stated R14 cannot move on her own and must be repositioned to a different side. Interventions in place for R14's pressure wound to her ear are ear cushions, daily treatment, and turning and repositioning. 08/21/2023 1:26 PM, V2 (Director of Nursing) stated residents who require repositioning every two hours are supposed to be repositioned from left to right or to back. V2 stated R14 has a stage 4 pressure wound on her right ear so she should be repositioned to her back to relieve pressure on her ears. V2 stated R14 should be gotten out of bed on Mon, Wed, and Fri by restorative staff. R14 is normally located in the dining room when she is gotten out of bed. 8/21/2023 at 2:53PM, V2 (DON) said R14 favors her right side but she should have foam behind her ears to prevent the oxygen tubing from rubbing on the skin. V2 stated they just in-serviced all staff and made sure everyone has the foam cushion available for R14's ear. 2. R1 is a [AGE] year-old male who was admitted to the facility 4/27/2023, with past medical history of fatigue, other symptoms and signs concerning food and fluid intake, dysphagia pharyngoesophageal phase, unsteadiness on feet, other abnormalities of gait and mobility, need for assistance with personal care, dementia, etc. R1 was not at the facility during the investigation and could not be observed or interviewed. Per record review, R1 was sent to the hospital on 5/27/2023 per family request. Facility Braden scale assessment dated [DATE] scored R1 as 15 at risk for skin breakdown. Minimum data set assessment (MDS) section G (Functional) documented R1 requires extensive assistance with two staff physical assist for bed mobility and transfers, requires extensive assistance with one or two staff physical assists for all other activities of daily living (ADLS). Wound care admission assessment dated [DATE] documented a DTI to right heel. Wound care note dated 5/10/2023, documented a healed skin condition to the sacrum, scar tissue noted to the area. Wound care note on 5/16/2023, documented healed scar tissue to sacrum opened. Interim/baseline care plan dated 4/27/2023 documented alteration in skin integrity goal: resident will show sign of healing through next review. Interventions include inspect skin daily, keep skin clean and dry, peri care after each incontinence episode, etc. Review of facility wound assessment dated [DATE] documented a stage 2 pressure ulcer to the sacrum measuring an area of 0.69cm squared, length 1.84cm and width 0.58cm, new-minutes old, acquired in-house. Wound evaluation on 5/23/2023 documented stage 2 pressure ulcer to the sacrum measuring 1.05 cm squared, length 1.61cm and width of 0.87cm. R1 was not placed on an air loss mattress until 5/16/2023, after the scar tissue in his sacrum opened. Review of physician orders for R1 show an order for weekly skin screen every day shift on Tuesdays and resident to be turned and repositioned every two hours or as tolerated every shift (order date 5/26/2023). Hospital record dated 5/27/2023 for R1 documented a pressure injury of left heel and a sacral -coccyx stage 3 pressure ulcer present upon admission. 8/14/2023 at 3:15PM, V39 (LPN/Wound care) said R1 acquired a stage 2 pressure ulcer to his sacrum but was admitted with a DTI to his left heel. Surveyor pointed out that there are several documentations of deep tissue injury (DTI) to right heel and questioned if resident had 2 facility acquired pressure ulcers. V39 said, I am sorry, he (R1) only had issue with the left heel, there was nothing on the right heel. We documented the wrong heel. V39 stated R1's pressure ulcer to the sacrum was a stage 2 before he left the facility. V39 stated, if interventions are put in place nut they are not implemented, then they are of no use. 3. R9 is an 81year-old female originally admitted to the facility on [DATE] with past medical history of adult failure to thrive, hemiplegia and hemiparesis, dysphagia oropharyngeal phase, weakness, pressure induced deep tissue damage of right heel, aftercare following joint replacement surgery, essential primary hypertension, etc. On 8/7/2023 during the complaint investigation R9 was sent to the hospital for complaints of chest pain, was admitted to the hospital and was found to have sepsis related to sacral wound vs UTI as documented in hospital record dated 8/7/2023. R9 was readmitted to the facility on [DATE]. R9 was observed in her room on 8/16/2023 around 10:30AM with V39 (wound care nurse), awake and alert. R9 stated she is doing okay but just wanted to be left alone. Braden scale dated 6/6/2023 scored R9 as a 9, indicating a very high risk for skin breakdown. MDS dated [DATE] section G (functional coded R9 as requiring extensive and 2-person physical assist for bed mobility, total dependence with persons physical assist for transfer and total to extensive assist with one to person assist for all other ADLs. Section H (bowel and bladder) of the same assessment documented R9 is frequently incontinent of bowel and bladder. R9 has an order for weekly skin screen dated 6/25/2023, ADL care plan initiated 6/27/2023 stated R9 requires assist with daily care needs. Interventions include to encourage and assist with turning and repositioning, keep lean and dry after each incontinent episode, etc. Per record review, R9 was admitted to the facility originally on 5/15/2023 with a DTI to left heel and healed pink scar tissue on the left/right buttocks and sacrum as documented in new admission head to toe assessment dated [DATE]. Wound care note dated 5/23/2023 shows, the scar tissue at the sacrum was documented to have an opening. R9 was discharged home on 6/5/2023 with a facility acquired stage 2 pressure ulcer to the sacrum. Wound care instruction and supplies given to the family. R9 was readmitted to the facility on [DATE], DTI to left heel resolved, wound to sacrum remained. On 7/5/2023, facility identified an unstageable pressure ulcer to R9's left hip as documented in wound care notes. Resident currently has an unstageable pressure ulcer to left hip and stage 4 pressure ulcer to the sacrum per wound report dated 8/1/2023. 8/14/2023 at 3:15PM, V39 (LPN/Wound care) said R9's unstageable pressure ulcer to the left hip was identified on 7/5/2023. The dressing was being changed daily with Dakin's, then it was changed to three times a week. V39 said R9 is completely dependent on staff and R9 requires mechanical lift to be turned and repositioned. 8/16/2023 at 12:45PM, V33 (Wound Doctor) said he is not sure when R9 got the air loss mattress. The facility has their own preventative measures and V33 cannot tell them how to implement them. V33 stated he is just in the facility to follow-up after the wound is identified. V33 stated if an intervention is not being implemented it will not be beneficial. Skin care prevention policy presented by V1 (Administrator) with a revision date of 1/2023 states that all residents will receive appropriate care to decrease the risk of skin breakdown. Under guidelines, item 2 states in part that all dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching erythema) and this will be reported to the nurse. The nurse is responsible for alerting health care provider. 5. All residents unable to reposition themselves will be repositioned as needed based on person-centered approach (minimum of 2 hours). Pressure injury policy revised 9/2017 states in part under guidelines to implement preventive protocol according to resident needs. Moisture: avoid prolonged periods of wetness, apply moisture barrier with each incontinent episode, etc. Activity: turn at least every two hours, provide appropriate pressure distributing devices, teach resident to weight shift if appropriate, ensure proper body alignment.

Based on interview, and record review the facility failed to lock and secure a resident's personal belongings after being sent to the hospital. This affects one (R7) of three residents reviewed for misappropriation of property. This failure resulted in R7 having his wallet and credit cards stolen. R7 expressed feelings of being violated, angry, and frustrated. Findings include: R7 was admitted on [DATE] with diagnosis listed in part to: End stage renal disease, Acute respiratory failure, Pressure ulcer of sacral region. R7 is alert and oriented x 3, able to verbalize needs to staff. Care plan indicated that R7 is at risk for abuse and neglect related to his medical diagnosis/condition. On 5/31/23 at 10:11am, observed R7 lying in bed. R7 is alert and oriented x 3, able to verbalize needs to staff. R7 said his wallet was stolen while he was in the hospital and fraudulent activities occurred in his credit cards. R7 said his former roommate took his wallet and distribute it to other residents and used it for their personal needs. R7 wanted to file a case against them, but the police and facility discouraged him. They said that these residents are old, indigent and they don't have anywhere to go. They said that R7 has poor chances of winning the case and advised R7 to go after the bank to refund his money and dispute the charges. R7 said he felt violated, angry, and frustrated. R7 said that he does not have lock drawer that he can keep his valuables. On 5/31/23 at 1:26pm, review of R7's incident report of misappropriation of property with V1 Administrator dated 5/1/23 indicated: Upon R7's returning to the facility from the hospital this afternoon, R7 stated that he is missing his wallet containing credit cards and insurance cards and a black cellphone. Facility searched R7's room and did not locate the items. Facility assisted resident with contacting credit card companies to lock cards and alert for fraudulent activities. Facility initiated investigated. Local police department called and reported incident to Officer. No police report was generated. Reported to IDPH and Ombudsman. It was discovered fraudulent charges were incurred while R7 was at the hospital. R7 is not sure if there is a connection between his wallet and phone missing because he believed the phone may have been misplaced while he was being provided incontinent care. Follow up investigation: Alleged Perpetrator: 1. R11 - R11 stated that R11 got the wallet (R7's) because he thought the resident (R7) was not returning from the hospital. R11 then gave the cards to 3 other residents (R8, R9 and R10) to purchase items for him. R11 stated that other residents used the cards for their own items, and he did not tell them to do that. When he heard that R7 returned from the hospital, he asked the other residents for the cards back and informed SW of the wallet's location. R11 apologized and stated the situation got out of hand. 2. R8 - R8 stated R8 was asked by R11 to go to the store on 4/30/23 using the cards that R8 thought was given to R11 by R11's family. R8 ran the errands and purchased the items for R11 and gave R11 back the cards. R8 stated that on 5/1/23 people in the facility were talking about missing cards and R8 realized he used credit cards that did not belong to R11' R8 asked R11 why R11 would give R8 cards that weren't his (R11) or his (R11) family's. R8 apologized and stated he wouldn't have used the cards if R11 told him it didn't belong to R11's family. 3. R9 - R9 stated R9 was given credits cards by R11, and R11 asked R9 to run errands for R11. R9 stated R11 gave R9 the cards again to order items from Amazon for R10. R9 stated R11 asked R9 to use the cards again to order pizza. R9 stated R9 had no idea where the cards came from until 5/2/23 when R9 heard the facility is looking for missing credit cards. R9 was apologetic and wanted to make a personal apology to R7 for using his cards. 4. R10 - R10 stated that R9 came to the room and got the cards. R10 stated R10 ordered a shirt for R10 but cancelled the order. R10 stated R9 tried to give R10 the cards but R10 refused since R10 did not know how to use the cards. Staff on the units were interviewed and stated they did not hear or witness anyone who may have taken the items from the resident's room while R7 was in the hospital. On 6/7/23 at 9:58am, review of R7's Police Report with V1 Administrator indicated: Police report dated 5/1/23. Nature: Citizen assist. Theft. Called by V1 Administrator. Wallet and cell phone missing. Spoke with subject (R7) who explained that his wallet and black cellphone were stolen between 4/21/23 to 5/1/23. His wallet contained 3 credit cards, Illinois driver's license and a link card. There was no cash inside the wallet, His credit one credit card had 4 fraudulent charges in the sum of approximately $1000.00. He (R7) contacted all 3 credit cards companies and cancelled all his accounts. No complaint wants to be signed. He (R7) just wants his incident documented for now. V1 has launched an internal investigation regarding this matter. Nothing further. A couple days after this incident the facility contacted me and advised me that they located the subjects missing items with another resident. The items have been returned to the subject. 5/10/23, The subject (R7) contacted me and left me a voice message explaining he wanted to sign complaints against the resident that had his items. 5/11/23, I called the subject back and advised him (R7) that since his items have returned and the credit card companies will eventually reimburse him for the fraudulent charges, charges should not be filed at the time. Advised subject to call me back if a problem occurs with the credit card companies. On 6/2/23 at 12:08pm, V3 DON said the nursing staff pack the belongings of resident when he/she is admitted to the hospital and will keep it in storage for safe keeping. On 6/8/23 at 10:15am V1 said that R7's personal belongings were not packed when R7 went to the hospital. They were kept in R7's room until R7 returned from the hospital. V1 said, nursing staff should have packed R7's belongings when R7 was discharged from the facility. The facility has storage to keep the belonging of the discharged residents. On 6/8/23 at 10:30am, V1 Administrator and this surveyor went to R7's room, observed bedside drawer with key inserted in the drawer. V1 opened the drawer and observed electric razor inside. Cell phone was located on top of the bedside table. R7's wallet and laptop were inside the unlocked drawer on the other side of R7's bed. Facility's policy on Abuse Prevention Program indicates: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this 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 and mistreatment of residents. This will be done by: *Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. *Identifying occurrences and patterns of potential mistreatment *Immediately protecting residents involved in involved in identified reports of possible abuse, neglect, exploitation, mistreatment and misappropriation of property. Definition: Misappropriation of resident property: means deliberately misplacement, exploitation or wrongful temporary or permanent use of resident belonging's or money without the resident's consent. Facility's policy on Personal Belongings-inventory indicates: Procedure: 6. Upon discharge to the hospital, the resident's belongings are packed and sent to the storage.

