Every finding on record at Norwood Crossing

Based on observations, interviews, and record reviews, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of communicable disease. The facility failed to ensure staff used appropriate personal protective equipment (PPE) when entering residents' contact isolation room, failed to properly handle and store contaminated linen and clothing, failed to follow facility protocol for laundering linens belonging to a resident diagnosed with crusted scabies, and failed to maintain required contact isolation by allowing the resident to leave the isolation room. These deficient practices affected two (R1, R3) out of five residents reviewed for infection prevention and had the potential to affect all 101 residents residing in the facility. Findings Include: R1's clinical records show an initial admission date of 4/25/25 with included diagnoses but not limited to Parkinson's Disease and Anxiety Disorder. R1's Minimum Data Set (MDS) assessment dated [DATE] shows R1 has cognitive impairment and is total dependent on staff's assistance with her Activities of Daily Living (ADL).R1's progress notes dated 7/14/26 at 6:23 PM documented by V20 (Licensed Practical Nurse/LPN) reads in part: [R1] returned from Dermatologist appointment with Dx [diagnosis] of scabies. [R1] to start Ivermectin 3mg tab, 3 tabs for two days then 1 week later 3 tabs x 2 day, and 1week after those, 3 tabs x 1 day for a total of 15 3mg tabs. Triamcinolone 0.1% bid [twice a day] x 2 weeks, then every other day. [(V40 (R1's Physician)] informed and said to treat [R1]. [V6 (R1's Family Member/Power of Attorney)] aware. [R1] on contact isolation.R1's progress notes dated 7/21/26 at 10:52 PM documented by V40 reads in part: [R1] seen and examined full note to follow diagnosis of scabies in hand. Seen by dermatology on 7/14/2026. Contact isolation due to rash/scabies.R1's physician orders read in part: Contact isolation due to rash/scabies ordered on 7/14/26. Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) Apply to rash on body topically every day and evening shift for rashes for 14 Days (Ordered on 7/14/26).R1's comprehensive care plan reads in part: R1 is on Isolation related to scabies. Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. (Date Initiated 7/21/26)R1's Dermatology visit note dated 7/14/26 reads in part: R1 is a new patient who is being seen for a chief complaint of rash, located on the arms and trunk. The rash is itchy and red and moderate on severity. An examination was performed including the head (including face), face, inspection of conjunctivae and lids, lips (but not teeth and gums), nose, right ear, left ear, neck, chest, abdomen, back, right forearm, left forearm, right hand, and left hand. Impression/Plan: Crusted Scabies. Erythematous eczematous patches distributed on the third web space left hand, inferior thoracic spine, left proximal dorsal forearm, right proximal; radial dorsal forearm, and left medial superior chest. Skin care: Permethrin cream applied neck down to feet x 8 hours and repeated in 1 week. Scabies is an infestation of mites that is very contagious. Household contacts should be treated. Contaminated clothing should be isolated x 72 hours and washed and dried on high heat.On 7/21/26 at 9:44 AM, V7 (Registered Nurse/RN) stated that R1 has scabies, is currently receiving treatment, and is on contact isolation. V7 reported that R1 stays out of her room and is placed by the nurses' station every day because V6 prefers her to be there. V7 stated that R3 (R1's roommate) has no scabies and was treated prophylactically and is also on contact isolation with R1. V7 stated R3 also goes out of her room.On 7/21/26 at 9:46 AM, R1 was observed sitting in her wheelchair near the nurses' station and was not interviewable.On 7/21/26 at 9:47 AM, R3 was observed sitting in her wheelchair in the dining room.On 7/21/26 at 10:00 AM, a contact precaution signage was noted posted on R1's door that reads in part: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. At approximately the same time, during R1's full body skin check conducted by V7 (RN) and V8 (Certified Nursing Assistant/CNA), R1 was observed with scattered red spots on her abdomen, back, hands, and legs. During the assessment, V9 (Housekeeping/Laundry) entered R1's contact isolation room without wearing an isolation gown or gloves and hung clean clothing in R1 and R3's closets. When the surveyor asked V9 if she was aware that she had entered a contact isolation room, V9 apologized and exited the room.On 7/22/26 at 9:02 AM, V13 (CNA) was observed dressing R1 in bed. Dirty nightgown and linens were observed on the floor, not bagged.On 7/22/26 at 9:19 AM and 2:30 PM, R1 was observed sitting in her wheelchair in the hallway in front of the nurses' station.On 7/23/26 at 12:15 PM and on 7/24/26 at 9:17 AM, R1 was again observed seated in the hallway in front of the nurses' station.On 7/21/26 at 2:57 Pm, V20 (Licensed Practical Nurse/LPN) stated that R1 was seen by dermatology last week, returning to the facility the evening of 7/14/26. V20 stated that V6 exited the elevator and handed her the dermatology paperwork, stating that R1 had been diagnosed with scabies. V20 reviewed the paperwork and noted that testing of R1's hand confirmed scabies. Dermatology prescribed triamcinolone cream and ivermectin. V20 notified the physician (V40), who agreed with the dermatologist's recommendations. R1 and R3 (R1's roommate) were then placed on contact isolation. V20 reported that R1 will remain on contact isolation until treatment is complete. R3 was treated prophylactically. V20 stated that although residents with scabies should remain in their rooms, V6 instructed staff not to isolate R1 in her room. As a result, staff seat R1 in her wheelchair near the nurses' station.On 7/21/26 at 11:26 AM, V10 (Infection Preventionist/Wound Care Nurse) stated that residents diagnosed with scabies are required to be placed on contact precautions, and staff must wear proper PPE that includes gowns and gloves before entering the room. V10 stated that the goal of isolation is to prevent the spread of infection, stating that staff and other residents could become infected if precautions are not followed. V10 explained that once a resident is identified with scabies, they must be placed on contact precautions and treated as ordered. V10 stated that residents with scabies on current treatment should remain secluded in their rooms and should not go out. V10 stated that she was informed that R1 had been seen by dermatology last week and that dermatology confirmed a scabies diagnosis. V10 stated she has not seen any reports of this appointment. V10 stated that because scabies is highly contagious, she emphasized that it is important for the condition to be properly contained. V10 stated they have not had any outbreak of scabies since R1 and no resident has been diagnosed with scabies since then. On 7/23/26 8:52 AM, a phone interview was conducted with V2 (Interim Director of Nursing). V2 explained that when a resident is on contact isolation, signage is posted on the resident's door indicating that individuals must check with the nurse before entering to ensure proper protocol is followed. Staff or visitors entering a contact isolation room are not required to wear full PPE per CDC (Centers for Disease Control and Prevention) guidelines if they will not have direct contact with the resident. V2 stated that it is not appropriate to place dirty linens or clothing on the resident's floor, regardless of isolation status. Resident rooms should have a designated bin for dirty clothing and linens. V2 stated that these items should be placed in a plastic bag and removed promptly to prevent the spread of infection from resident to resident or employee to employee. V2 stated that she is not aware of anyone currently diagnosed with scabies in the facility. If a diagnosis is confirmed, the resident must be treated and placed on contact isolation. If the resident has a roommate, the roommate must be tested or moved, and both should be treated if exposure occurred. Anyone who has had close contact with the resident should also receive treatment. V2 stated scabies diagnoses are confirmed by dermatology. V2 recalled that residents with confirmed scabies should not leave their rooms for at least 24 hours after treatment. V2 stated that there is a full protocol that must be followed according to CDC guidelines, including laundering clothing and linens at specific temperatures. V2 stated the same protocol is followed for both regular and crusted scabies.On 7/23/26 at 10:05 AM, V36 (Director of Housekeeping and Laundry) stated that for contact isolation rooms, V36 stated she expects staff to wear a gown, gloves, mask, and sometimes hair covering and shoe covers. V36 stated laundry staff deliver clean linens and place them inside the resident's closet. V36 stated laundry staff must wear full PPE (gown and gloves) because they touch environmental surfaces such as door handles, hangers, and closet doors. V36 stated that this is important to prevent the spread of illness and avoid contaminating items that could expose other residents or staff. V36 explained that residents' clothing and linens, when dealing with scabies, must be washed separately from other residents' items. CNAs pick up dirty linens, place them in a bag, and label the resident's name. Nurses communicate with [V36] if any resident is diagnosed with scabies, and she then communicates with the laundry and housekeeping teams. V36 stated she believes there is one resident on the second floor with scabies. V36 stated that the water temperature for laundering should be at least 85 degrees using hot water. Items are washed twice and dried on medium heat for a total of one hour. V36 stated that they began separating R1's dirty linens on Tuesday (7/21/26), which is when she was informed that R1 had scabies not on 7/14/26.On 7/23/26 at 10:22 AM, a follow up interview was conducted with V10 (Infection Preventionist/Wound Care Nurse). V10 stated that it is not appropriate to place a resident's dirty gown or linens on the floor. There should be a designated bin inside the resident's room for collecting dirty linens and gowns. V10 stated that placing dirty items on the floor can contribute to the spread of infection, and proper handling is essential to prevent contamination throughout the facility.The facility's Scabies Identification, Treatment and Environmental Cleaning policy and procedure (8/2016) reads in part: The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. Environmental Control: Crusted/Atypical Scabies: Maintain contact precautions until treatment is complete and/or resident is determined (by dermatologist or primary care provider) to be scabies free. Assign resident to a private room, if possible. Restrict visitors until treatment regimen is complete; alternatively, require visitors to gown and glove as required for contact isolation precautions. Employees must wear gloves and a long-sleeved gown with the wrist area covered to attend to resident needs, for housekeeping duties, and handling of laundry. Remove gown and wash hands before leaving the room. Bed linens, towels and clothing used by the affected persons during the 4 days prior to initiation of treatment should be placed in plastic bags inside the resident's room, handled by gloved and gowned laundry staff without sorting, and laundered in hot water for at least 10 minutes. The hot cycle of the dryer should be used 50 degrees Celsius (122 degrees Fahrenheit) for at least 10-20 minutes. Non-washable blankets and articles can be placed in a plastic bag for 7 days, dry cleaned or tumbled in a hot dryer for 20 minutes.The facility's Isolation - Categories of Transmission-Based Precautions (October 2018) reads in part: Staff and visitors will wear gloves (clean, non-sterile) when entering the room.While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves will be removed and hand hygiene performed before leaving the room. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.The CDC's Public Health Strategies for Crusted Scabies Outbreaks in Institutional Settings that can be found on this website: https://www.cdc.gov/scabies/php/public-health-strategy-crusted/index.html reads in part: Isolate patients with crusted scabies from other patients/residents who do not have crusted scabies. Maintain contact precautions until skin scrapings from a patient with crusted scabies are negative. Limit visitors for patients with crusted scabies; visitors should use the same contact precautions and protective clothing as staff.The CDC's Transmission-Based Precautions that can be found on this website: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html reads in part: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.The facility's residents' roster dated 7/21/26 shows a total of 101 residents residing in the facility.