Based on interview and record review the facility failed to provide safety by not utilizing two-person assistance while providing resident care during bed bath. This affected 1 of 3 residents (R20) reviewed for safety. This failure resulted in R20 falling from the bed while under staff direct care sustaining a subarachnoid hemorrhage, and right-sided frontal scalp hematoma. Finding include: R20 is an [AGE] year-old female admitted on [DATE]. Care plan review dated 3/13/2023 documents R20 as high risk for falls related to impaired cognition due to diagnosis of encephalopathy. Minimum Data Set (MDS) section G with ARD/Target Date of 5/25/2023 documents: A. Bed mobility - Two plus persons physical assist. B. Transfer - Two plus persons physical assist. On 6/8/2023 at 09:30 am, R20 was observed lying on her bed with bruises on her face and forehead. R20 said that she fell . R20 recalled standing at the edge of the bed for a second when she fell and hit her face on the dresser. R20 said there was one staff assisting her to stand up. R20 said usually its only one person assisting her. On 6/8/2023 at 09:40 am, R21 (R20's roommate) said she witnessed R20 fall. R21 said a CNA (V33) was giving R20 a bed bath. The CNA (V33) turned R20 to her right side when R20 started to fall and the CNA (V33) pulled the sheet underneath to try to prevent R20 from falling but R20 fell and hit her face on the air conditioner. On 6/7/2023 at 11:04 AM, V32 (Registered Nurse - RN) said she was charting on the computer when V33 (CNA) started yelling out for help from R20's room. V32 said when she got to R20's room, she saw R20 on the floor. R20 said she hit her head on the floor and was in pain. V32 called 911. V32 said she knows R20 is a two-person assist for transfer but is not sure if R20 requires 2 persons assist for turning. V32 said she didn't check if R20 is a 2 person assist for turning because she assumed that V33 knows her since she works with R20 often. On 6/7/2023 at 2:00 PM, V33 said after giving R21 (R20's roommate) a bed bath, V33 checked R20's incontinent brief which was soiled and her skin was flaky so V33 decided to give R20 a bed bath. V33 said she gathered supplies for R20's bed bath and noticed there were no other CNA's on the unit. V33 said she told R20 she will proceed to give R20 a bed bath without any other CNA's assistance, and R20 said OK. V33 said as she turned R20 to her side, R20 started leaning to reach out to the window. V33 said she started pulling R20 back but R20 fell with face forward. V33 said she yelled out for help for a while before the nurse came in and the other 3 CNA's working on the unit returned. V33 said she has been working with R20 since the last 2 months. V33 said that R20 needs 2 persons assist with mobility/transfer, but V33 proceeded to give R20 a bed bath without the 2nd assist. V33 said she thought R20's bed was locked, but it was not. On 6/8/2023 at 2:00 PM, V3 (Director of Nurses - DON) said R20 was receiving a bed bath from CNA (V33) when R20 started to fall from the bed. V33 CNA tried to try to pull R20 back with the sheet but couldn't and R20 continued to fall. R20 fell to the floor and stated she hit her head on the floor. R20 was sent to the hospital for evaluation and diagnosed with subdural hemorrhage. V3 said R20 is 2 persons assist and should have two people providing the bed bath. Facility Fall Prevention Management Review Date 9/2022 General: 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's falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on observations, interviews, and record reviews the facility failed to inform a physician of the onset of a resident's change of condition (R227), failed to monitor a resident's vitals as ordered (R227), failed to monitor blood sugars levels for residents with diabetes (R220 and R227). This failure affected 2 of 52 sampled residents. As a result, R227 was unable to be aroused by staff for over 5 hours (6:38AM-12:26PM) and experienced decreased oxygen levels before nursing/medical interventions were given. Findings include. 1. According to a face sheet, R227 is an [AGE] year-old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R227's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Does not offer new symptoms today, Vital signs remained stable, Oxygen saturation is good. Examined to be awake and confused. R227's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R227's current care plan included the following: Transfer to hospital and/or intensive care unit if indicated; R227 is at risk for signs/symptoms including [CONDITION(S)], [CONDITION(S)], or Uncontrolled diabetic status related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer medication as ordered. Monitor vital signs during routine care and notify physician of abnormal findings; R227 has potential risk for altered cardiac function related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Give meds for hypertension and document response to medication. Monitor blood pressure. Notify physician of any abnormal readings; R227 is at risk for complications including fluid volume overload related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor for signs and symptoms of fluid overload or fluid loss. Monitor vital signs as ordered. Monitor/document/report to physician the following signs and symptoms: difficulty breathing (Dyspnea); increased heart rate ([CONDITION(S)]); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness. On 11/01/22 from 11:21 AM - 11:45 AM the surveyor observed V22 (Agency Certified Nursing Assistant - CNA) enter R227's room to provide care. R227 was noted to be non-responsive to several attempts from V22 to stimulate him by calling his name, touching his arms, legs, and repositioning him for incontinence care. R227 did not open his eyes during these activities and move his arms very little when firmly touched. V22 stated R227 did not rouse when she took his vitals earlier in the morning. V22 repositioned R227 and provide incontinence without rousing him. V22 stated she doesn't even think R227 ate breakfast because he could not be roused. V22 stated she's not sure how R227 even received medication in his current condition. V22 stated R227 had been unresponsive since she started working at 6:38AM and didn't even rouse when she took his blood pressure earlier in the morning. On 11/01/22 at 12:26 PM V25 (Registered Nurse) entered R227 room. V25 reported she gave R227 medication this morning and he opened his eyes for her. V25 stated she called his name multiple times, but he won't rouse. At the time of the observation, V25 reported R227's oxygen levels were at 64 and fluctuating and he needed oxygen. V25 left R227's and return to the room with an oxygen tank. V26 (Nurse Manager) came into R227's room to measure his oxygen levels with the fingertip oxygen measuring device. On 11/01/22 at 12:34 PM while in R227's room, V25 (Registered Nurse) and V26 (Nurse Manager) administer oxygen to R227. V25 stated R227's oxygen levels are going back up. V25 stated R227 was lethargic this morning. V25 stated she was trying to get ahold of the physician. V25 stated V26 called the doctor for instructions, we'll wait five minutes for her to call back and if she doesn't respond in that time frame, we'll call 911. V25 stated she was informed by V22 (Certified Nursing Assistant - CNA) this morning R227 was not able to be roused. Observed R227 to remain unresponsive to stimuli while receiving oxygen. On 11/01/22 at 12:52 PM the surveyor observed R227 to remain unresponsive to stimuli while being taken by paramedics to the hospital. V25 (Registered Nurse) reported R227's oxygen saturation was fluctuating between 50-64% when she initially assessed him at 12:26PM. On 11/01/22 at 01:02 PM V22 (Agency Certified Nursing Assistant) stated at 10:51 this morning (15-20 minutes before encountering the surveyor) she informed V25 (Registered Nurse) that R227 could not be roused when she took his blood pressure earlier in the morning. On 11/01/22 at 01:13 PM V25 (Registered Nurse) stated R227's initial oxygen levels were at 94 and his respirations at 17 when she assessed him in the morning while giving him medication between 8:30 AM - 9:00 AM. V25 stated she was alarmed by that oxygen level because she prefers it to be at least 95 and over so she wrote down all R227's other oxygen levels. V25 stated V22 informed her twice that R227 was lethargic and didn't want to get up. V25 stated because of what was reported to her by V22, she checked in on R227 multiple times, entered his room at least twice and rubbed the center of his chest firmly to rouse him and he would open his eyes. V25 stated when giving R227 medications in the morning he opened his eyes and turned his head although he didn't say much. V25 stated when V22 informed her the 2nd time about not being able to rouse R227, she then went in his room to check on him. V25 stated she did not inform the physician about the difficulty arousing R227 and wishes she would have. V25 stated she didn't notify the physician because R227's blood pressure and heart rate were normal. V25 stated she assumed R227 was not responding to her attempts to rouse him by calling his name because he was hard of hearing. V25 stated it's not normal to have to firmly rub an individual's chest to rouse them regardless of whether they are hard of hearing or not. R227's vital measurement reports from 10/28/2022 - 11/01/2022 document the following: -no oxygen saturation, respirations, or temperature measurements for 10/29/22 and 10/31/22, one oxygen saturation, respiration, temperature measurement 10/28/22 and 10/30/22, no pulse measurement 10/29/2022, one pulse, and one blood pressure measurement 10/28/22, 10/30/22, and 10/31/22. -from 10/28/22 - 10/30/22 low - normal blood pressure levels, and on 10/31/22 elevated blood pressure level of 132/67. -on 11/01/22 at 07:45AM a 94% oxygen saturation level with room air, pulse rate of 98 beats per minute (noted as not applicable), blood pressure rate of 139/77; at 12:27PM a 64% oxygen saturation level with room air, pulse rate of 88 beats per minute (noted as unable to determine), and blood pressure level of 164/79. R227's progress note dated 11/1/2022 12:25PM (created at 5:08PM) documents: Writer observed resident unresponsive, color ashen, lips bluish tinged, oxygen saturation 64% room air. Manager notified. Oxygen via nonrebreather applied at 6L, oxygen saturation increased to 99% within 2-3 mins. Physician notified per manager. Received order to send resident out via emergency medical services. R227's progress note dated 11/1/2022 12:32 (created at 6:06PM) documents: order received by physician to transfer him to hospital emergency room via 911 emergency medical transportation. R227's progress note dated 11/1/2022 12:45 (created at 5:11PM) documents: Paramedics here, resident sent to hospital emergency room with appropriate paperwork. R227's progress note dated 11/2/2022 12:56AM documents: patient admitted to the hospital with diagnose of Urinary Tract Infection (note not provided by facility). On 11/03/22 at 03:51 PM V35 (Medical Director) stated when a resident who is alert and oriented has a change in condition the nurse should notify either the Director of Nursing, Assistant Director of Nursing, or their physician. V35 stated if a resident was alert and interactive and becomes unresponsive to a sternal rub then there is a change of condition and their vital measurements such as pulse, oxygen saturation, and blood sugar should be assessed. V35 stated in a change of condition such as this there are many ways to determine the possible causes of their change in condition. On 11/04/2022 from 2:46PM - 3:25PM V2 (Director of Nursing) stated R227's vitals should be taken every shift and include blood pressure, respirations, pulse, temperature, and oxygen saturation. V2 stated R227's blood pressure on 10/30/22 was elevated compared to previous days. V2 stated R22's 7:45 AM and 12:27PM blood pressure levels on 11/01/22 was elevated compared to his previous ones. V2 stated R227's blood oxygen saturation 11/01/22 at 12:27PM was abnormal at 64%. V2 stated there is an issue with not following orders to monitor changes in R227's vital signs by not ensuring his vitals were measured each shift daily. V2 stated since R227 was still not responding to stimuli when his oxygen levels increased while receiving oxygen, there should have been an emergency transfer. V2 stated responsiveness would include eyes opening and responding appropriately to stimuli such as responding to his name being called or to touch. V2 stated emergency transfers would include calling 911 while performing interventions which is part of the facility's emergency management policy. V2 stated as soon as V22 (Agency Certified Nursing Assistant) notified V25 (Registered Nurse) of R227's change in condition of non-responsiveness he should have been immediately assessed by the nurse which would have included taking all his vital signs and checking his responsiveness to his name being called and being touched. V2 stated it is not normal to have to firmly rub a resident's chest to rouse them. 2. R220 is an [AGE] year-old male with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R220's current care plan does not include diabetic care. On 10/31/22 at 11:25 AM V27 (Family Member) reported R220 is supposed to receive morning insulin. V27 stated R220s's blood sugar levels during breakfast were measured by a student nurse to be at 272. V27 stated at around 8:30AM R220 ate a muffin, oatmeal and drank apple juice for breakfast and hasn't received insulin. R220's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R220's October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R220's blood sugar measurements from 10/28/22 - 10/31/2022 documents multiple measurements of 200's to 300; no blood sugar measurements in the late afternoon/evening or at bedtime 10/28/2022; blood sugar levels of 358 on 10/28/2022 at 11:31AM, 271 on 10/30/2022 at 5:19PM, 172 on 10/31/2022 at 9:40AM, 322 on 10/31/2022 at 11:14AM. On 11/03/22 at 11:34 AM V2 (Director of Nursing) reported that there were two missed blood sugar reading documentations for R220 on 10/28/2022. Next, according to the face sheet R227 is an [AGE] year-old male with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R227's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders were included for blood sugar measurements. R227's progress note dated 10/29/2022 5:30PM documents: Physician in facility today with new orders for blood sugar measurements 4 times per day. Orders carried out. R227's blood sugar measurements from 10/28/22 - 10/31/22 documents one blood sugar measurement from 10/29/22 - 10/31/22, blood sugar levels of 272 on 10/28/2022 at 8:39AM, 222 on 10/28/2022 at 11:35PM, 286 on 10/30/2022 at 5:45AM, 239 on 10/31/2022 at 6:25PM. On 11/04/2022 from 2:46PM - 3:25PM V2 (Director of Nursing) was interviewed. The information included but not limited to the following: V2 reported, she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated they R220 and R227 should have orders for blood sugar measurements, however they should have blood sugar checked each time they receive their insulin. V2 stated if blood sugars are not measured as ordered for residents there is no way to appropriately assess changes in levels so the physician can be notified to address the changes. V2 stated, R220 not receiving insulin as ordered could result in altered blood sugar levels which could contribute to high blood sugar levels.