Based on interview and record review, the facility failed to follow its policy to provide medical records within 30 days of the request for one resident (R2) out of four residents reviewed for resident rights. Findings Include: R2's health record shows admission date on 1/26/26 and discharge date on 2/5/26 with diagnoses not limited to Pneumonia, Respiratory syncytial virus as the cause of diseases classified elsewhere, Non-ST elevation (NSTMI) myocardial infarction, Atherosclerotic heart disease of native coronary artery, Chronic kidney disease stage 3A, Hyperlipidemia, Sepsis, Heart failure, Hypertensive heart and chronic kidney disease, Unspecified atrial fibrillation, Presence of coronary angioplasty implant and graft, Anemia, Personal history of other venous thrombosis and embolism, Disorder of adrenal gland, Benign neoplasm of right adrenal gland, Cognitive communication deficit, Unspecified fall, Laceration with foreign body of scalp.On 7/21/26 at 2:04 PM, V4 (Medical Record Retrieval Specialist for a law firm) stated she requested R2's medical records on 4/6/26 but did not receive a response from the facility. She reported that on 04/13/26, she contacted the facility again and was transferred to the voicemail of V5 (former Administrator). She stated she left a voicemail requesting a status update but did not receive a return call. V4 stated that on 4/18/26 she called the facility again and was advised to submit the medical record request via email to V5, which she did; however, she did not receive a response. She reported that additional follow up calls were made on 4/21/26 and 4/27/26, but she did not receive any updates. V4 stated that on 5/4/26 she attempted to contact V5 again, but there was no answer. She left another voicemail but did not receive a return call. She contacted the facility's main line, spoke with the front desk, and was told her message would be forwarded to V5. V4 stated that on 5/11/26 she called the facility again and was informed that V26 (former DON) could assist with medical record requests. The call was forwarded to voicemail, and she left a message. V4 stated that on 5/12/26 she spoke with V25 (Receptionist), who advised her that only V5 handled medical record requests. She then sent another follow up email, including V26. V4 reported multiple follow up calls and emails regarding R2's medical record request on 5/19/26, 6/1/26, 6/4/26, 6/16/26, 6/18/26, and 6/25/26, but she never received any response or call back from the facility regarding the status of the request. She stated she has still not received R2's medical records and has not received any communication from the facility. V4 reported that the medical record request is for litigation purposes and that litigation is ongoing.On 7/22/26 at 9:22 AM, V25 (Receptionist) stated she recalled receiving a medical record request for R2 a couple of months ago, but she could not remember who made the request. V25 stated she forwarded the call and believed she verbally informed V5 (former Administrator). She stated she notified V5 because he was responsible for handling medical record requests. V25 stated that when a medical record request is received, she typically reports it to the Administrator.On 7/22/26 At 2:42 PM V26 (Former DON / Director of Nursing) stated she had worked in the facility for approximately 4.5 months and left employment in June 2026. She reported receiving a phone call requesting medical records for R2 a couple of months ago and stated she forwarded the call to the front desk because she was not responsible for handling medical record requests. V26 stated she transferred the call so it could be addressed or directed to the appropriate person, as she did not know how to obtain the requested information. She stated that if she receives a medical record request, she always transfers it to the front desk.On 7/23/26 at 1:44 PM, V37 (Former Medical Records Staff) stated she was laid off in December 2025 and had worked in the facility for eight years. She reported that when a medical record request was received, she would gather the requested information and provide it to the CEO (Chief Executive Officer) of the company, who would complete the required forms and release the records. V37 stated the timeline for releasing records depending on the number of documents requested, but records were typically released within 30 days from the date the request was received.On 7/24/26 at 9:56AM V1 (Administrator) stated he started working in the facility in June 2026. He reported the facility does not currently have a designated staff person specifically assigned to handle medical record requests. He stated he is not aware of past processes used for medical record requests. V1 stated that if a request is received from a law firm or other legal entity, he would reach out to corporate to handle the release of records. He stated he does not know the turnaround time for record requests but believes records are released as soon as possible, typically within 30 days from the date the request is received. He acknowledged that obtaining / accessing medical records is a resident right. V1 stated he reached out to corporate regarding R2's medical record request to follow up, but he has not received an update yet. He stated that no medical records for R2 have been released or sent to the requestor at this time. He confirmed that the request was received via email. He stated the processing time can range from 24 hours to 30 days depending on the nature of the request.Reviewed multiple email correspondences between the facility and the law firm dated 4/21/26, 4/27/26, 5/4/26, 5/12/26, 5/27/26, and 6/1/26 indicate, in part, discussions regarding R2's medical record request, which was initially submitted on 4/6/26.Facility's access to personal and medical records policy (undated) shows in part: each resident has the right to access and / or obtain copies of his or her personal and medical records upon request. Access to the resident's personal and medical records will be provided to the resident within 30 days (excluding weekends and holidays) of his request. The resident may obtain a copy of his or her personal or medical record within two business days of an oral or written request. The resident, or his / her legal representative, may grant others the right to access the resident's records if such request is made in writing and identifies the information that is to be released and to whom the information is to be released. Facility's resident rights policy dated 2/2021 shows in part: federal and state laws guarantee certain basic rights to all the residents of this facility. These rights include the resident's right to access personal and medical records pertaining to him or herself.

Based on interviews and record review, facility failed to ensure that one resident (R4) is free from verbal abuse from a staff member. These failures affected one resident (R4) out of three residents reviewed for abuse. Findings include:Facility document for R4's Initial Investigation Report (7/7/2026 at 10:20PM) reported by V1 (Administrator) showed in part that R4's incident on 6/21/2026 was not first identified and reported and involved R4 and V3 (Former CNA) and that V5 (RN) heard V3 yelling at R4 and that V5 told V3 that V3 cannot yell at residents. V3 threw R4's meal ticket from lunch at R4 and said, I don't give a f***. V5 instructed V3 to leave the room and V3 complied and then came right back to R4's room and shouted again I (V3) don't give a f*** repeatedly. V5 once again told V3 to leave the room and not to yell at residents and explained to V3 that V3 needs to go home and that V3 complied and clocked out and left facility. On 7/6/2026 at 11:47 AM, R4 stated that on 6/21/2026, V3 (Former CNA) had attitude and yelled at R4, calling R4 vulgar and racist names like F*** you and [NAME] Motherf****r and that nurse (V5) heard V3 screaming and yelling and came to R4's room and told V3 not to use profanities and racist remarks. R4 said that V3 left but came right back to R4's room and yelled f*** you again and V5 told V3 to leave the room. R4 said that V3 did not physically hurt R4 but verbally screamed and yelled at R4.On 7/6/2026 at 12:05 PM, V6 (Registered Nurse/RN) stated sometimes V3 would get stressed with residents but would leave the room and decompress then go back and complete the task. V6 said that any type of abuse should be immediately reported to supervisor and administrator.On 7/6/2026 at 12:37 PM, V5 (RN) stated that V5 remembers that V3 (Former CNA), was complaining that R1 was saturated and that previous shift did not clean R1 up. V5 said that after V3's care of R1 on 6/21/26, V4 (CNA) brought R1 in a reclining wheelchair to V5 and that R1 told V5 that V3 was crazy, that V3's eyes got really big and that V3 called R1 you filthy B****** and pulled his hair and head and that said .you white people come here and that is what happens when you run out of money. V5 said that V5 asked R1 to repeat what happened three times and that each time R1 said the same story. V5 said that V5 was calling administration and while calling, V3 went to R4's room and started yelling at R4 and telling R4 F*** you and [NAME] Motherf****r and V5 immediately told V3 to leave R4's room. V5 said that V3 left the room and returned quickly back into R4's room and threw dietary ticket at R4 and yell at R4 again F*** you two times and at that time, V5 told V3 that V3 needs to leave the premises. V5 stated that after full assessment, R1 or R4 did not have injuries.On 7/6/2026 at 1:40 PM, V1 (Administrator) stated that V1 was notified about R1's incident around 3:45 PM, on 6/21/2026 (Sunday) and showed emailed initial incident report submission to the agency dated 6/21/2026 at 5:27 PM. V1 stated that at that time V1 did not report R4's incident separately and that V1 should submit R4's initial report separately from R1's initial report.On 7/7/2026 at 9:15 AM, V3 (Former CNA) stated that about the 6/21/2026 incident, V3 is not sure why the facility is reporting abuse, because V3 did not do anything. V3 said that she came to R1's room and found him lying in the bed soiled and called V4 (CNA) to witness, and V4 said that most likely R1 was not cleaned. V3 said that V3 cleaned R1 and that V3 never pulled R1's hair or head and did not call him racial names. V3 said that V3 is familiar with R4 and that V3 remembers that on that day (6/21/2026), R4 pushed a call light and that V3 was helping another resident and when V3 came to R4's room, R4 started telling V3 that it took long time, and that R4 had to wait long time. V3 said that V3 was trying to calm R4 down, but R4 was talking to her with raised voice and that triggers V3 because of an abusive relationship. On 7/7/2026 at 10:00 AM, V1 (Administrator) stated that V1 is the Abuse Coordinator and to keep residents safe, V1 educates all employees on resident abuse prevention and the different types of abuse, such as physical, verbal, sexual, financial, mental and neglect. V1 stated that every type of abuse should be reported within 2 hours to the state agency and an investigation should be started.On 7/7/2026 at 10:54 AM, V2 (Interim Assistant of Director of Nursing/ADON) stated that any resident that was allegedly abused should be immediately separated and placed in safe environment and any abuse should be reported to the administrator. V2 said that if employee was allegedly abusive towards resident, that employee would be immediately removed from the building and placed on suspension pending investigation. V2 said that V2 did not know V3 (Former CNA), that V3 worked at the facility for short period of time.On 7/7/2026 at 11:45 AM, V13 (Nursing Scheduler) stated that V3 called V13 and was crying and apologizing and that that V3 did not mean to behave that way. V13 said that on 6/21/26, V5 (RN) called V13 and notified about V3 having issues with residents and V13 told V5 to send V3 home immediately and to notify V1 (Administrator).On 7/7/2026 at 12:30 PM, V14 (Social Service Coordinator) stated that if resident would notify V14 about any abuse allegation, V14 should report it to the administrator who is the Abuse Coordinator.On 7/7/2026 at 2:07 PM, V9 (Staffing Development