Based on observation, interview and record review, the facility failed to implement interventions to prevent and treat pressure ulcer/pressure injury (PU/PI) development for residents who were at increased risk for PU/PI development, failed to provide ongoing skin assessments for the residents, failed to provide proper treatment to prevent worsening of pressure ulcers or infection and provide appropriate pain management. These failures affected four of four residents (R39, R228, R269 and R377) identified with issues concerning pressure ulcer or injury. As a result, R269 and R377 were admitted without pressure ulcers and developed infected pressure ulcers while at the facility. In addition, R377 death was linked to sacral [CONDITION(S)]. Findings include: 1. R269 is a [AGE] year-old male who was admitted to the facility on [DATE] with past medical history including, but not limited to unspecified protein-calorie malnutrition, metabolic [CONDITION(S)], nonchronic ulcer of unspecified part of unspecified lower leg with unspecified severity, urinary tract infection. [DATE] at 12:45PM, resident's son came to the dining room during lunch and stated that he would like to speak to someone regarding his father, R269. V4 (Family member) stated that he thinks his father is being neglected, he does not like the condition he found him in. Surveyor went to the room with V4 and V6 (nurses). Upon entering R269's room, the surveyor noted a strong smell of urine and feces. R269 had indwelling catheter draining via gravity and some dark yellowish colored urine. R269 was lying on a regular mattress and did not have any heel boot applied, contracture noted to R269's left hand that was placed on a pillow. V6 (nurse) said that the urine is more yellow in color than the last time she saw the resident, she will call the doctor and let him know. V5 (C.N.A/certified nurse aide) was called to the room and she said that she is the assigned C.N.A for the resident but she has not had the time to check him today. V6 was asked to pull the blanket on the resident and resident was noted with a big bowel movement stuck to his butt and on the bed cover. R269 not have any adult brief. R269 also noted to have wound dressing on the buttocks that was saturated with drainage and brown in color. [DATE] at 9:15AM, the surveyor observed dressing change for R269 with V7 (wound care nurse). V7 said that R269 has two pressure ulcers and both are facility acquired. She described them as an unstageable pressure ulcer to the left buttocks and a Deep Tissue Injury (DTI) to the right hip. V7 said that she became aware of the pressure ulcers on [DATE]. V7 removed the dressing on the left buttock and there was a large area of excoriation with greenish brown drainage that has a foul smell. V7 said that the wound care doctor has not seen the resident. V7 added that she will ask the nurse to call and get some antibiotics for the resident because the wound looks like it is infected. On the resident's right hip is a large area of breakdown that is brownish ping in color. V7 said that she will change the current treatment and use collagen with foam dressing, the current treatment is peeling off his skin. Surveyor asked V7 if they can just change the order without calling the doctor and she said that she is just using her judgement and she will call the doctor and inform him, when he makes rounds, he can change the treatment again if needed. V7 added that she ordered an air loss mattress and foam boots for resident. Resident was placed on oral antibiotics for wound infection as indicated in physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Braden scored assessment dated [DATE] coded R269 as a 13, moderate risk for pressure sores. Nursing admission assessment dated [DATE] documented pain to the right lower leg and toe, and pain to the left lower leg and toe. Skin condition was documented as normal, with old scabs and dryness to the lower extremities. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Activities of Daily Living (ADL) care plan dated [DATE] reads: Resident requires assist with daily care needs r/t dx/hx of AMS, [CONDITION(S)], CKD, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] with lower [CONDITION(S)]. Resident is a total assist of two staff members for bed mobility, toileting and transfers Interventions include: Assist resident with ADLs, encourage/ assist with turning and repositioning every two hours and as needed, Hoyer lift with two assists for transfers. Review of records did not show any care plan or interventions in place for alteration in skin integrity for the resident. R269 Minimum Data Set (MDS) dated [DATE] coded R269 as ,d+[DATE] indicating total dependence with 2 persons physical assist for bed mobility and transfer, ,d+[DATE] (Extensive assist with one- person physical assist for dressing, toilet use and personal hygiene and 2-person physical assist for bathing. Section H of the same assessment coded resident as always incontinent of bowel. [DATE] at 3:34PM, V35 (Medical Director) said that that he is not aware of the increased number of facilities acquired pressure ulcers. V35 stated the staff should be doing skin assessment on residents as ordered by the physician and the attending physicians should be rounding on the residents. V35 was asked how often the attending physicians are expected to see residents and he said that it varies and depends on cases. He added that the resident's nutritional status should also be monitored as that can also affect wound healing. V35 said that preventive measure like turning and repositioning, daily skin assessment during showers/baths and air loss mattress could help to avoid development of pressure ulcer. V35 stated he will discuss with the DON to see how to deal with the issue. Facility skin care prevention policy with a review date of ,d+[DATE] presented by V2 (DON) stated in part that all residents will receive appropriate care to decrease the risk of skin breakdown. Under guideline the same document states that the nursing department will review all new admissions/readmissions to put a plan in place for prevention based on resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. For residents who are bed or chair bound, provide a chair cushion and pressure reducing mattress. Another document presented by V2 (DON) titled skin management, monitoring of wounds and documentation dated ,d+[DATE] states: it is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. 2. R377 was a [AGE] year old female admitted to the facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (dated [DATE]), R377 had mild cognitive impairment with a BIMS score of 10. R377 had a functional assessment requiring extensive 2 person physical assistance with transferring and toileting; required extensive 1 person assist with bed mobility and was incontinent of bowel and bladder function. Timeline according to progress notes and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE]: R377 developed Moisture Associated Skin [CONDITION(S)] (MASD) to sacral area. Order placed for [MEDICATION(S)] barrier cream to the sacrum three times daily and as needed. This order was later discontinued [DATE] [DATE]: V36 Wound care coordinator noted shearing MASD to Sacrum. New order placed to clean sacrum with normal saline, pat dry and apply [MEDICATION(S)] barrier cream and applu foam dressing three times weekly and as needed. [DATE]: NP ordered [MEDICATION(S)] suspension for 7 days due to elevated White Blood Count of 12.04 and multiple blisters presenting over axilla and breast. [DATE]: Nurse charted no new skin concerns during bathing [DATE] Assessed by V36 Wound Care coordinator with MASD with intact blister to sacrum. No new orders placed with continued use of Zinc barrier cream. [DATE]: Nurse noted blister to sacrum ruptured and notified wound care team. [DATE]: V36 wound care coordinator assessed sacrum with ruptured blister, slough tissue, and granulation tissue with odor. Placed orders for air loss mattress and wound care consult. Treatment orders placed to cleanse with normal saline, apply honey and cover with foam dressing three times weekly and as needed. [DATE]: Seen by Wound care MD; assessed sacrum wound as unstageable. Debridement and culture taken at the bedside. [MEDICATION(S)] antibiotic ordered by Infectious Disease Nurse Practitioner for multiple blisters. Does not address sacral wound within progress notes. Nursing staff note that resident accepts antibiotic and supplement despite refusing other meds per baseline behavior. V36 Wound care coordinator revised order to cleanse with Dakin's Solution, rinse with normal saline and apply honey with foam dressing three times weekly and as needed. [DATE]: No treatments administered to the sacrum according to Treatment Administration Record. No further wound care notes or observations identified in resident chart [DATE]: Seen by V38 Nurse Practitioner who ordered CBC and CMP to be collected in the AM. V37 Wound coordinator ordered Dakin's solution soak to sacral wound with dry dressing daily. 11:41AM Nurse received orders to send Resident to the hospital for sacral wound infection debridement. 1:15PM Resident transferred via ambulance to hospital. Did not return to the facility. Expired on [DATE] at hospital with primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12 30PM V2 Director of Nursing said, R377 was at risk of developing pressure wounds but did not have a history of any pressure related wounds prior to this one. There are no skin assessments available that depict the worsening of the sacral wound. There are no measurements documented after the wound was identified and I would have expected the nursing staff to communicate with the nurse practitioner or the primary doctor any progression of the wound. There was a time where the facility did not have a Wound Care Coordinator, Nurse or provider due to staffing issues. On [DATE] at 1:45PM V36 said, I was alerted by the nursing staff that the rash on R377's sacrum was progressing after the blister ruptured. I was not following her prior to this because she didn't have any wounds. I usually expect for MASD to be resolved with barrier ointment, but for residents who are incontinent, it may take longer to heal because they are always sitting or lying in bed. I placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The next day, the wound care doctor identified the wound as unstageable because it contained some necrotic tissue with some slough and drainage. We debrided the wound to obtain a culture, and I placed orders for low air loss mattress and updated the treatment order. R377 did not have an air mattress in place at the time. We suspected that the wound may be infected based on how it presented. I abruptly ended my employment shortly after that and was not able to complete an investigation as to how the wound progressed. On [DATE] at 12:56PM V37 Wound Care nurse said, I began working at the facility [DATE] and there was no wound care team in place. I came in and found that dressings and assessments were not being done and some residents didn't have wound orders or they weren't updated. The first time I was able to assess R377, she was in a lot of pain associated with the wound while I was providing care. I placed orders but decided that she needed to go to the hospital because the wound was beyond the level of care that we could provide in the facility. I asked the primary nurse at the time to contact Infectious Disease Nurse Practitioner and I told them that this wound was beyond our care. I felt that R377 needed quick antibiotics intravenously and a debridement because it was so bad. The wound care doctor wasn't expected to come for another week, and I didn't think we could wait that long. The wound was red, draining and necrotic. On [DATE] at 1:56PM V38 Nurse Practitioner (NP) said, I am the house NP and am in the facility 3 days a week. The nurses did not inform me of the sacral wound, and I did not review the progress notes from nursing or wound care that were in the chart. I did not discuss the sacral wound with the Infectious Disease Nurse either. R377's primary physician was not available to interview during this survey. V35 Medical Director interviewed on [DATE] at 3:35PM. V35 said, [CONDITION(S)] is an infection of the bone that can spread to the bloodstream. This can be caused by a wound or a pressure sore and requires extensive IV antibiotics usually at a minimum of 6 weeks. If a wound is infected and has some necrotic tissue it requires debridement to discover what is underneath. [CONDITION(S)] is hard to miss without an x-ray to determine the diagnosis. For a resident with a sacral wound, [CONDITION(S)] can be caused when bacteria is introduced such as episodes of incontinence. Facility policy titled Skin Care Prevention states in part; Dependent residents will be assessed during care for any changes in skin condition including redness, and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. For residents who are bed or chair bound, provide a chair cushion and pressure reducing mattress. Facility policy titled Monitoring of wounds and documentation states in part; General Monitoring Guidelines: With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the Pressure Ulcer/Pressure Injury) should be documented. At minimum, documentation shoild include the date observed and : Location and staging; size; exudate; pain; wound bed; and description of wound edges and surrounding tissue. If a wound shows no signs of healing after three weeks, a reevaluation of the treatment plan including determining whether to continue or modify the current interventions is done. If the decision is made to retain the current regimen, documentation of the rationale of continuing the current plan will occur. R377's progress notes reviewed, and it was noted that no admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Death Certificate dated [DATE] lists primary cause of death as Sacral [CONDITION(S)]. 3. R39 is a [AGE] year-old male with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:31 Observed R39 in his bed sleeping in a gown with his lunch meal at bedside. On [DATE] at 11:21 AM V22 (Agency Certified Nursing Assistant - CNA) reported R39 stated his but hurt when she informed him she was going to get him up out of bed. V22 stated she was going to give R39 a shower, but staff advised her not to because of his wound. V22 stated she was told by the nurses and CNA's not to get the residents dressed and out of bed. V22 stated a staff reported to her she had never seen R39 in clothes and never seen him up. V22 stated R39's bottom was raw and red. V22 stated multiple residents beds are worn out and sunken in and that's why they have wounds. Observed R39's mattress was tattered and sunken in the middle. Observed R39's mattress was not a pressure relieving mattress. V22 stated when she began providing care to R39 she observed him to be in a gown with a large amount of dried feces which means he was likely in that condition for a long time. Observed R39's removed gown with a large amount of dried feces on it. On [DATE] at 11:58 AM Observed R39 sitting in his wheel chair in his room. R39 stated he has wounds on his butt and legs and they hurt. No offloading booties observed on feet. On [DATE] at 1:36 PM R39 lying in his bed. R39 wearing socks on both feet with no off-loading items on him or in his bed. During this time, V23 remove (Wound Nurse) R39's socks to reveal a dime sized wound on his left heel. V23 (Wound Nurse) was presented at the time. V23 reported R39 has a foam dressing for his left heel wound. V23 also reported, R39's left heel wound is from pressure, and he should have heel protectors. R39's heel wound is open, draining and reaches past the first skin layer. V23 stated R39's heel is treated three times per week. Surveyor observed V23 applied barrier cream to R39's buttock wound without cleaning the area. V7 (Wound Nurse/Licensed Practical Nurse) stated R39's left heel wound is a vascular wound. V7 reported the following: R39's wound was noted in his medical records as a diabetic wound and possibly he has diabetes. V7 stated a pressure wound would be open. She would label R39's heel wound as unstageable due to not being able to fully observe the depth of the wound and having slough on the surface. V7 stated R39's heel wound should be treated with med honey and she will update his treatments and have the physician update the stage of his wound. V7 stated the wound physician was aware of his heel wound and he is on a list to be seen tomorrow. R39 has had a stage 3 wound to his left and right buttocks which he has had for a couple of weeks. V7 believes those wounds have resolved and the treatments for that area should be changed to a barrier cream. V7 stated R39 does not have a pressure relieving mattress. She believes R39 has developed a fungal rash around his buttock area due to moisture and it requires barrier cream. Observed R39's buttock area to with red, scaly, irritated skin. V7 stated R39's buttock wound was not as red when she last observed it during treatment. V7 stated R39's sunken mattress wound hinder his wound from healing because the cushion is compromised and no longer providing protection for his skin. V7 stated R39 needs a new mattress or a pressure relieving mattress. V7 stated she began working for the facility [DATE], went on vacation [DATE] and returned from vacation on [DATE] during which time she began working as the wound coordinator. V7 stated she oriented with the previous wound coordinator for a few days before going on vacation then when she returned began providing wound care on her own. R39's current care plan documents he has MASD (Moisture Associated Skin Damage) to sacral area; diabetic left heel wound. R39 has potential for further skin impairment related to Disease processes of Immobility and history of pressure injuries with interventions including: Anticipate and meet the resident's, care and safety needs. Be sure the resident's, call light is within reach and encourage to use it for assistance as needed. R39 has, an ADL (Activities of Daily Living) Self Care Performance Deficit related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's wound care progress notes dated [DATE] documents: R39 is noted as [AGE] year old male admitted with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's initial wound evaluation report dated [DATE] documents he was examined with newly developed one day old stage 3 pressure wounds of the left and right buttocks with interventions including: house barrier cream every shift for 30 days, off load wound, Low air loss mattress, Turn side to side and front to back in bed every ,d+[DATE] hours if able; newly developed one day old diabetic left heel wound with interventions including: medicated honey apply three times per week for 30 days, Gauze dressing applied three times per week for 30 days, Float heels in bed; Off-load wound; Sponge boot. R39's wound care progress note dated [DATE] 3:24PM documents resident was assessed by wound team. Wounds to left and right buttock noted resolved no open area noted, but buttocks noted with bright red redness with white patches (Fungal) orders updated. Resident may have an air loss mattress, Heel boots worn while in bed. 4. R228 is a [AGE] year-old male with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:50 PM Observed R228 in a gown in his bed receiving feeding assistance by V28 (Certified Nursing Assistant). On [DATE] at 11:21 AM V22 (Agency Certified Nursing Assistant - CNA) reported that she observed R229's adult brief to be heavily soiled while providing incontinence care to him earlier and she couldn't place a new brief on him because of the condition of his wound. V22 stated R228's wound was in such poor condition that the wound nurse expressed frustration with the condition of his wound. On [DATE] from 1:11 PM - 1:30 PM V7 (Wound Nurse/Licensed Practical Nurse) stated R228 receives wound care on Tuesdays, Thursdays, and Saturdays. R228 has an unstageable sacral (between his lower back and tailbone area) wound. V7 stated R228's sacral wound has 50% dead tissue slough which is a result of pressure. The frequency of the med honey treatment helps to eat away the dead tissue. V7 stated R228's wound bandaging was last changed yesterday. V7 stated R228's wound is treated with med honey and foam during scheduled treatments and as needed. V7 stated R228's back condition appears to be a rash. V7 stated R228's back should be treated with barrier cream and moisturizer during daily care. V23 (Wound Nurse) stated R228 appears to have moisture associated yeast around his groin area and if left untreated the skin will break down. At the time of the interviews, the surveyor observed R228's sacral area to be raw and show deep skin injury and a large area of reddened skin on his back. During the wound treatment, R228 yelled loudly in pain when being repositioned for skin assessment and when treatment was applied by V23 to his sacral wound. V23 applied cream to R228's groin area without cleaning the area. V23 stated R228's current care plan documents he requires assist with daily care needs related to chronic kidney disease, Pressure ulcer of sacral region unstageable hypertension, afibrillation, Obstructive sleep apnea, pulmonary fibrosis, retention of urine, low back pain. Resident is a total assist of two staff members for transfers and toileting. Resident is an extensive assist of two staff members for bed mobility; with interventions including: Encourage/ Assist with turning and repositioning every two hours and as needed. R228's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R228's point of care bed mobility reports from [DATE] to [DATE] document he was provided extensive assistance once on multiple days and twice on multiple days; once on [DATE] and once in the morning and night shift on [DATE] and [DATE]. R228's point of care bed bowel incontinence reports from [DATE] to [DATE] document he was checked for bowel incontinence once during the afternoon on [DATE] at 2:59PM and once [DATE] at 6:41AM and once during the night at 9:45PM. On [DATE] from 3:25PM - 3:40PM V2 (Director of Nursing) stated it is not documented in the medical records if residents are repositioned. V2 stated resident's incontinence status should be checked and changed every 2 hours and as needed and incontinence checks and changes are documented in the residents medical records. V2 stated the only way to confirm that a resident is being repositioned every 2 hours would be for it to be observed and monitored by the Certified Nursing Assistants and the Nurses. V2 stated the only way for administrative staff to monitor if residents are being repositioned every 2 hours would be to observe them repositioned. V2 stated she is not conducting rounds every 2 hours to monitor whether residents are being repositioned every 2 hours. V2 stated if R228's wound has worsened since it was developed, and the wound nurse indicated pressure as a contributing factor to the wounds current condition, it could potentially be due to not being turned and repositioned every 2 hours. V2 stated wound areas should be cleaned prior to applying barrier cream and if this is not being done there is a risk of holding moisture or irritation to the skin. V2 stated if R39 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated not having these interventions in place could cause R39's heel wound to worsen and his sacral wound to redevelop.