Coordinator) stated that V1 (Administrator) and V9 were aware of R4's incident with V3 (Former CNA), and that the incident should be reported to the agency in a timely matter. V9 also said that any type of abuse should be reported to the state agency and investigated thoroughly.R4's Face Sheet showed in part that R4 was admitted to facility on 3/26/2026.R4's Diagnosis include but is not limited to Heart failure, Muscle weakness, Dysphagia, Need for assistance with personal care, Body mass index (BMI) 50 to 59.9, Morbid obesity, Acute respiratory failure, Low back pain, pain in right hip, pain in right knee, Peripheral vascular disease, Chronic Gout, Atherosclerotic heart disease, Polyosteoarthritis, Atrial Fibrillation, Supraventricular tachycardia, Hemorrhage of Anus and rectum, Hypothyroidism, Essential hypertension, Right foot drop, Left artificial knee joint, Obstructive sleep apnea, Generalized anxiety disorder and Major depressive disorder.R4's Minimum Data Set (MDS), (4/2/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 14 which showed intact cognition. MDS section GG for Functional Abilities showed in part that R4 used manual wheelchair, and mechanical lift, upper and lower extremities impairment, and was dependent for most of activities of daily living (toileting, shower, dressing, putting and taking off shoes, and transfers). MDS in section H for Bladder and Bowel showed in part that R4 was always incontinent or urine and bowel.R4's Care Plan, (6/22/2026), showed in part focus that R4 is at risk for abuse/neglect related to dependence on staff for ADL care and behaviors of screaming at staff and peers, R4 said that CNA used derogatory language when speaking to R4 and that R4 should be free from physical harm and feel safe. CP also showed that R4 has an ADL self-care performance deficit and needs assistance from staff for transfers, dressing and grooming, bathing and personal hygiene, R4 has frequent incontinence and that R4 is at risk for falls related to impaired mobility.R4's Progress Note (6/22/2026) documented by V5 (RN), showed in part that when V5 was at the nurse's station, V5 heard shouting coming from R4's room and observed assigned CNA shout at R4, F*** You and that V5 intervened and told CNA that can't talk to the resident this way and V5 directed CNA to leave the room. CNA left the room but while V5 was assessing R4, CNA re-entered R4's room and threw the dietary ticket onto R4's lap and shouted again F*** you two times. V5 told CNA that CNA needs to leave the facility until further notice and that V1 (Administrator) and on call supervisor and physician were notified.R4's Physical Questionnaire/Interview Form (6/22/2026), showed in part that R4 answered NO to all questions on the physical abuse form, but on verbal abuse form, R4 answered YES. Explanation detail showed in part that CNA swore at me motherf****r. Form also showed in part that R4 answered YES to question if anyone ever yelled, swore or spoke disrespectfully on 6/21/2026.Facility's Document titled Teammate Termination Notice, (6/26/2026), showed in part that V3's (Former CNA) V3's conduct and behaviors did not align with the facility's standards of care and customer service in accordance with resident's rights.Facility's document titled Investigation Verification Form, 6/21/2026 showed in part that R1's incident with V3 (Former CNA) occurred on 6/21/2026 at 3pm and that it was reported to state agency and the police. The document also showed in part that V3 allegedly pull R1's hair and head and stated, .you B******, you white people are filthy. and that at the time of incident, there were no other witnesses. Document also showed in part that Administrator, was notified on 6/21/2026. Page 3 and 4 of the documents showed in part that V3 pulled R1's hair and called R1 names.Facility's provided nursing and CNAs schedule (6/21/2026) showed in part that V3 (Former CNA) was scheduled and assigned to 4th floor unit. Facility's provided CNA Assignment Sheet (6/21/2026) for 7AM-3PM shift showed in part that V3 (Former CNA) was assigned to R4's Rooms.V13's (Nursing Scheduler) written statement (6/23/2026) showed in part that V3 (Former CNA) called V13 on 6/21/2026 at 12:55 PM, crying and apologizing, that V3 didn't mean to do it and then hanged up the phone and called back at 1:03 PM, still crying and that V3 was triggered when someone yells at V3 because V3 was in abusive relationship.Facility's Document titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program(Revised April 2021), showed in part that the residents have the right to be free from abuse, neglect and exploitation and that includes verbal and physical abuse. Policy also stated that program should protect residents from abuse by anyone including facility's staff and that facility should train employees on abuse prevention, identification and reporting of abuse, caregiving responsibilities, stress management, ways to address interpersonal conflicts and how to handle verbally or physically aggressive residents. Policy also showed in part that the facility should identify and investigate all possible incidents of abuse, neglect and mistreatment and investigate and report any allegations within timeframes required by federal standards.Facility's Document titled Identifying Types of Abuse, (April 2021), showed in part that employees of the facility should be able to identify the different types of abuse that could occur against residents and that abuse of any kind against