Based on observation, interviews and record reviews, the facility failed to prevent further decline of a contracture on bilateral hands for one (R78) of one resident reviewed for restorative program. This deficiency resulted in R78's range of motion on left wrist deteriorated from normal to moderate loss/50% of norm and on the right hand from normal to mild loss/75% of norm. Findings include: R78 is a [AGE] year old female, admitted in the facility on 02/12/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/31/22 at 11:30 AM, R78 was observed in bed, alert and verbal. Her hands are both contracted, fist like position, fingers were curled inward and tight. R78 stated she cannot move her hands. There was no splint, or any devices applied on both hands. On 10/31/22 at 2:59 PM, V21 (Family Member) was visiting R78. V21 verbalized that he is concerned about R78's hands. He (V21) further stated that she (R78) used to wear a splint on both hands, but it was not applied anymore. On 11/01/22 at 12:47 PM, R78 was observed asleep on bed. No splints observed on both hands. On 11/01/22 at 12:50 PM, V15 (Restorative Nurse) was asked regarding R78s splint. V15 stated, She is on restorative nursing. She wears splint during the day and into the night. V16 (Restorative Aide) was also asked on 11/01/22 at 12:53 PM if R78 needs to wear a splint on both hands. V16 replied, She has a splint that she wears every day to prevent hands from contracting further. Facility's Nursing Rehab Standard Task documentation dated 05/18/22 for R78 documented: Standard Task: Nursing Rehab - Assistance with splint or brace Description: Assistance with bilateral splints. Should be applied during the day into the night. V15 was asked on when was the last time R78's splint was applied. V15 stated, She is on the program for a splint, it is in the rehab plan of care but it was not scheduled. That is why it is not in the system. She was not wearing it probably because the Aide (V16) did not see it in POC (point of care). V16 is a new Aide, been here for two and a half months. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She does not have any logs to be signed when splint is applied. When I put it in POC, I did not put the shift that is why it did not populate. There were no documentation or logs on R78's medical records regarding application of bilateral splints. There was no care plan for restorative related to R78's bilateral splints application prior to 11/01/22. V15 was asked on 11/02/22 at 1:16 PM regarding R78's care plan for splint. V15 stated, I formulated the care plan for splint only yesterday, but OT referral is for her to wear splints. I guess, I oversight it. I did not do a care plan for the bilateral splints. A care plan for R78, dated 11/01/22 documented: Splint: Requires the use of bilateral splints to her hands related to contractures. (R78) doesn't like to wear her splints that often due to her stating they cause her pain. Interventions: Encourage resident (R78) to assist with applying and removing brace. encourage resident to demonstrate ability to apply the brace and praise participation with program and improvements. Observe skin for complications related to brace usage every shift and each time it is removed. Provide proper cleaning of brace on residents (R78) specific shower days and PRN (when necessary) when soiled. Provide verbal cues as to proper placement of brace when applying. Splint to be on during the AM (morning) and off at PM (evening) up to eight hours as tolerated. On 11/02/22 at 10:54 AM, V14 (Director of Rehab, Long-Term Care) was asked regarding R78. V14 replied, She was evaluated for OT on 08/02/22 for three times a week for four weeks. The goal is for her to wear her splint bilaterally for two hours every day. Her hands are both contracted, in fist position, tight and painful for her when fingers are straightened out. During therapy, she improved from not wearing the splint to wearing it for two hours as tolerated. She was discharged from OT on 08/29/22, she met his goals for wearing the splint and able to perform other set goal tasks. She was referred to Restorative Nursing to continue wearing the splint. R78's OT DC summary 08/29/22: Summary since eval (evaluation)/SOC (start of care): Patient response - patient has reached maximum potential with skilled services; Discharge status and recommendations: Restorative Nursing Program On 11/03/22 at 1:15 PM, V2 (Director of Nursing) was interviewed regarding R78 and splint application. V2 stated, Splints should be applied according to doctor's orders. For R78, there should be an order obtained for her splint at the time that splint was recommended. I am not sure what happened. Restorative Department is the one responsible for the orders and the application of splints or braces. R78's OT evaluation dated 11/03/22 documented in part: Range of Motion (ROM) Goniometric Measurements: Joints - Shoulder = impaired; Elbow/Forearm = impaired; Wrist = impaired; Shoulder = impaired; Elbow/Forearm = impaired; Wrist = impaired R78's Range of Joint Motion Screen dated 09/28/22 documented: A. Evaluation 6. Left wrist and fingers (flexion and extension) 1. Within normal limits 7. Right wrist and fingers (flexion and extension) 1. Within normal limits R78's Range of Joint Motion Screen dated 11/02/22 documented: A. Evaluation 6. Left wrist and fingers (flexion and extension) 3. Moderate loss/50% of norm. 7. Right wrist and fingers (flexion and extension) 2. Mild loss/75% of norm. On 11/03/22 at 1:54 PM, V34 (Physician) was interviewed regarding R78 and use of splint. V34 stated, She is a long-term patient. Been taking care of her for five to six months now. She had history of stroke before, has contracture on both hands due to inability to move them. Use of splints can help in preventing further decline in contractures. Facility's policy titled, Splints review date 10/2021 stated in part but not limited to the following: Guideline: 1. Residents will be evaluated for the use of a splint based on their assessed deformity or contracture. 2. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews and records reviewed the facility failed to develop and implement an individualized care plan for a post surgical wound and failed to follow the surgeons discharge instructions to have resident seen 2 weeks post operatively. This affected 1 of 3 residents (R2) reviewed for care of surgical wound and discharge instructions. This failure resulted in R2's follow up appointment being delayed over 6 weeks. R2 presented to the follow up appointment with an infected surgical site and required emergency surgery. Findings include: Review of R2's faces sheet documents a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS section C dated 7/27/2022 documents R2 with a score of 11/15 which indicates moderate cognitive impairment. R2 MDS section C dated 7/7/2022 documents R2 required extensive to total dependence on staff for activities of daily living. Review of R2's hospital discharge instructions dated 7/20/2022 documents R2 to follow up with V16 (Surgeon) in 2 weeks for suture removal. R2's Wound evaluation forms dated 7/21/2022 document's R2 admitted with 3 wounds: left thigh surgical wound with 13 sutures and 23 staples, right lower back laceration, and Moisture associated Skin damage to sacrum. Review of R2's full Care plan is absent of any skin or wound care plan. Review of R2's Wound Care progress notes and found there to be 3 progress notes: one on the day after admitted d 7/21/2022 (by V44, Wound care nurse), one on 8/17/2022 (V44) when the Left AKA is noted to have multiple sites of dehiscence and eschar tissue and third wound care note is dated 8/30/2022 (by V13, Wound Care Nurse) that documents yellow exudate and Eschar tissue. On 9/8/2022 at 10:40 AM V42 (Daughter of R2) stated, her mother's 8/3/2022 follow up appointment was canceled by the facility due to transportation issues and they never rescheduled it. V42 stated she was at the facility once or twice a week and she mentioned it several times to the nurses on duty and the V5 (Unit supervisor), V41 (Director of social services) and V14 (Assistant Administrator). V42 stated she left messages for V14 twice and did not get a call back. On 9/8/2022 at 3:01 PM V9 (Scheduler) stated she scheduled R2 for her follow-up on 8/3/2022 and scheduled a wheelchair to transport her. V9 stated a day or two before she talked to the nurse on Duty about R2's transportation she found out that R2 needed a stretcher that R2's insurance would not pay for. V9 stated the transportation company would charge over $2000 for the transport. V9 stated she told the daughter this and that they would have to pay for transportation. V9 stated, V42 (Daughter of R2) told her they could not afford that. On 9/20/2022 at 9:38 AM V9 stated she called the surgeons office a day or two before R2's follow-up appointment of 8/3/2022. V9 stated, she cancelled the appointment and asked if doctor could come to the facility or if the facility could take out the stitches. V9 stated and a few days later the surgeon's office called and said no to taking out stiches, and the surgeon needed to see R2. V9 stated, it was her responsibility to get appointment and arrange transportation. V9 stated, she did not do anything else after the initial call to the Surgeon's office. V9 stated she was not the only person who knew that the R2 needed to go to the doctor. I did everything I was supposed to do. I'm not a nurse. No one followed up with me and I didn't hear anything else regarding R2 until the day she went out to the hospital. V9 stated she doesn't know of a policy or protocol describing what to do if an appointment is cancelled. On 9/20/22 at 10:22 AM V5 (unit supervisor) stated, the first V5 heard that R2 missed appointment was when the V42 (R2's Daughter) came in and said R2 missed appointment and still had staples. V5 stated she spoke to V9 (scheduler) and V9 said the appointment was canceled because of insurance. V5 stated she told daughter they would look into it. V5 stated after that conversation with R2's daughter, a week or so later, we had care conference and the daughter brought it up again. I spoke to scheduler again the day R2 was sent out. V5 stated, V9 said she called Surgeon's office and the said they couldn't get R2 in to be seen quickly so send R2 to the emergency room . V5 stated she saw V18 (Primary Care Doctor) and asked if he could look at the patient's wound. V18 then took the sutures and staples out. V5 stated after her initial conversation with V9 more than a week ago, V5 did not do anything else regarding R2's transportation because V9 said she was dealing with the issue. On 9/21/2022 at 12:33 PM V41 (Social Services Director LTC) stated, the care conference with V42 (R2's daughter) was on 8/31/2022 at 11:30 AM. During the conference V42 mentioned she had concerns about her mom not getting to appointment and transportation. V41 stated, no one mentioned this to her prior to the Care conference on 8/31/22. V41 stated, during the conference, she called V9 (Scheduler) to ask about what was going on with R2's appointment. V41 stated that V9 said there was a problem with transportation and R2 not fitting in wheelchair. V41 stated, V9 said she was working on it, and they were going to try to reschedule the appointment. On 9/20/2022 10:03AM V2 (DON) was not aware of the situation with R2. V2 stated, it was V9's responsibility to reschedule the appointment and arrange transportation. V2 stated, she is not sure if they would have come to different conclusion but V9 could have come to her or administrator to see if we could work out payment or something. V2 stated, it did not make sense for V9 to do nothing else after the initial call to the surgeon's office. On 9/21/2022 at 2:29 PM V44 (Wound Care Nurse) stated R2's Surgical wound had no signs infection or necrotic tissue on the admission of 7/21/2022 and she would have documented it if there was. V44 stated, wound evaluations should be done weekly. V44 stated she did not complete weekly wound assessments. V44 stated, the wound care nurse or wound care coordinator are responsible for doing weekly wound assessments, but V44 was still in training. V44 stated V13 wound care coordinator was doing the weekly assessments because V44 was in training. V44 stated, What I was told is when a resident has a surgical site they need to follow up with the surgeon. The facility's wound care doctor does not follow the surgical patient's. V44 stated, she notified the nurse on duty of the dehiscence and eschar and told her that R2 probably needs to follow up with surgeon. V44 stated, she also told V13 (Wound Care coordinator) and showed V13 the pictures because V13 was training V44 and she had to show her all of her work. V44 stated she did not notify the R2's surgeon or doctor of the change in wound. V44 stated, V13 usually handles any change of condition notifications. Review of R2's nurse progress note dated 9/1/2022 at 1:00 PM by V4 documents the following: patient was sent out to the hospital by physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R1's vascular surgeon, V16 documents in his operative report dated 9/1/2022 the following: Preoperative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure performed: excisional debridement of left above knee amputation wound. Findings: liquefactive fibrinous necrosis of the subcutaneous fat essentially down to the level of the adductor and hamstring myodesis. There is some purulent fluid deep to this fat and it was sent for microbiological analysis. Indications: This is a [AGE] year old woman who presented to the emergency room for evaluation of dehiscence and concern for infection of a left above -knee amputation that was performed in July. She never followed up as an outpatient despite communication with the nursing facility regarding the importance of outpatient office postoperative follow up. The nursing facility would not facilitate transportation for the patient to be evaluated as an outpatient and requested to remove the sutures at the facility, which my office communicated was not acceptable solution for this. However, she now subsequently presents to the emergency room with no sutures in place and dehiscence of the wound with obvious liquefactive necrosis of the underlying subcutaneous fat and is indicated for operative exploration and excisional debridement of the nonviable tissues both to stabilize the wound and determine if a revisional above-knee amputation is necessary. On 9/13/2022 at 3:35 PM V2 (DON) stated, the facility's protocol is that wounds should be assessed upon admission and weekly and documented. V2 stated, there is a skin and wound form, and a picture should be taken weekly. V2 stated, all wounds including surgical wounds should be assessed for measurements, notate any drainage, redness, [CONDITION(S)] or other signs of infection. V2 stated, if there is any change in condition or signs of infection like redness or tenderness, increase drainage, pain, or foul odor, the staff should notify the doctor immediately. The facility's Appointment and Transportation policy documents the following: 9. If the resident is unable to keep the appointment, it is the staff nurse or designee's responsibility to cancel the appointment and reschedule it at the earliest time. The facility's Skin Management: monitoring of wounds and documentation documents the following: With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), and evaluation if the PU/PI should be documented. At minimum, documentation should include: Location and staging; size; exudate, if present and type, Pain; wound bed: color and type of tissue/character including evidence of healing; and description of wound edges and surrounding tissue as appropriate. If a wound shows no signs of healing after 3 weeks, a reevaluation of the treatment plan including determining whether to continue or modify the current interventions is done. If the decision is made to retain the current regimen, documentation of the rationale for continuing the current plan will occur.

A. Based on interview and record review the facility failed to implement fall prevention interventions to minimize fall risks for a resident with history of multiple falls, poor safety awareness, and unsteady gait. This failure affects 1 of 3 residents (R4) reviewed for falls. This failure resulted in R4 slipping and falling to the floor then sent to the hospital and diagnosed with a non-displaced left intertrochanteric fracture. B. Based on observations, interviews and records reviewed the facility failed to provide supervision for a resident with altered mental status, unsteadiness and abnormal gait: the facility also failed to respond to an audible alarm from an exit door for approximately 14 minutes. This failure affected 1 of 3 residents reviewed for supervision. This failure resulted in door alarm alarming for 14 minutes before facility staff responded. This failure resulted in R1 walking out the 2nd floor alarmed door and later found laying on the 1st floor in the stairwell. R1 was sent to the hospital and diagnosed with a right femoral head fracture. Findings include: A. R4 was admitted to the facility on [DATE]. R4 face sheet shows diagnosis for speech and language deficits following a cerebral infraction, [CONDITION(S)] and [CONDITION(S)] following cerebral infraction affecting the right dominant side, weakness and hypertensive [CONDITION(S)], dementia in other disease without behavior disturbance. R4's facility admission hospital report dated 8/26/22 shows in-part, handwritten by V25 (Nurse) multiple falls, unsteady on feet. On 9/15/22 at 3:58p.m V25 (RN) stated she received an admission report from the hospital nurse who mentioned that R4 has an unsteady gait and a history of multiple falls. V25 said the nurse did not say R4 had any fractures during the facility-to-facility report. R4 MDS dated [DATE], section J for fall history denotes no fall history for R4. Section C shows a BIMS score of 9 (cognitive deficits). Section G shows R4 required extensive assistance (R4 involved in activity, staff provide weight bearing support) with bed mobility and needed one-person physical assist. R4 required extensive assistance (R4 involved in activity, staff provide weight bearing support) with transfers and needed two-person physical assist. Walk in room/ corridor- activity did not occur, locomotion on unit-shows R4 required extensive assist (R4 involved in activity, staff provide weight bearing support) with one-person physical assist. Locomotion off unit shows R4 assist extensive assistance (R4 involved in activity, staff provide weight bearing support) with two-person physical assist. Dressing shows R4 required extensive assistance (R4 involved in activity, staff provide weight bearing support) with two-person physical assist. Eating shows R4 required extensive assistance (R4 involved in activity, staff provide weight bearing support) with one-person physical assist, toilet use shows R4 required extensive assistance (R4 involved in activity, staff provide weight bearing support) with one-person physical assist, personal hygiene shows R4 required extensive assistance (R4 involved in activity, staff provide weight bearing support) with one-person physical assist. R4 base line plan of care dated 8/26/22 shows in-part falls, resident (R4) is at risk for falls, resident will remain free of falls through next review, interventions show call light within reach, provide clutter free environment, encourage use of assistive devices, provide proper well-maintained footwear. R4 occupational therapy evaluation and treatment plan dated 8/26/22 under assessment summary shows R4 presents with impairment in dysarthria, memory, sequencing/ segmentation, following instructions, safety judgement/ awareness, unsteady functional transfers, hands dexterity and self-care. R4 fall risk evaluation dated 8/27/22 shows score of 18 (high fall risk), reason for assessment initial/ readmission, mobility- unsteady gait and or use of ambulatory devices, decreased mobility, predisposing conditions- [CONDITION(S)], [CONDITION(S)], Parkinson, [CONDITION(S)], seizures, [CONDITION(S)], physical restraint- none, visual/ hearing- no deficits, mentation- confused, impaired memory or judgement, falls, accidents, fractures- none, age- 75 and above, medications- none, elimination status- incontinent. R4 physician telehealth evaluation for date of service 8/26/22, signed dated of 8/29/22 shows in-part fall Risk: keep call bell in reach. PT/OT evaluation related to fall risk. Fall precautions per facility policy. Patient is at risk for falls due to weakness. Patient is at risk for falls due to [CONDITION(S)]. M6281 - Muscle weakness (generalized), Does the patient have any acute symptoms OR complaints? No History of Present Illness (TE): Patient was admitted to the facility and is awaiting full H&P (history and physical) and review by the primary team. The nurse consulted (company name) to review and reconcile discharge medications and orders and to ensure safe transition of care. Facility final report to the department dated 9/8/22 reported by V2 (DON-Director of Nursing) shows in-part date event occurred 9/1/22, during nurse assessment noted with swelling and pain to left knee with decreased mobility. Order obtained to send resident to ER for evaluation, X ray result at hospital showed left hip fracture. Staff interview and no report of fall or incident during the 4 days he was in the facility. Resident has a history of multiple falls prior to admitting. Hospital report noted osteopenia throughout bones and joint of left hip. Due to resident cognitive impairment and speech deficits, it is possible fracture was sustained prior to admitting to facility. Resident remains at the hospital. Care plan to be updated upon return. Facility ruled out abuse. On 9/15/22 at 2:10p.m V23 (CNA) said she worked with R4 on 8/30/22 on the morning shift. V23 said around 10:30am she went into R4's room to pick up breakfast trays and to check on R4. V23 said she observed R4 out of bed sitting on the floor mat next to the bed. V23 said she immediately went to get the nurse (V24) to assist her to get R4 up off the floor/ floormat. V23 said V24 and herself lifted R4 up manually (placing their arms under his arms and brought R4 to a standing position) and placed R4 in the bed. V23 said she then put an adult brief on R4. V23 said R4 was then placed in the chair (transferring R4 from the bed) and taken to the nurses station for observation. V23 said R4 was in another room when R4 fell . V23 said R4 was on the floormat and the mattress was on the opposite side of the bed. V23 said she didn't remember R4 having on any footwear on (shoes or grip footies). V23 said she does not know if V24 assessed R4 because after they picked R4 up she left the room to get the adult chair for R4. V23 said R4 was a fall risk. On 9/16/22 at 10:01a.m V24 (Nurse) said she was the nurse working with R4 on 8/30/22 when R4 was observed out of the bed. V24 said the top half of R4's body was in the bed and the bottom portion of R4 body was off the mattress. V24 said she assisted V23 to get R4 up from that position. V24 said she checked R4's body for bruises, bleeding, and any swelling. V24 said she took R4's vitals and assessed R4 for pain. V24 said she did not report this occurrence immediately to V2 (Director of nursing), V28 (Restorative Nurse) or the manager on duty because she did not consider R4 to have sustained a fall. V24 said V3 (ADON) did contact her last week and asked her to give a detail statement of what occurred on 8/30/22 during her shift. V24 said she thought she gave a detailed statement when she reported that R4 was attempting to get out of bed and was not on the floor. V24 said she didn't remember what R4 had on his feet. V24 said R4 would always try to get out of bed. V24 said R4 was a fall risk. V24 said R4 had the mattress on the floor, and it was as high as the bed that R4 was in, and that's why she did not consider R4 to have had a fall. On 9/13/22 at 3:19p.m V35 (CNA-certified nursing assistant) said on 8/31/22 she worked with R4 on the 3pm to 11pm shift. V35 said she assisted R4 with dinner and after dinner R4 had an episode of vomiting. V35 said when she was cleaning R4, R4 began to scream out in pain, saying ouch. V35 said she reported this to V19 (Nurse) said she also reported to V19 that R4 was having pain and that R4 leg did not look right. V35 said she did not work the entire shift and that's the only information that she can provide regarding that situation. On 9/14/22 at 10:09a.m V19 (Nurse) said she was the nurse responsible for R4 care on 8/31/22 and R4's daughter made her aware that R4 was having pain in the knee. V19 said upon assessing R4, R4 complained of pain in the left thigh. V19 said she called the after hour physician and orders were given for an X-ray. R4's family did not want to wait for an Xray and requested R4 be sent to the hospital for further evaluation. V19 said the physician was notified and gave orders to send R4 to the hospital for further evaluation. V19 said she was not aware of R4 having a fall the previous day. V19 said she worked with R4 the entire morning and R4 did not have any complaints of pain. On 9/16/22 at 12:01 p.m. V3 (ADON) said the facility identifies a fall as a change in planes. When R4 was observed on the floor mat at the side of the bed, that is identified as a fall. V3 said she is not familiar with the facility having a mattress that could be placed on the floor as high as the bed (when bed in lowest position). 9/16/22 at 3:322pm V28 (Restorative Nurse) said R4 is a fall risk. Review of R4's fall risk evaluation with V28, V28 said the evaluation was R4's initial admission evaluation. R4 has an unsteady gait, decrease mobility, has predisposing condition of [CONDITION(S)] (cerebral vascular accident-stroke), R4 has confusion and impaired memory or judgement due to dementia, and experiences incontinence. Review of R4 baseline care plan with V28, V28 said R4 is at risk for falls. R4 will remain free from falls through next review, and interventions are call light within reach, staff should encourage R4 to use call light for assistance, V28 said provide a clutter free environment, which is to ensure the environment does not have tripping hazards, V28 said R4 should be encouraged to use assistive devices, for mobility (wheelchair) so that R4 is not up walking, and R4 should have proper, well maintained footwear. R4 should wear well fitted shoes (that encase the entire foot, shoes that he cannot trip over) or skid free socks, skid free socks keep the feet from sliding on the floor, skid free sock should be worn in bed and out of bed. On 9/16/22 at 12:08p.m V34 (Medical Director) was contacted due to surveyor having to complete legal documentation to obtain an interview with the routine medical provider. Survey findings were reviewed with V34. V34 said any minor trauma can cause an intertrochanter hip fracture. V34 said diagnosis of osteopenia could increase the risk of an intertrochanter fracture with a fall. V34 said R4's fall on 8/30/22 could have contributed to R4's hip fracture. R4 hospital record with encounter date shows in-part chief complaint- leg pain, fall, [AGE] year-old male with history of hypertension presenting from rehab with left leg pain. History obtained by daughter at bedside due to patient's dementia baseline. Patient has been in rehab. He has been doing well up until today when daughter came to visit him. Patient has been unable to walk with left leg in pain, shortened and externally rotated. Patient fell per history obtained by him. Rehab facility did not notify daughter that patient fell . Was ambulating well prior to today. No other fevers, coughs, nausea, vomiting, chest pain, shortness of breath, diarrhea. No other injuries noted. Physical exam left leg externally rotated and shortened, tenderness with log rolling, 2 plus pulse. Xray impression- moderately displaced intertrochanteric fracture, findings show bones/ joints- there is a moderately displaced intertrochanteric fracture. Diffuse osteopenia throughout the visualized bones. No dislocation. Soft tissue unremarkable. Clinical impression, ED diagnosis, closed left hip fracture, acute [MEDICATION(S)] without hematuria. Facility falls prevention and management policy dated 5/2015 with last review date 07/2022 shows in-part the facility is committed to maximizing each resident 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 prevention strategies and facilitate a safe environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be modified as needed. The fall evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. Resident at risk for falls will have fall risk identified on the interim plan of care and the ISP with interventions implemented to minimize fall risk. Evaluate the resident for any injury and notify the physician and emergency contact. Complete a fall evaluation incident report in the PCC risk management portal. A fall evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less than 10 indicates at risk for fall, Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. Complete the follow up monitoring form every shift for 72 hours. All incidents and accidents with serious physical injury will be reported to IDPH within 24 hours. A full written investigation report is required by IDPH five (5) days of the incident. B. Review of R1's faces sheet documents a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include: Altered mental status, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side, Dysphagia flowing cerebral infarction, Acute embolism and [CONDITION(S)] of right femoral vein, Unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, Malignant neoplasm of the prostate, weakness, Visuospatial deficit and spatial neglect following cerebral infarction. R1 resided on the second floor. R1 MDS section C dated 8/24/2022 documents R1 with a score of 00/15. On 9/16/2022 at 11:37 AM V29 (Social Services Coordinator) states a score of 00 BIMS (Brief Interview for Mental Status) score indicates that the resident was not able to answer questions or answered incorrect and is severely cognitively impaired. On 9/9/2022 at 3:40 PM V15 (CNA) stated, I was in another resident's room and the moment I walked out of the room I heard the alarm. I was in a different hallway from R1's room. I was the only CNA on the floor and the other CNA (V36) was running late. V15 stated, I heard the alarm and went to check rooms while alarm was going off. I noticed R1 was gone then I checked the door that was alarming. I never turned alarm off at that point. V15 stated she then went to find the nurse. V15 stated she found V3 (ADON) and V14 (Assistant Administrator) on C side unit. V15 stated, she informed V3 and V14 that R1 was not in his room and the alarm was going off. V15 stated when she arrived at alarming exit door with V3 and V14, she turned the alarm off. V15 stated, that her, V3, and V14 went through the exit door down the stairs and found R1 on the first floor, lying in front of the entrance door to the 1st floor unit. V15 stated herself, V3, and V31 (CNA), got R1 up. V15 stated she could hear the alarm from the office from where V3 and V14 were standing and talking. On 9/13/2022 at 10:21 AM V3 (ADON) stated she was working on the unit because V17 (LPN) was running late. V3 stated she was caring for another resident, speaking with their POA when V15 (CNA) told her that R1 was not in his room and the alarm had gone off. V3 stated at no point while on the floor did she hear the alarm and she was on the floor from 3:30pm unit 5 PM. V3 stated when she got to the exit door with V3 and V14 the exit door alarm was not on. V3 stated the exit door alarms until someone turns it off. V3 stated her, V14, and V15 went through the exit door and found R1 lying on the floor on the 1st floor. On 9/13/2022 at 2:44 PM, V3 stated she arrived on the unit that day (8/30/2022) at around 3:30PM. She was on the unit from 3:30 PM until after 5:00 PM. She did not leave the unit. V3's progress note dated 8/30/2022 at 5:40 PM documents V3 found R1 on the on the 1st floor in the stairwell laying on the floor with his back against the door. The facility's incident report dated 8/31/2022 documents the following description of the occurrence: Resident sustained unwitnessed fall. Upon nurse assessment no signs of injury noted. No complaint of pain. Order obtained to send patient to ER for evaluation. Patient noted to have closed fracture of right hip. Review of R1's hospital records X-ray report dated 8/30/2022 diagnosed R1 with a Right Femoral Neck Fracture. On 9/13/2022 at 12:42 PM V32 (LPN) stated she went to break from 4:00 PM to 4:30 PM and she made V3 (ADON) aware that she was leaving. Review of V17's (LPN) Time Card Report documents she clocked on 8/30/2022 at 4:28 PM Review of V36's (CNA) Time Card Report documents she clocked on 8/30/2022 at 4:24 PM On 9/13/2022 at 11:58 AM this surveyor reviewed recorded video from R1's 8/30/2022 incident in 2B hall with permission of and the presence of V1 (Administrator). Observed video recording dated 8/30/202 from 4:05 PM until 4:25 PM of the 2B that documents the following: At 4:05PM V15 (CNA) came out of Room, went to the cart with V3 (Assistant DON) and then V15 left area (went behind the camera view). At 4:06 PM V3 left medication room and view of the cameras. At 4:07 PM R1 walked out of room with gown on. R1's gown got caught slightly on a cart. R1 walked along right wall and then crossed over to the left to the exit door. At 4:09 PM R1 disappeared through the exit door. At 4:22 PM - V15 (CNA) went into room with what looked like a cup in her hand. V1 came out to the cart and then went back in the room. At 4:23 PM V15 left the area (behind the camera view). At 4:23:41 PM V15 is back in view, she is looking around and looks into R1's room. V15 then went to exit door. V15 then went back into R1's room and looks around, then V15 leaves the area. At 4:25 PM V15 came back to the 2B hall with V15 (ADON) and V14 (Assistant Administrator). Staff responded to the alarming exit door at 4:23 PM which is 14 minutes after R1 was observed going through the 2nd floor exit door. Review of the facility's Staff statement by V2 (DON) dated 9/5/22 documents the following: Video footage reviewed and observed resident walking in hallway unassisted to stairwell. On 9/15/2022 at 3:37 PM V22 (Director of staffing) states that there should always be 1 nurse per hall that is occupied. V22 states that they always staff 2 nurses on the first and second floors for the 7:00 AM to the 3 PM (1st) shifts and the 3pm -11:00 PM (2nd) shifts. V22 states they will add a third nurse to the 2nd for if the third hall is occupied with residents. V22 states that for the 1st and 2nd shifts on both the 1st and 2nd floors the CNA's are staffed as follows: 1-15 residents =1 CNA, 16-25 residents = 2 CNAs, 26-35 residents= 3 CNA. Review of facility's Census for 8/30/2022 documents 13 residents on 2A hall and 7 residents residing on 2A hall on the 2nd floor. On 9/15/2022 at 3:15 PM V2 (DON) stated, on 8/30/22 there were 2 nurses and 2 CNAs scheduled to work the 2nd shift on the second floor. V2 stated, they try to have staff communicate with the other nursing or CNA who should be watching unit. V2 stated, V32 (LPN) was on break. V3 and V15 should have been monitoring the unit. Surveyor asked, if there was there anyone else on the floor monitoring the residents while V3 and V15 were occupied? V2 stated, there was no one else on the floor. V2 stated, Ideally, there should be someone there watching the residents and monitoring the unit when other staff is occupied. V2 stated, they could have called someone to come look after the residents while they were occupied. V2 stated, We do not have any protocol or practice to monitor the unit when the assigned staff are in with other residents. V2 (DON) stated, I'm not aware of any of the precautions the hospital had R1 on. We don't use bed or chair alarms. On 9/15/2022 at 4:10 PM V3 (ADON) stated when she and V15 (CNA) were helping another resident to the restroom, she was aware that there was no one else on the unit to monitor the other residents. V3 stated, If we had somebody then, yes, I would have loved someone to be there to monitor other residents. I didn't call someone else because I didn't have the staff that was available to come. V3 stated, they do not have a practice or policy she knows of to monitor residents when staff is occupied in another room or otherwise. Review of facility's Elopement policy dated 9/2022 documents the following: Guideline: 7. All facility staff are responsible for responding to a door/elevator alarm immediately. This response will include visual check of the immediate vicinity surrounding the door/elevator that tripped the alarm, including the stairwells and outside area.

Based on interview and record review, the facility failed to ensure one resident's bed was in safe condition to prevent an avoidable accident. This affected 1 of 3 resident (R1) reviewed safety. This failure resulted in (R1) sustaining a laceration requiring 23 sutures during a transfer. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes, repeated falls, chronic pain, congestive heart failure, respiratory failure, [CONDITION(S)], unsteadiness on feet and lack of coordination. R1's brief interview for mental status score dated 6/29/22 documents a score of 12/15 which indicated cognitively intact. R1's facility final reportable dated 7/18/22 documents under occurrence resolution: Upon investigation it was concluded that while doing a transferring back to bed resident leg made contact with the bed frame causing laceration. R1's ambulance run report dated 7/11/22 documents: RN reports that patient was being transported from her [CONDITION(S)] chair to her bed, when metal part of the bed made a 8 inch laceration on the patient's outside left calf. She stated pain was 9/10 and pointed to her leg. R1's hospital record dated 7/11/22 documents: Patient was in nursing home being transferred to the bed and her leg got cut on bed frame. Under skin documents 14 (cm) centimeter irregular laceration to the left lateral shin. Under treatment: 23 sutures placed. On 8/19/22 3:40 pm, V3 Director of Nursing (DON) said they determined that R1 leg was cut on the side of bed where an end cap should have been placed on the bed. Surveyor observed R1's hospital bed that had metal rod noted in the middle of the bed frame. The end of metal rod had a small square plastic insert to cover the edges of the rod. V3 said the small square insert was not present in R1's bed at time of the incident and sharp edges caused the laceration.