residents is strongly prohibited. Document also showed in part that abuse is identified as willful infliction of injury, intimidation or punishment that results in physical or mental harm and pain; abuse includes but is not limited to verbal, physical and mental and that physical abuse includes but is not limited to hitting and slapping and verbal abuse includes but is not limited to any verbal or gestured communication directed at the resident regardless their ability to comprehend.Facility's Document titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating (Revised April 2021), showed in part that all reports of resident's abuse, neglect, exploitation and theft should be reported to local, state and federal agencies as required per current regulations and should be thoroughly investigated, documented and reported by facility's management. Document also showed in part that suspicion of resident's abuse should be reported immediately to the administrator and other officials according to the law and to the state licensing/certification agency and that immediately would be defined as within two hours of an allegation involving abuse. Document also showed in part that the administrator should be consulted with the investigator daily on the progress and findings of the investigation and the investigator then documents findings and presents to the administrator and the administrator should provide written report to the appropriated agencies within five working days from the occurrence of the incident.Facility's Document titled Resident Rights Policy Statement, (Revised February 2021), showed in part that Employees shall treat all residents with kindness, respect and dignity and that resident has the right to be free from abuse, neglect, misappropriation of property and exploitation and have the right to be treated with respect, kindness and dignity.Facility's Document titled Dignity Policy Statement, (Revised February 2021), showed in part that each resident should be care for in the way to promote and enhance sense of well-being, level of satisfaction and feelings of self and residents should be treated with dignity and respect at all times and staff should speak to residents respectfully at all times which includes addressing residents by name of choice and that staff is expected to treat cognitively impaired residents with dignity and sensitivity and not challenging or contradicting resident's statements.Facility's Document titled Job Title: Certified Nurse Aide, (5/2024), showed in part that Certified Nurse Aide (CNA) should provide routine Activities of Daily Living (ADL) care in the way to the resident's comfort and safety and is responsible for performing person centered care according to care plan and assigned duties and should communicate professionally and effectively with residents, document and report all incidents and complaints.

Based on interviews and record review, facility failed to timely report verbal abuse incident to the state agency within 2 hours and failed to follow facility's abuse and abuse reporting policy for one resident (R4) in the sample of three residents reviewed for physical and verbal abuse/assault.Findings include:On 7/6/2026 at 11:47 AM, R4 stated that on 6/21/2026, V3 (Former Certified Nursing Aide/CNA) had attitude and yelled at R4, calling R4 vulgar and racist names like F*** you and [NAME] Motherf****r and that nurse heard V3 screaming and yelling and came to R4's room and told V3 not to use profanities and racist remarks. R4 said that V3 left but came right back in R4's room and yelled F*** you again and V5 told V3 to leave the room. R4 said that V3 did not physically hurt R4 but verbally screamed and yelled at R4.On 7/6/2026 at 12:16 AM, V4 (CNA) stated that during 6/21/2026 shift, V3 (Former CNA) was verbally abusive towards R4 and cussed R4 out. V4 said that V5 (Registered Nurse/RN) was in R4's room when V3 was yelling at R4 and that V3 got sent home.On 7/6/2026 at 12:37 PM, V5 (RN) stated that V5 remembers that on Sunday, 6/21/2026, during day shift, V3 (CNA) was already agitated and complaining that residents were saturated and were not cleaned up from previous shift and that when V5 was at nurses station, V3 went to R4's room and V5 heard V3 yelling at R4 and telling R4 F*** you and calling R4 [NAME] Motherf****r. V5 stated that V5 went to R4's room and told V3 to leave the room. V5 said that V3 left R4's room but came right back in R4's room to yell at R4 again and that V5 told V3 to leave the premises. V5 said that V5 called the manager on call and notified administration about V3's incidents and that V3 was sent home.On 7/6/2026 at 1:40 PM, V1 (Administrator) stated that V1 was notified about R1's incident around 3:45 PM, on 6/21/2026 (on Sunday), and showed surveyor emailed initial incident report submission to the agency dated 6/21/2026 at 5:27 PM. V1 stated that at that time, V1 did not report R4's verbal abuse incident separately and that V1 should submit R4's initial report separately from R1's initial report.On 7/7/2026 at 9:15 AM, V3 (Former CNA) stated on 6/21/2026, R4 pushed a call light for assistance and V3 remembers that V3 was helping another resident and took few minutes before answering R4's call light. V3 said that when V3 came to R4's room that R4 started yelling at V3 and that V3 was trying to calm R4 down, but R4 kept talking to V3 with raised voice and that triggers V3 because of abusive relationship. V3 denied calling R4 with racial and derogatory