Based on interviews and records reviewed the facility failed to provide interventions to prevent or reduce the risk of falling for a resident known to be a fall risk with confusion. The facility also failed to ensure a resident was positioned in the center of the bed after providing direct care. These failures affected 2 of 3 residents (R2, R9) both reviewed for safety and falls. This failure resulted in R2 having a fall incident resulting in a right [CONDITION(S)], and R9 falling from bed sustaining a laceration to left forehead area requiring 3 sutures. Findings include: a. R2 face sheet documents R2 is an [AGE] year-old admitted to the facility on [DATE]. R2's admission fall risk assessment dated [DATE] documents R2's fall risk score of 13.0 which designates R2 as a high risk for falls. R2 progress note date 1/21/2022 at 4:23 AM by V9 (RN) documents R2 started to doze and slid out of wheelchair onto the floor. The facility Reported incident (FRI) dated 1/21/2022 documents resident alert and oriented x2 with periods of confusion and diagnoses including: [CONDITION(S)], dysphagia, non-traumatic [CONDITION(S)], cerebral aneurysm, TIA, and Cerebral infarct. The FRI final report dated 1/21/22 at 6:18 AM documents resident noted sliding from wheelchair to the floor. During physical therapy later in the resident complained of pain. MD notified and x-ray Completed. Results of x-ray showed a right femur fracture. V9's (Nurse) hand written account of the fall documents the following: Upon making rounds at approximately 3:30 AM, author noted patient trying to get out of the bed and walk. She was alert but confused to place and time. Knowing patient's medical history author was concerned for her safety. Author assisted Patient to wheelchair and placed her at the nursing station with wheelchair in locked position. At approximately 4:00 am author and Certified Nursing Assistant (CNA) had backs turned. Patient started to slide and fall out of the wheelchair as author turned head and noted patient falling to the floor and landing on her right side. On 4/12/2022 at 8:03 AM V9 states R2 was one assist to wheelchair and incontinent. V9 states she had cared for R2 a couple of times before. V9 states R2 was confused and a fall risk. V9 states, R2 had very unsteady gait. V9 states, At around 3:00 am R2 was in her room sitting at the edge of the bed. She kept trying to get up by herself. V9 states after she made sure R2 did not have to go to the restroom or anything else, she saw that R2 kept trying to get up. V9 states she then helped R2 into the wheelchair and wheeled her to the nurse's station where she and a CNA were sitting. V9 states, I turned my back to get charting done and heard her [R2] trying to move. I saw movement out of the corner of my eye. By the time I could get up, she was already falling. It was a witnessed fall. She fell on her right side. Surveyor asked why V9 didn't have R2 in her field of vision at all times. V9 states, I didn't think she would try to get up. X-ray results dated 1/21/2022 documents the following findings: Right hip: Examination reveals an impacted [NAME] cervical fracture of the right femoral neck with varus deformity and no significant displacement. On 4/7/2022 at 1:45 PM V2 (Director of Nursing, DON) states staff should make sure residents that are high fall risks are monitored more frequently and are safe, not slipping and falling to the floor or trying to stand up without assistance. V2 states, the staff should be within reach to intervene if resident tries to get up. b. R9 is [AGE] year-old with diagnosis including but not limited to Adult Failure to Thrive, Pressure Ulcers, Pain in Arms, Dysphagia, Lack of Coordination, Repeated Falls, [CONDITION(S)] in [CONDITION(S)], Hypertensive Chronic Kidney, Cachexia, [CONDITION(S)], Depression, and Unilateral Primary [CONDITION(S)]. On 4/6/22 at 11:33AM the surveyor observed R9 in the dining room in a wheeled reclining chair. The surveyor noted a pink scar above and along R9's left eyebrow. R9 did not respond verbally when surveyor spoke to her. On 4/6/22 at 1:46PM V38, Certified Nursing Assistant (CNA), said on 3/14/22 she was in the dining room when she was notified that R9 was on the floor. On 4/6/22 at 3:00PM R9 observed sitting in the reclining chair in the dining room with V24, R9's family. V24 said we (the family) were notified R9 fell but we don't know how she fell . V24 said she visits 3 or 4 times a week. V24 said R9 does not move, I have never seen her moving around, only her hands. On 4/7/22 at 1:35PM V2, Director of Nursing, said R9 should be placed in the center of the bed. V2 said the air mattress and the sheet would cause her to slide in the bed. V2 said it is not likely that R9 slid from the center of the bed when she fell . V2 said she was not sure who was the last person to provide care to R9 before she fell on [DATE]. V2 said the intervention after the fall for R9 was education of the staff on proper placement of a resident while in the bed. On 4/7/22 at 2:20PM V25, Wound Nurse, said R9 usually remains in the same position. V25 said pillows and wedges are used to position her and minimize positioning on her back. On 4/12/22 at 9:53AM via phone interview V35, CNA, said R9 must have slid out of the bed. V35 said someone must have removed R9's floor mat and that is why she got hurt. V35 said she did not realize the floor mats were not in place when she saw R9 earlier. V35 said R9 was able to sit up and move around before she fell on [DATE]. On 4/12/22 at 11:15AM V2 said new interventions after R9 fell on [DATE] were to get her up at breakfast and place floor mats to prevent injury. V2 said residents determined to be a high fall risk will get floor mats as an intervention. V2 said high fall risk residents are those with previous falls and fall risk as determined on the fall risk assessment. V2 said a score 10 or more on the assessment indicates the resident is a fall risk. V2 said a score of 14 is a high risk for falls. V2 said [CONDITION(S)] medications can make a resident groggy contributing to their fall risk. V2 said R9 should have had floor mats in place before her fall on 3/14/22. On 4/12/22 at 11:20AM V34, Restorative Nurse, said R9 had interventions for floor mats since before her fall on 3/14/22. V34 said R9 was not able to stand before 3/14/22. On 4/12/22 at 11:45AM V33, Licensed Practical Nurse, said she was notified that R9 was on the floor on 3/14/22. V33 said she saw R9 on her side on the floor next to her bed. V33 said R9 had a laceration over her left eyebrow. V33 said she sent R9 to the hospital for further evaluation. On 4/12/22 at 12:57PM V16, Physical Therapy, said R9 was treated by physical therapy from 3/1/22-3/4/22. V16 said we did not see progress and therapy services were discontinued. V16 said R9 was not able to turn or sit herself up while she was on therapy caseload. R9's Cognitive Pattern assessment dated [DATE] notes a score of 10, moderately impaired cognition. R9's Functional Status assessment dated [DATE] notes R9 required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene. Balance test note R9 was not steady. R9's Fall Risk Evaluation effective date 2/15/22 notes a score of 14. A document titled Fall date 3/14/22 notes R9 was on the floor. R9 has ½ cm laceration to left eyebrow. Review of R9's progress notes dated 3/14/22 at 2:00PM indicates R9 returned to the facility from the hospital. R9 received 3 sutures to left brow. R9's care plan initiated on 12/13/21 notes R9 is at risk for falls due to diagnosis and history of unilateral primary [CONDITION(S)], [CONDITION(S)], Hypertension, Acute Kidney Failure. Resident has medication ordered that may alter gait and balance. Interventions include anticipates and meet resident's care and safety needs. The facility policy for Fall Prevention and Management Review date 10/2021 notes: The facility will identify and evaluate those residents at risk for falls, place for preventive strategies, and facilitate as safe an environment as possible. A score of 10 or greater indicated the resident is as high risk for falls. The facility's Fall Prevention and Management Guideline dated 10/2021 documents the following: 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.

Based on interviews and records reviewed the facility failed to follow their policy for all employees to be vaccinated or have documented exemptions in place. This failure resulted in the facility currently listing 4 positive Covid residents R18, R24, R30 and R31. Findings include: On 4/6/22 at 1:57PM The surveyor reviewed the COVID 19 vaccination declination forms provided. On 4/7/22 at 10:39AM V24, Human Resources, said if a staff member wants to decline the COIVD-19 vaccination then we have a declination form for them to complete. V24 said staff who decline require either a doctor's note for a medical exemption or documentation for religious exemption. V24 reviewed said V49's, Nurse, declination statement with the surveyor and V24 said V49 just declined to be vaccinated because she does not want it. [No reason for declination is indicated on the form.] V24 said this is not following policy for declination. After reviewing V50 and V51, both CNAs, Declination Statements V24 said I will double check for additional documentation related to their reasons for declination. On 4/7/22 V2, Director of Nursing, reviewed COVID-19 positive resident list with the surveyor. The 30 day COVID 19 list includes R18, R24, and R31. V2 said R30 should be included on the list. On 4/13/22 at 4:49PM additional documentation was provided related to V51's declination. V51's declination states she declines due to religious reasons. A religious Accommodation Request form was provided to the surveyor. The Date of Request and R51's signature is not dated. Page 2 of the form is not completed. [This was requested by the surveyor at the end of V24's interview on 4/7/22.] V50's, CNA, declination form stated medical exemption on 12/17/21. The facility provided a vaccination card for R50 dated 4/8/22. [The day after V24 was interviewed.] No additional information was provided for V49's declination. The facility COVID 19 Vaccination for Staff Member policy revised on 1/19/22 notes the facility mandates that all employees participate in the COVID 19 vaccination program or complete a statement of declination. All staff are required to receive the 1st dose of vaccination unless they complete a declination with medical contraindication or because of religious beliefs.

Based on interview and record review the facility failed to evaluate a resident's tolerance to bolus tube feeding and have documentation of a resident's administration of a tube feeding according to a resident's care plan and facility's policy. This applies to 1 of 3 sampled residents (R2) receiving an enteral tube feeding. As a result, R2 aspirated on the tube feeding formula. Findings include: 1. R2 is a [AGE] year old female who was admitted to the facility on [DATE], with the following past medical history; Encounter for attention to [CONDITION(S)], encounter for attention to gastrostomy, type 2 diabetes, unspecified asthma, unspecified severe protein calorie malnutrition, pneumonitis due to inhalation of food and vomit, [CONDITION(S)] of face, pressure ulcer of sacral region, unsteadiness on feet, malignant neoplasm of mouth, dysphagia oropharyngeal phase, nausea with vomiting, etc. R2's hospital discharge record date 12/3/2021 contained the following information: patient tolerating continuous TF (tube feedings) formula at goal rate of 50ml/hr (milliliter per hour) times 24 hrs with saline flush of 100 ml (milliliters) every 4 hours. Recommended to discharge (R2) with continuous feeds to prevent aspiration. R2's admission notice dated 12/09/2021 specified the need for a [CONDITION(S)] and feeding pump. R2's facility physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for the tube feeding was discontinued on 12/22/2021, the day R2 was transferred to the hospital. R2's hospital record dated 12/22/2021 documented the following: Physician & History: [AGE] year old female with SCC (squamous cell carncinoma) of head/neck, dysphagia/g-tube (gastric-tube) dependent, hypertension and diabetes presenting with cough. R2 reported coughing for the last month. She felt like she was aspirating on food. R2 stated the coughing got worse with eating and sometimes when she got tube feedings. R2 thought the tube feedings she received at the nursing home were too fast which made her nauseated and resulted in vomiting and aspirating. The same document also documented the resident (R2) was seen by her ONC (oncology) team in the clinic yesterday and was found to have aspiration on her chest x-ray. R2's hospital physician notes for 12/26-12/29/21 dated 12/22/2021 included the following active medical issue: Aspiration, pneumonitis vs pnemonia -have coughing for one month with sensation of aspiration -chest x-ray 12/21 showing aspiration, can't rule out infection s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] R2's hosptal Adult Nutrition notes 12/28/2021 documented: R2 with oral cavity cancer s/p resection and b/l neck dissection. Pt (patient admitted with c/f aspiration PNA. Pt wasgiven bolus feedings at facility, where continuous feeding had been recommended. 2. The following are the interviews conducted with staff member about services provided for R2 regarding her tube feeding: On 12/29/2021 at 1:58PM V17 (Advance Nurse Practitioner/APN) said, R2 was readmitted . He evaluated her at the nursing home. The guidance given to the facility was for R2 to be on a feeding pump for her tube feedings. The facility was not willing to use the available supply and it was stated on the hospital discharge instruction R2 needed to be on a feeding pump. On 12/29/2021 at 2:33PM, V2 (DON) said the facility was aware R2 needed a feeding pump and she was admitted with some cartons of tube feeding formula. The feeding pump the facility had would not connect to her G-tube. R2's daughter did not bring any supply apart from the feeding formula. The facility received an order from the dietician to switch resident to bolus feeding until they received the ordered pump. On 01/03/2022 at 11:34AM, V13 (Dietician) said, I am aware R2 came in with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . We decided to put her on a bolus feeding. I am assuming the nurses told me of this otherwise, I would not have done it. I think there was a problem with the feeding pump or that it was not available. I changed her back to the feeding via the tube feeding pump on 12/16/2021 because I got information from the diet tech was R2 needed to go back to the pump on the 21st. Later, I got a text from the unit manager to go back to bolus. The bolus feeding was discontinued on the 22nd. The surveyor asked V13 if she gave any special instruction for the staff to monitor how R2 was tolerating the bolus feeding and V13 said, nursing is supposed to take care of that. 1/03/2022 at 12:57PM, V8 (diet tech) stated, R2 was changed back to bolus feeding on 12/21/2021. Nursing asked if they can have a different feeding. They did not tell V8 why and she did not ask either. V8 just referred the request to the dietician. V8 added, she does not handle any tube feeding orders, the dietician does. She is not sure what type of tube feeding orders R2 came with. She cannot recall if she was here the day R2 was sent to the hospital or the type of feeding she was getting. 01/03/2022 at 11:11AM V2 (DON) said, nurses are expected to administer tube feeding according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At 1:35PM V2 added, she is not aware that R2 was switched back and forth from pump to bolus feeding. She was aware of the initial time she was placed on bolus while waiting on the pump. She was not aware that she was on bolus feeding before she was transferred to the hospital. 3. R2's care plan dated 12/12/2021 under gastrostomy had the following interventions in part: -check tube placement and gastric contents/residual volume per facility protocol and record -monitor/document/report to MD (medical doctor) PRN (as needed) aspirations, fever, shortness of breath (SOB), diarrhea, nausea and vomiting, etc. The facility's policy for tube feeding administration with a revision date of 9/2021 states that nasogastric, gastrostomy and jejunostomy tubes are used when an alternate method of nutrition is needed. Under bolus feeding, the same document indicated staff should check tube placement by aspiration or air insertion, instill formula and run over appropriate time frame, monitoring resident for signs and symptoms of aspiration, document feeding and alert the health care provider of any issues or problems. There was no documentation found in R2's medical records for the monitoring of R2's tube feeding administration. Upon request the facility could not provide any documentation that resident was being monitored as specified in her care plan and facility policy.

Based on interviews and records review the facility failed to transcribe treatment orders during admission and failed to follow physician treatment orders for wound care treatment for 1 (R1) of 4 residents reviewed for wound care. This failure resulted in R1's wound worsening, developing [CONDITION(S)] with suspected [CONDITION(S)] and R1 being admitted to the local hospital for septic. Findings include: Review of R1's face sheet documents a [AGE] year-old male admitted to the facility on [DATE] after a right above the knee amputation and left above the knee amputation revision. Minimum Data Sheet (MDS) dated [DATE], section C, documents R1's mental status was severely impaired as noted in the Brief Interview for Mental Status (BIMS) score of 7 out of 15. Section G of MDS documents R1 requiring extensive assistance with all Activities of Daily Living. Review of R1's After Visit Summary from the hospital dated 9/24/21 includes recommended wound care and documents R1 had bilateral lower extremity wounds, a pressure ulcer to the sacrum, and 5 deep tissue pressure injuries to the lumbar-sacral spinal column. After Visit Summary also documents the following plan: Palliative care: Family requests SNF for Wound Care, awaiting placement. Following wound care recommendation. Ortho: Follow up in 2-3 weeks as outpatient Review of R1's Braden scale for predicting pressure sores risk was 13 on admission 9/25/2021. The score of 13 suggests R1 was a moderate risk for pressure ulcers. First visit by wound care doctor is documented on 10/7/2021 via Wound Evaluation & Management Summary. On this wound evaluation V6 (Wound Care Physician) documents, R1 is at high risk for wound decline and new wound development. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Clean Sacrum with normal saline, pat dry, then apply Dakin's soaked gauze and cover with dry dressing daily and as needed. According to Dakin's manufacturer website: getdakins.com, Dakin's kills MSRA, VRE and more within 30 seconds. Effective against biofilm-forming bacteria. On 11/19/2021 WebMD.com documents Dakin's Solution is used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses. Review of R1's Wound Treatment Administration Record (TAR) is absent of any initials that wound treatments for R1's sacral wound was done for 10/30/31, 10/31/2021, 11/1/2021 and 11/2/2021. On 11/17/2021 at 2:35 PM V3 (ADON) states she expects nurses to follow doctor's orders. On 11/17/2021 4:32 PM V18 (Wound Care Director) stated (she) understands if TAR is not signed then it's not done. On 11/18/2021 at 1:38 PM V11 (LPN), states she remembers caring for R1 on 10/30/2021. V11 stated, normally wound care nurse does wound changes and if not, the nurse assigned does it. V11 stated once wound care is done, we sign off on Treatment administration Records (TAR). It was a pretty busy weekend. I remember signing off the TAR. On 11/18/2021 at 1:44PM V9 (LPN) states she remembers R1 and caring for him on 10/31/2021 and 11/2/2021. V9 stated, if the wound care nurse isn't available, the nurses do the wound care treatments. V9 stated they (Nurses) look at the MAR and TAR and follow treatment per doctor orders, then they sign out the TAR. I probably didn't sign off on it on the TAR. On 11/18/2021 at 1:57 PM V10 (LPN) stated she remembers taking care of R1 on 11/1/2021. In regard to 11/1/2021 wound care, V10 states, No I did not do his wound care that day. I don't recall if the wound care nurse did it. On 11/17/2021 at 11:18 AM V12 (CNA) stated R1 was a feeder and Hoyer lift and had wounds and [CONDITION(S)] of both legs. R1 was alert to self once in a while. V12 stated I went to change R1 and noticed he wasn't soiled; it was his wound that was smelling. V12 stated, No one in the previous shift mentioned it to me. I believe it was V9 (LPN) who I told to look at it. This happened a day or two before he left (to the hospital). On 11/18/2021 at 4:02 PM V6 (Wound Care Doctor) stated, on 10/28/21 R1 displayed no signs and symptoms of an underlying infection. V6 stated when she saw R1's sacral wound on 11/4/2021, she suspected [CONDITION(S)]. V6 stated. It was purple and dark and odorous. V6 stated, With a normal person perhaps missing 4 wound care treatments would have caused infection, but not R1. It probably would not have mattered in terms of his total clinical picture. Review of wound evaluation and management dated 11/4/21, V6 documents wound shows significant decline, wound joined with buttock wound, malodorous, necrotic, bone exposed, concerning for clinical [CONDITION(S)]. Review of 11/5/2021 Progress notes by V8 (LPN) documents, R1 was noted to be lethargic, with shallow, labored breathing. Rapid response called, EMS called, and resident sent to the hospital. Hospital Physician note dated 11/5/21 19:32 documents the following: Clinical Impression: [CONDITION(S)], due to unspecified organism, unspecified whether acute organ dysfunction present (HCC) Dehydration. Emergency Department provider notes dated 11/5/2021, includes but not limited to the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure that a newly admitted resident was prescribed anti-[CONDITION(S)] medication at a therapeutic level for the management of epileptic seizures. This failure resulted in a resident experiencing symptoms related to [CONDITION(S)] and being hospitalized with subtherapeutic anti-[CONDITION(S)] medication levels and applied to one (R4) of three residents reviewed for physician orders. Findings include: R4 was admitted into the facility on [DATE] from an acute care facility. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing progress note dated 10/17/21, written by V3 (LPN, Licensed Practical Nurse) reads: Writer spoke with V4 Family Member, V4 verbalized some concerns regarding her dad's medications. V4 verbalized that her dad normally takes [MEDICATION(S)] ER 250mg at bedtime. [MEDICATION(S)] 100mg three times daily 5 days a week, alternating with [MEDICATION(S)] 100mg twice daily 2 days a week. Endorse to night shift nurse to follow up with MD in the am regarding these new orders. Review of R4's current POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] Tablet 1000mg Give 1 tablet by mouth two times a day for anti-epileptic Start Date: 10/8/2021 - [MEDICATION(S)] Capsule 100mg Give 1 capsule by mouth two times a day for anti-epileptic Start Date: 10/9/2021 Additional orders include: - [MEDICATION(S)] Capsule 100mg Give 1 capsule by mouth three times a day every Mon, Wed, Fri, Sat, Sun for anti-epileptic, Start Date 10/18/2021 - [MEDICATION(S)] ER Tablet Extended Release 24-hour 250mg Give 1 tablet by mouth at bedtime related to [CONDITION(S)] Start Date 10/18/2021 - [MEDICATION(S)] Capsule 100mg Give 1 capsule by mouth two times a day every Tue, Thu related to [CONDITION(S)] Start Date: 10/19/2021 Nursing progress note dated 10/18/21 at 12:06 AM, V5 (LPN), documented: During rounding, pt. noted having [CONDITION(S)] like symptoms. Body shaking, no response, eyes rolling in the back of head. Pt turned on side until subsided. Vitals taken and neuro check performed. Pt noted with left sided weakness. Call third eye and spoke with V6 Physician. Orders given to give [MEDICATION(S)] 1 gram by mouth now then daily and to obtain labs in the am (CBC Complete Blood Count, CMP Complete Metabolic Panel, [MEDICATION(S)], [MEDICATION(S)]). Called V4 Family Member. 10/18/21 at 12:33 AM, V5 (LPN) conducted a telehealth visit for R4 with V6 (Physician): patient with [CONDITION(S)] x 3 over the weekend. Patient is on [MEDICATION(S)] for seizures. However, when nurse called V4 Family member V4 stated the patient should be on both [MEDICATION(S)] and [MEDICATION(S)]. Patient has not received [MEDICATION(S)] since he has been at the facility. Diagnosis, Assessment/Plan: patient not receiving [MEDICATION(S)] in addition to [MEDICATION(S)] per V4 Family Member and has had seizures as a result. No current lab work. Will send blood work and start [MEDICATION(S)] and obtain neurology consult to assist with [CONDITION(S)] management. Give [MEDICATION(S)] 1 gm (gram) by mouth x 1 stat dose now then give daily. Obtain neurology consult this week. Disposition: Stay at Facility. 10/18/21 at 3:51 PM, V9 (Nurse Manager) documented: spoke with V4 Family Member and went over all medications. V9 (Nurse Manager) spoke with V10 (Physician) regarding changes in medications voiced by V4 and for R4 to return to regular scheduled medications as ordered and how he was taking them at home. V10 ok with changes. 10/19/21 V8 (RN, Registered Nurse) documented: V4 Family Member at nurse's station, expresses frustration regarding the care R4 has been receiving. R4 expresses frustration about how patient [CONDITION(S)] medications have been ordered and administered. V4 requests R4 be transferred to the hospital to receive [MEDICATION(S)] intravenously. At 3:53 PM, V21 (Previous DON) met with V4 (Family Member) and addressed concerns with medication changes made during hospitalization . Medication adjustments done previously to reflect at home routine. V4 now concerned with R4's [MEDICATION(S)] level. Refusing in house interventions. V4 prefers transfer to the hospital for IV therapy. At 5PM, R4 was transferred to the hospital via ambulance. Hospital emergency department documentation indicates: R4 stated, The nursing home has been getting his medication dosing wrong. Therapeutic drug monitoring [MEDICATION(S)] ([MEDICATION(S)]) lab work dated 10/18/21 documents: 3.3 (L) low (Reference range is 10.0-20.0 ug/ml). The 10/19/21 hospital emergency department diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Subtherapeutic serum [MEDICATION(S)] level. R4 was admitted for observation. Hospital lab work indicates: [MEDICATION(S)] value- 4.0 (L) Low, Reference Range: 10.0-20.0 mcg/ml (micrograms/milliliter). 11/9/21 at 2:49 PM, V10 (Physician) stated, There is no clear-cut policy on [MEDICATION(S)] monitoring, it varies patient to patient. Baseline is once a week but when a patient is stable with no changes on a medication it is usually monitored monthly. If the patient is stable from the hospital no labs are ordered upon admission. 11/9/21 at 3:35 PM, V2 (DON) inquired on facility's policy for therapeutic drug monitoring and V2 stated, We don't have a policy, it's according to each patient.