remarks and names. V3 did state that V3 was sent home and suspended on 6/21/2026.On 7/7/2026 at 10:00 AM, V1 (Administrator) stated that V1 is the Abuse Coordinator and that every type of abuse should be reported within 2 hours to the state agency. V1 also stated that V1 was aware that R4 had verbal abuse incident occur on 6/21/2026 in conjunction with R1's physical and verbal abuse incident happening on the same day that involved V3 (Former CNA) and that V1 found out during investigation. V1 stated that V1 did not report R4's verbal incident to the state agency within two hours and that R4's incident with V3 should be reported to the agency separately and additional investigation started. V1 said that V5 (RN) heard V3 calling R4 derogatory remarks on 6/21/2026 during day shift.On 7/7/2026 at 10:54 AM, V2 (Interim Assistant of Director of Nursing/ADON) stated that every abuse allegation should be reported immediately to the administrator and that administrator reports to agency.On 7/7/2026 at 11:45 AM, V13 (Nursing Scheduler) stated that V3 (CNA) called V13 and was crying and apologizing and that that V3 did not mean to behave that way. V13 said that V5 (RN) called V13 before and notified about V3 having issues with residents and V13 told V5 to send V3 home immediately and to notify V1 (Administrator).On 7/7/2026 at 2:07 PM, V9 (Staffing Development Coordinator) stated that V1 (Administrator) and V9 were aware of R4's incident with V3 (Former CNA), and that the incident should be reported to the agency in a timely matter and within 2 hours. V9 also said that any type of abuse should be reported to the state agency.R4's Diagnosis include but is not limited to Heart failure, Muscle weakness, Dysphagia, Need for assistance with personal care, Body mass index (BMI) 50 to 59.9, Morbid obesity, Acute respiratory failure, Low back pain, pain in right hip, pain in right knee, Peripheral vascular disease, Chronic Gout, Atherosclerotic heart disease, Polyosteoarthritis, Atrial Fibrillation, Supraventricular tachycardia, Hemorrhage of Anus and rectum, Hypothyroidism, Essential hypertension, Right foot drop, Left artificial knee joint, Obstructive sleep apnea, Generalized anxiety disorder and Major depressive disorder.R4's Minimum Data Set (MDS), (4/2/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 14 which showed intact cognition. MDS section GG for Functional Abilities showed in part that R4 used manual wheelchair, and mechanical lift, upper and lower extremities impairment, and was dependent for most of activities of daily living ( toileting, shower, dressing, putting and taking off shoes, and transfers). MDS in section H for Bladder and Bowel showed in part that R4 was always incontinent or urine and bowel.R4's Care Plan, ( 6/22/2026 ), showed in part focus that R4 is at risk for abuse/neglect related to dependence on staff for ADL care and behaviors of screaming at staff and peers, R4 said that CNA used derogatory language when speaking to R4 and that R4 should be free from physical harm and feel safe. CP also showed that R4 has an ADL self-care performance deficit and needs assistance from staff for transfers, dressing and grooming, bathing and personal hygiene, R4 has frequent incontinence and that R4 is at risk for falls related to impaired mobility.R4's Progress Note ( 6/22/2026) documented by V5 (RN) , showed in part that when V5 was at the nurse's station, V5 heard shouting coming from R4's room and observed assigned CNA shout at R4 , F*** You and that V5 intervened and told CNA that can't talk to the resident this way and V5 directed CNA to leave the room. CNA left the room but while V5 was assessing R4, CNA re-entered and threw the dietary ticket onto R4's lap and shouted again f*** you times two. V5 told CNA that CNA needs to leave the facility until further notice and that V1 (Administrator) and on call supervisor and physician were notified.R4's Physical Questionnaire/Interview Form (6/22/2026), showed in part that R4 answered NO to all questions on the physical abuse form, but on verbal abuse form, R4 answered YES to ever been verbally harmed by a staff member question and answered that it occurred on 6/21/2026. Explanation detail showed in part that CNA swore at me mother****er. Form also showed in part that R4 answered YES to question if anyone ever yelled, swore or spoke disrespectfully which occurred on 6/21/2026.Facility document for R1's Initial Incident Investigation Report for physical and verbal abuse (6/21/2026) showed in part that on 6/21/2026, V3 (Former CNA) displayed agitated nature since beginning of shift according and that nurse heard derogatory language and yelling coming from another resident room. V3 had earlier incident (physical and verbal abuse towards R1) that was reported to V5 (Registered Nurse/RN) around the same time when V5 heard V3 yelling at another resident and calling other resident [NAME] Mother****er and F*** you on two different occasions. R1's Facility Initial Incident Report did not identify R4 (no name given). R1's Final Incident Investigation report (6/26/2026) was reported to the agency for R1, but R4 (no name given) was not included in the final incident investigation report. R4's Facility Initial Incident Report of verbal abuse from V3 was reported on 7/7/2026 to the state agency. Facility document for R4's Initial Investigation Report (7/7/2026 at 10:20PM) reported by V1 (Administrator) showed in part that R4's incident on 6/21/2026 was not first