Based on interview and record review the facility failed to ensure a resident was assisted and supervised during ambulation and toileting for 1 of 5 residents reviewed for safety and supervision in the sample of 5. This failure resulted in R1 falling and sustaining a fracture of left humerus and left parietal scalp abrasion. The findings include: R1's electronic medical record accessed on 10/29/21 shows R1 is a 68 y/o female who was admitted to the facility on [DATE] with diagnoses that includes [CONDITION(S)], diabetes, [CONDITION(S)] and weakness. R1's facility assessment dated [DATE], shows R1 is cognitively intact. The same assessment shows R1 needs extensive assist of 1 person for toileting and ambulation. R1's progress note dated 10/9/21 at 17:23 (5:23 PM), shows R1 was heard yelling in the hallway, 'I am falling'. Resident was observed lying on the floor in an upward position without proper footwear. Resident obtained a laceration to the back of her head and skin tear to left forearm. Resident stated, 'I was going to the bathroom and I lost my footing and just fell .' Resident was placed in mechanical lift and transferred to wheelchair; nursing assessment was completed 911 was called MD notified R1's emergency report (ER) dated 10/9/21 shows, [R1] arrived from [nursing home] after falling. Pt is c/o head pain and left arm pain. Pt has skin tear to left elbow, no LOC per EMS pt. was hypotensive. R1's Radiology report dated 10/9/21 shows, X ray of left shoulder confirms there is a comminuted fracture of the proximal left humerus. R1's hospital record also shows R1 sustained left parietal scalp abrasion. The Facility Reported Incident sent to the state agency- Final Report dated 10/15/21 shows X-ray performed at hospital, [R1] has acute fracture involving surgical neck of the humerus . On 10/29/21 at 11:36 AM, V9 (License Practical Nurse-LPN) said she was the nurse working on 10/9/21, the day of the incident. V9 (LPN) said she was told R1 was not feeling well. V9 said as she was walking towards R1's room, R1's call light was on. V9 said when she entered R1's room, she saw V10 (Certified Nursing Assistant-CNA) was already in R1's room. V9 said she saw R1 walking to the bathroom by herself. V9 said since V10 was already in the room, she assumed V10 would assist R1, so V9 said, she left R1's room. V9 said she then heard R1 yell I'm falling! V9 said she rushed back to the room and found R1 on the bathroom floor bleeding. V9 said R1 told her she hit her head. V9 said R1's left arm was also bleeding. V9 said she should have stayed in the room and assisted R1 to make sure R1 was safe, but she left R1's room thinking that the CNA (V10) was going to assist and supervise R1. V9 said R1 was sent to the ER via 911. On 10/29/21 at 1:25 PM, V10 (CNA) said she was in R1's room but she was not assisting R1. V10 said then she heard the nurse (V9) say R1 fell in the bathroom. On 10/29/21 at 1:05 PM, V13 (Nurse Practitioner) said residents should be supervised and provided staff assistance when needed for residents safety. R1's latest care plan shows R1 is at risk for falls due to diagnoses of diabetes, [CONDITION(S)] and [CONDITION(S)] with intervention that include anticipate and meet the resident's care and safety needs. On 10/29/21 at 2:00 PM, V1 (Administrator) and V2 (Director Of Nursing) both said they just started last Monday (10/25/21) and will work on improving issues brought up to them including resident's care and safety. The facility policy entitled Fall Prevention and Management dated 10/2021 shows, this facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. 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.

Based on interviews and record reviews, this facility failed to meet professional standards of quality care for one resident (R5) out of three residents reviewed for a fall with injuries and timeliness of transport to the hospital in a sample of 18. This failure resulted in a delay of 2 hours and 25 minutes in R5 receiving intensive monitoring and hospital-level treatment for [REDACTED]. Findings include: Review of the medical record notes R5 with [DIAGNOSES REDACTED]. On 12/7/18 at 2:50pm, V7 CNA (certified nurse aide) stated that R5 was total dependence on staff for ADLs (activities of daily living). V7 stated that V7 had another CNA assist V7 with R5's care due to R5's inability to participate in care. On 12/11/18 at 1:00pm, V2 DON (director of nursing) stated that after reviewing R5's medical record, R5 fell out of bed while receiving care by V11 CNA at 7:00pm on 11/10. V2 stated that at 7:30pm, EMS (emergency medical services) arrived to transport R5 to the hospital. This surveyor reviewed the EMS run sheet for 11/10/18 with V2. V2 acknowledged that EMS was not contacted by staff until 9:25pm. V2 was not able to articulate why EMS was not contacted for 2 hours 25 minutes or what, if any, care was provided to R5 during that time. On 12/12/18 at 1:40pm, V15 LPN (licensed practical nurse) stated that V15 was called about 9:15pm by V12 LPN to see if V15 could sit with R5 while V12 called physician and paramedics. V15 stated that V12 did not inform V15 of what time R5 fell just that R5 fell while receiving care. On 12/12/18 at 2:30pm, V16 CNA stated that a CNA came and got V16 to help lift R5 into bed. V16 stated that V11 CNA, V12 LPN, and another CNA were in room when V16 arrived. V16 stated that a mechanical lift device was used to transfer R5 back into bed. V11 and V12 are no longer employed at this facility and were unavailable to speak with regarding this incident. Review of R5's EMS (emergency medical services) run sheet, dated 11/10/18, notes EMS was contacted at 9:25pm to transport R5 to hospital due to bleeding from mouth. EMS arrived at this facility at 9:27pm. Crew knocked on facility door for approximately 5 minutes with no answer. The door the crew was knocking on is the designated door requested by this facility for EMS crew to enter. Crew waited several minutes until a staff member escorted EMS crew around the building to a door on the west side. Crew waited an additional 1-2 minutes before accessing this facility. R5's room was on the opposite side of where crew entered. Upon EMS arrival to R5, R5 was found lying in bed, responsive to painful stimuli. Blood was observed coming from R5's mouth. R5 had a contusion around left eye. Blood was observed on the floor. R5's family relayed to EMS crew that the staff told them that R5 fell and was placed back in bed. No nurse was found on scene. CNA staff could not provide information of the incident to the crew. R5 was placed on cot and loaded into ambulance where ALS (advanced life support) continued. Review of R5's hospital record, dated 11/10/18 at 9:50pm, R5 was taken emergently for a head CT (computed tomography) scan which noted an acute subdural hematoma with a 2mm (millimeter) shift of the midline towards the right. In the emergency department, R5's speech was incomprehensible and with decreased level of consciousness. At 11:30pm, R5 was transferred via ALS ambulance to a higher level of care for further treatment. Review of R5's medical record, dated 11/10/18 at 7:00pm, notes while receiving care, R5 was repositioned to the left side by V11 CNA (certified nurse aide), V11 looked away, R5 fell to floor. V11 called V12 LPN (licensed practical nurse) to room to assess R5, body assessment done. V12 noted hematoma to left eye, ice pack applied, and bleeding from nostril, pressure applied to nasal area. Vital signs taken blood pressure 154/64, heart rate 84 beats/minute, respirations 20/minute, temperature 97.2 degrees Fahrenheit, and oxygen saturation 95%. Neurological checks in place. R5 had no complaints of pain. R5's physician paged and family contacted made aware per family request 911 call immediately. R5 continues to be monitored by staff on duty. Review of R5's MDS (minimum data set), dated 10/3/18, notes R5 required extensive assistance by two or more staff for physical assistance with bed mobility (turning/repositioning). R5 was totally dependent on two or more staff for toileting/incontinence care. Review of R5's falls care plan, dated 9/1/18, notes R5 is at high risk for falls related to impaired mobility and dementia. R5 has limited range of motion to both upper and lower extremities. R5 is dependent on staff for all aspects of care. R5 is non-ambulatory and has poor trunk control. R5 requires two person assistance with ADLs (activities of daily living). Interventions identified include: anticipate and meet R5's care and safety needs and follow facility fall protocol. Review of R5's range of motion screen, dated 10/17/18, notes R5 has severely limited mobility of left arm and no joint mobility of right arm, right leg, or left leg.

Based on interviews and record reviews, this facility failed to ensure adequate supervision to prevent an accident for one (R5) out of three residents who required two person assistance with ADLs (activities of daily living) in a sample of 18. This failure resulted in R5 sustaining significant injuries requiring hospitalization . Findings include: Review of the medical record notes R5 with [DIAGNOSES REDACTED]. On 12/7/18 at 2:50pm, V7 CNA (certified nurse aide) stated that R5 was total dependence on staff for ADLs (activities of daily living). V7 stated that V7 had another CNA assist V7 with R5's care due to R5's inability to participate in care. On 12/12/18 at 1:40pm, V15 LPN (licensed practical nurse) stated that V15 was called about 9:15pm by V12 LPN to see if V15 could sit with R5 while V12 called physician and paramedics. V15 stated that V12 did not inform V15 of what time R5 fell just that R5 fell while receiving care. On 12/12/18 at 2:30pm, V16 CNA stated that a CNA came and got V16 to help lift R5 into bed. V16 stated that V11 CNA, V12 LPN, and another CNA were in room when V16 arrived. V16 stated that a mechanical lift device was used to transfer R5 back into bed. V11 and V12 are no longer employed at this facility and were unavailable to speak with regarding this incident. Review of R5's EMS (emergency medical services) run sheet, dated 11/10/18, notes EMS was contacted at 9:25pm to transport R5 to hospital due to bleeding from mouth. Upon EMS arrival to R5, R5 was found lying in bed, responsive to painful stimuli. Blood was observed coming from R5's mouth. R5 had a contusion around left eye. Blood was observed on the floor. R5's family relayed to EMS crew that the staff told them that R5 fell and was placed back in bed. No nurse was found on scene. CNA staff could not provide information of the incident to the crew. R5 was placed on cot and loaded into ambulance where ALS (advanced life support) continued. Review of R5's hospital record, dated 11/10/18 at 9:50pm, R5 was taken emergently for a head CT (computed tomography) scan which noted an acute subdural hematoma with a 2mm (millimeter) shift of the midline towards the right. In the emergency department, R5's speech was incomprehensible and with decreased level of consciousness. At 11:30pm, R5 was transferred via ALS ambulance to a higher level of care for further treatment. Review of R5's medical record, dated 11/10/18 at 7:00pm, notes while receiving care, R5 was repositioned to the left side by V11 CNA (certified nurse aide), V11 looked away, R5 fell to floor. V11 called V12 LPN (licensed practical nurse) to room to assess R5, body assessment done. V12 noted hematoma to left eye, ice pack applied, and bleeding from nostril, pressure applied to nasal area. Vital signs taken blood pressure 154/64, heart rate 84 beats/minute, respirations 20/minute, temperature 97.2 degrees Fahrenheit, oxygen saturation 95%. Neurological checks in place. R5 had no complaints of pain. R5's physician paged and family contacted made aware per family request 911 call immediately. R5 continues to be monitored by staff on duty. Review of R5's MDS (minimum data set), dated 10/3/18, notes R5 required extensive assistance by two or more staff for physical assistance with bed mobility (turning/repositioning). R5 was totally dependent on two or more staff for toileting/incontinence care. Review of R5's falls care plan, dated 9/1/18, notes R5 is at high risk for falls related to impaired mobility and dementia. R5 has limited range of motion to both upper and lower extremities. R5 is dependent on staff for all aspects of care. R5 is nonambulatory and has poor trunk control. R5 requires two person assistance with ADLs (activities of daily living). Interventions identified include: anticipate and meet R5's care and safety needs and follow facility fall protocol. Review of R5's range of motion screen, dated 10/17/18, notes R5 has severely limited mobility of left arm and no joint mobility of right arm, right leg, or left leg.

Based on observations, interviews and record reviews, the facility failed to accurately complete the Braden Skin Risk Assessment Tool, re-assess and complete the Braden Assessment after the development of a pressure ulcer, monitor and follow the care plan interventions for daily skin checks for one resident, R15, out of 4 residents reviewed for pressure ulcers from a total sample of 29. This failure resulted in R15 developing an unstagable necrotic pressure ulcer measuring 3.9 centimeters by 3 centimeters. Findings include the following: R15 is an [AGE] year old male resident who was admitted to the facility September 5, 2012 from an acute care hospital with the following Diagnosis: [REDACTED]. According to the facility's "Clinical Assessment Report for Skin Wound Assessment" for September 6, 2012, R15 was noted with no pressure sore upon admission to the nursing facility. In addition, R15's Braden Assessment for pressure ulcers completed on September 6, 2012 indicates that R15 is low risk for pressure ulcers. The Braden assessment dated [DATE] also indicates that R15 is a low risk for pressure ulcers. R15 ' s initial care plan dated September 5, 2012 from admission states the following: " resident at risk for skin complications r/t (related to) impaired mobility, incontinence of bowel and bladder, disease process, and co morbidities. " The care plan also documents as an intervention the following: " Observe skin daily, with ADL (Activities of Daily Living) care for any changes such as redness, bruising in skin, tender areas and report to nurse. " The nursing progress notes of September 22, 2012 indicate that R15 was noted with an open area to the coccyx during morning care. Nursing notes state the following: " Resident was noted with a small open area to coccyx. " The Skin Wound assessment dated for September 22, 2012 states the following under wound assessment: " Resident observed with Unstageable to sacrum pink/yellow/gray in color 20% pink and 80% necrotic tissue. " The wound was measured to be 3.9 centimeters by 3.0 centimeters. As of October 23, 2012 skin-wound assessment, R15's wound has increased in size and continues to worsen. The wound was measured to be a Stage IV wound 5.0 centimeters by 4.0 centimeters by 3.5 centimeters. On 11/1/12 at 9:50am, R15 was in bed, opened eyes to name called, but unable to participate in a conversation. E14 and E 13 (Treatment Nurses) performed wound care on R15's sacral pressure ulcer. E13 stated that R15 is incontinent of bowel and needs to be cleaned after each incontinent episode. E13 stated R15 should be turned, re positioned, and checked for incontinence every 2 hours. On 11/1/12 at 1pm, E13 stated the floor nurses really don't know how to do a Braden scale. R15 is a higher risk for skin breakdown than assessed on the Braden Scales on 9/13/12 and 9/20/12. On 11/1/12 at 4:30pm, Z10 (Physician) was interviewed and stated R15 is at risk for skin breakdown due to immobility and incontinence. Z10 stated that R15's wound already had dead tissue on it when it was discovered, this could lead to infection. Z10 stated close monitoring of R15's skin would have identified the breakdown earlier and before it was a necrotic unstageable pressure sore. On 11/5/12 at 10am, E 14 stated Braden Scales are done with a change in condition which is the development of a new wound, change in an existing wound or change in functional status. E14 stated R15 should have had a Braden Scale on 9/22/12, upon discovery of the necrotic sacral pressure ulcer, but one was not completed. On 11/5/12 at 12:30pm, E3 (Asst Director of Nursing) stated skin assessments are to be done daily and with skin care. Skin condition is documented daily on the Bath and Skin Report Sheet when residents are cleaned and with baths. E3 verified that R15's Bath and Skin Report Sheet was not completed from 9/19/12, 9/20/12, and 9/21/12. There is no other documentation in the chart regarding the condition of R15's skin on these three days, prior to the discovery of the necrotic sacral pressure ulcer.

Based on interview and record review, the facility failed to provide adequate supervision for one (R7) of 3 residents with multiple falls in a sample of 9 residents. R7 fell , 9/3/2011 resulting in a hospital emergency room visit. R7 was diagnosed with [REDACTED]. Findings Include: 1. Z1 (Sister of R7) was interviewed by telephone 2/28/2012 in the AM. Z1 was R7's POA. Z1 stated that she received a call from the facility that her brother had fallen and fracture a bone in his face. "My family had planned a picnic for Labor day (9/5/2011) and they called the day before, 9/4/2011. I talked to a CNA (E5). E5 said that she saw my brother and some other residents go out of the facility. E5 told me that my brother walked from the facility (104th & Robert's Road) down to some banquet hall passed 95th & Robert's Road. A wedding party was going on. They (wedding guest) knew that he didn't belong there because he had on his pajamas. My brother fell and they called an ambulance." During the phone interview, Z1 stated that her brother was not to leave the facility accept with staff or family. A progress note dated 9/3/11, 21:57 hours written by E4 (CNA) stated that R7 had fallen and was taken to the emergency room for treatment. Both his Physician and family was notified. E 4 could not be interviewed concerning the fall, because she no longer works for the facility. The facility submitted an incident report dated 9/5/11 that was sent to the Illinois Department of Public Health (IDPH). The incident report does not contain any information about where the fall took place; who called for an ambulance; or whether or not staff knew the resident was out of the facility. An emergency room hospital record dated, 9/4/2011, substantiates that R7 was treated for [REDACTED]. 9/5/2011, the facility initiated a care plan for elopement for R7. R7 had a care plan for falls originally dated 6/7/11. It was updated 7/21/2011 because of a fall. R7 was found on the floor in his room. R7 had misjudged where the bed was when he tried to sit down. His fall assessment for this fall states that R7 has a balance problem when walking. Previous to this fall, he had fallen 1 to 2 times in the last 3 months. A note was added to approaches, about feeling the bed with the back of his legs before sitting down. Another note was added to the resident's fall care plan, 8/23/2011. "R7 to be escorted by staff or family for walks." R7 had a [DIAGNOSES REDACTED]. The resident was put into hospice, 6/21/2011. At the time of the 9/4/2011 incident, R7 was taking psychotropic drugs and potent pain medication. A 7/26/11 at 10:31 hours states that R7 is noncompliant with his walker. However, no update to his care plan. 3/14/2012 at approximately 1PM, during a Daily Status report, E1 (Administrator) admitted that the resident was out of the facility for the fall of 9/3/2011. "He took himself out." R7's sister had Power over Health for the resident and should have been consulted before allowing the resident out by himself.

A. Based on observations, record review and interview, the facility failed to assess and document the effectiveness of the pain medication for 2 residents (R5, R6) inside the sample and one resident (R29) in the supplemental sample. The findings include: 1) On 7/20/11 at 12:55 p.m., R6 was seated in his wheel-chair in the hall when he informed the surveyor he has pain in his ankle wound. He says the pain stays between 9 and 10 (zero being no pain and 10 being the worst pain). R6 stated he told the nurse today, yesterday and the day before about the pain. He stated he was told by E20 (nurse), the nurse on duty today, she would check into the medication. R6 stated he gets the [MEDICATION NAME] at 9 a.m. and 9 p.m. but he needs something in between the dosages for the pain. He stated the medication works for 2 and half hours before it starts to wear off. Throughout the week, R6 would be in his room on the bed or seated by the bed. R6 would leave his room via wheel-chair to go outside for a smoke or to go to the dining room to the vending machines. R6 took all his meals in his room. When R6 propelled himself in the wheel-chair, he would have his right leg elevated on the foot-rest and would use his left leg to propel himself. He would take frequent breaks to rest. R6 is [AGE] year old male who speaks Polish and English. On 7/20/11 at 1 p.m., E20 stated when she spoke to R6 at 9 a.m. he informed her of the pain being at 9 - 10. She stated he gets the [MEDICATION NAME] at 9 a.m. and 9 p.m. and she gave the medication at 9 a.m. When she was back in his room at 11:20 a.m., doing his accucheck, he stated he was still having pain in the ankle wound. E20 stated she looked for another order for pain medication but did not find one. Surveyor asked E20 if she assessed his pain at 11:20 a.m. she responded she assessed the pain at 9 a.m. At 1:15 p.m., E20 stated she called the physician and left message. At 1:40 p.m., E20 stated she received an order for [REDACTED]. On 7/21/11 at 11:40 a.m., R6 was seated in his wheel-chair. R6 stated he received the [MEDICATION NAME] yesterday but it only worked for 2 and half hours. He stated he received the [MEDICATION NAME] and Tylenol this morning but it only worked for 2 and half hours. R6 stated the pain is at a "9-10" in the ankle wound. E22 (nurse), who over heard us talking, stated he received the [MEDICATION NAME] at 9:40 a.m. and is not due for his [MEDICATION NAME] until 12 noon. The MAR indicated [REDACTED]. Review of the pain assessment dated [DATE] documents he is not on scheduled pain medications but has an order for [REDACTED]. There were no other pain assessments provided except the 6/19/11. Review of the care plan (6/28/11) documents pain as a problem with the approaches to evaluate the effectiveness of pain medications, assess pain daily and implement pain relief measures to promote rest and comfort. The care plan for the [MEDICAL CONDITION] documents R6 is orient times three. The current (6/19/11) MDS confirms R6's orientation. Review of the P.O.S. for June 2011 documents [MEDICATION NAME] 300 mg three times a day at 6a.m, 2 p.m 10 p.m . and an order for [REDACTED]. Review of the July 2011 P.O.S. documents [MEDICATION NAME] 15 mg twice a day, [MEDICATION NAME] 300 mg daily both started 7/15/11. Review of the MARs documents the [MEDICATION NAME] and [MEDICATION NAME] were given as ordered but no documentation of the effectiveness of these medications. The [MEDICATION NAME] was not given to R6 but no documented reason. R6 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].O.S. Review of the nurses' noted dated 7/11/11 document R6 was sent to the hospital for right leg pitting (+4) [MEDICAL CONDITION] and redness and re-admitted [DATE]. There was no pain evaluation provided except the 6/19/11 assessment. 2) On 7/19/11 between 9:43 a.m. to 11:06 a.m. during the initial tour with E4 and E26, R5 who on his bed and dressed stated he ached everywhere and takes a lot of medication. Earlier during report from staff, R5 wheeled himself to the nurses' station and stated he was having chest pains and his last two left fingers were numb. Later at 1:45 p.m., R5 was back on his bed and stated the chest pain and numb fingers had subsided. On 7/20/11 at 9:55 a.m., R5 was on his bed very upset. He stated he is going home no matter what. He stated he has a friend picking him up tomorrow at 10 :30 a.m.. R5 would like the okay from the physician but if he does not get it he states he is leaving anyway. R5 stated that he has not gotten relief from the pain and needs his [MEDICATION NAME]. He stated he received it on Monday and now he can't get it. R5 stated he has had many surgeries in his life. R5 proceeded to give a litany of surgeries, heart surgery requiring 3 stents, 2 laminectomies, surgery on his leg and so on. R5 stated he has his own doctors and lives in Downers Grove independently in an apartment. He stated on 7/15/11 he left his home and went to the emergency room due to hurting his leg. He walked on it without using his ankle/foot splint and he fell down on it. So he stated he went to the ER and everything just snow-balled. He stated he was bounced from the hospital to a nursing home, back to another hospital and then here. R5 stated he went to the hospital to get physical therapy on his leg and he was sent to the nursing home. R5 stated he wants to return to his apartment and his own doctors. On 7/20/11 at 10:15 a.m., E19 (nurse) stated a call has been place to R5's physician. E19 stated the [MEDICATION NAME] and [MEDICATION NAME] were discontinued on 7/18/11 and presented the telephone order. The P.O.S. did not reflect the medications being discontinued. During this conversation with E19 at the nurses' station, R5, who was seated in wheel-chair, was present complaining of pain and saying it was a "9". R5 stated the [MEDICATION NAME] at 6 a.m. only brought his pain down to "9" from a "10". E19 asked the location of pain and R5 responded it is in his legs, back and neck. E19 stated she can not give another [MEDICATION NAME] until 12 p.m. Surveyor asked about the PRN order for [MEDICATION NAME]. E19 responded that it is for every 6 hours as needed so she can not give it until 12 p.m. E19 agreed the PRN order is not clear about the break through pain. E19 stated she placed a call into the physician about R5's desire to leave and requesting a stronger pain medication. On 7/20/11 at 11:07 a.m., R5 stated he has had no pain pill since morning and his pain is at a "9". R5 stated he was told he needs to wait until 1 p.m. before he can have another pain pill. R5 is insistent that the [MEDICATION NAME] he took at home works best but it was discontinued the other day. R5 stated the facility put him on the [MEDICATION NAME] and [MEDICATION NAME] when admitted but he did not want the [MEDICATION NAME] and told them. R5 stated they discontinued the [MEDICATION NAME] and the [MEDICATION NAME]. He does not understand why they also discontinued the [MEDICATION NAME]. R5 stated his community doctor had prescribed it and he takes it at home. Later at 1:15 p.m., R5 stated he received the [MEDICATION NAME] at 12 noon but needs the [MEDICATION NAME] for the break-through pain. R5 stated he feels like no one is listening and the pain interferes with his concentration. He stated maybe it would be better for them if he was dead. R5's eyes filled with tears and he stated he uses the wheel-chair because of the pain when he walks. Review of the current P.O.S. documents [MEDICATION NAME] ER 15 mg twice a day at 6 a.m. and 6 p.m., [MEDICATION NAME] 10/325 mg every 8 hours at 6 a.m., 2 p.m. and 10 p.m. and [MEDICATION NAME] 4 mg every 4 hours as needed for pain. There is an order for [REDACTED]. Review of the current MAR indicated [REDACTED]. There was no documentation on the effectiveness of the medication or any other medication for pain. The [MEDICATION NAME] and [MEDICATION NAME] were discontinued on 7/18/11 per telephone order. There was no pain assessment provided for R5. R5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R5 is alert, orient times three. 3) On 7/19/11 between 9:43 a.m. to 11:06 a.m. during the initial tour with E4 and E26, R29 stated she was having pain in her lower back. R29 stated she received a pain pill, regular Tylenol, at 6 a.m. which brings the pain down but it still hurts. E4 stated to R29 maybe we can get your order changed. E19 (nurse) at the nurses' station stated she gets [MEDICATION NAME] at 4 p.m. Review of R29's P.O.S. documents regular Tylenol 325 mg (milligrams) every 6 hours at 12 a.m., 6 a.m., 12 p.m. and 6 p.m.., 81 mg of aspirin and the [MEDICATION NAME] at 4 p.m.. There is another order for regular Tylenol to be used (PRN) as needed every 6 hours but no parameters as to when to give this medication when getting the same medication already. Review of the current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The PRN Tylenol was given on 7/3/11 at 9 a.m. for back pain but no documentation on the effectiveness of it. 4) Review of the facility's policy on pain management it documents a comprehensive pain assessment will be conducted when on routine pain medications and the pain is not controlled and/or pain medication use is significantly increased. A pain flow sheet will be initiated when reporting pain and completed on each shift. The effectiveness of the pain interventions should be measured every 1 to 2 hours after administration of treatment using the pain scale. B. Based on observation, interview and record review the facility failed to ensure staff followed proper technique during incontinent care for 2 residents (R12, R13 ) in a sample of 7 residents assessed as needing incontinence care assistance.The sample size is 24 residents. Findings include: 1.During provisions of incontinent care for R13 on 7/20/2011 at 10:20 a.m , E15 ( Certified Nursing Assistant -CNA ) with gloved hands used the wet towel brought in to clean the rectal area. E15 removed two diapers from R13 , cleaned the rectal area and applied vaseline before putting on the diaper without changing gloves. The perineal area of R13 was not cleaned by E 15.The Minimum Data Set, dated dated dated 5/22/11 indicates 0 which means always continent. However this resident was wearing diapers. Interview on 7/26/11 at 10:30 a.m , E15-Certified nurse's assistant-CNA said "I have worked here since March 2011 and I was trained by another CNA in my orientation". E15 futher explained that" I can't stand in front of R13 to clean him, so I clean his bottom and then put my arm through to clean his front area". "I change my gloves before I exit the room and I did not know I had to change them before then". 2.During provisions of incontinent care for R 12 on 7/20/2011 at 12:15 p.m , E 12 ( Certified Nursing Assistant- CNA) with gloved hands brought in a wet towel and applied a cleaning agent to the rectal area of R12. E12 was giving care to R12 with both siderails up on the bed and the foot of the bed was elevated. E 12 removed R12's diaper and threw it on the floor. She cleaned R12's rectal area and put a new diaper on without cleaning the perineal area. The Minimum Data Set, dated dated dated 06/06/11 indicates 3 for bowel and bladder which means need extensive assistance.