identified and reported, and this incident involved R4 and V3 (Former CNA) and that V5 (RN) heard V3 yelling at R4 and that V5 told V3 that V3 cannot yell at residents. V3 through R4's meal ticket from lunch at R4 and said, I don't give a f***. V5 instructed V3 to leave R4's room and V3 complied and then came right back in R4's room and shouted again I don't give a f*** repeatedly. V5 once again told V3 to leave R4's room and not to yell at residents and explained to V3 that V3 needs to go home and that V3 complied and clocked out and left facility. The report also showed in part that at such time, the initial report was sent for R1 but failed to mention the act of CNA towards R4 as witnessed initially.Facility's Document titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating (Revised April 2021), showed in part that all reports of resident's abuse, neglect, exploitation and theft should be reported to local, state and federal agencies as required per current regulations and should be thoroughly investigated, documented and reported by facility's management. Document also showed in part that suspicion of resident's abuse should be reported immediately to the administrator and other officials according to the law and to the state licensing/certification agency and that immediately would be defined as within two hours of an allegation involving abuse. Document also showed in part that the administrator should be consulted with the investigator daily on the progress and findings of the investigation and the investigator then documents findings and presents to the administrator and the administrator should provide written report to the appropriated agencies within five working days from the occurrence of the incident.Facility's Document titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program(Revised April 2021), showed in part that the residents have the right to be free from abuse, neglect and exploitation and that includes verbal and physical abuse. Policy also stated that program should protect residents from abuse by anyone including facility's staff and that facility should train employees on abuse prevention, identification and reporting of abuse, caregiving responsibilities, stress management, ways to address interpersonal conflicts and how to handle verbally or physically aggressive residents. Policy also showed in part that the facility should identify and investigate all possible incidents of abuse, neglect and mistreatment and investigate and report any allegations within timeframes required by federal standardsFacility's Document titled Identifying Types of Abuse, (April 2021), showed in part that employees of the facility should be able to identify the different types of abuse that could occur against residents and that abuse of any kind against residents is strongly prohibited. Document also showed in part that abuse is identified as willful infliction of injury, intimidation or punishment that results in physical or mental harm and pain ; abuse includes but is not limited to verbal, physical and mental and that physical abuse includes but is not limited to hitting and slapping and verbal abuse includes but is not limited to any verbal or gestured communication directed at the resident regardless their ability to comprehend.

Based on interviews and records reviewed the facility failed to investigate an allegation of abuse for one resident (R3). This failure affects two of three residents (R2/R3) reviewed for abuse on the sample list of five. Findings include: R2's progress notes dated 12/5/25 written by V2 states writer notified residents attempted to touch another male inappropriately while both in the common area. Staff observed resident reaching towards other male resident leg and groin area. Staff noticed due to resident's distress and intervened. R2 proceeded to attempt multiple times after that. Writer notified administrator, POA, physician, and supervisor.On 5/1/26 at 1:08PM R3 observed in the dining room, in a wheelchair, has assistive devices for support of right leg and upper right body. Interviewed R3 in his room. R3 answers yeah, smiles, gives audible laughter for most responses can give thumbs up, shakes head left to right to say no. Noted facial expressions change depending on question. R3 says yes and visibly smiles when discussing staff care, changing him, bathing him, bringing medications, and assisting when needed. Visible change in facial expression when asked about R2 touching him in the dining room. He said yeah when asked if he remembers. Asked him if the person is still here R3 said die. When asked what happened R3 indicated the man (pointed outwards) touched towards his groin (pointing and gesturing towards groin area). R3 was asked if he consented to the touch he shook head left to right and made unpleasant face. Indicated it only happened 1 time (put hand up and held up 1 finger) and nodded yes when asked if staff took the person away from him. On 5/1/26 at 12:21PM V2, Registered Nurse, said there were multiple incidents with R2. V2 said I was told the first incident was with a nursing student. V2 said I didn't see that, I was told R2 touched a male student and the student reported it. V2 said I witnessed at dinner time, we were in the cafeteria and we were passing meal trays. R2 rolled up to R3, on R3's weak side. V2 said R2 was touching R3 inappropriately. V2 said the CNAs said this was not the first time R3 did something like that. V2 said the CNAs said that a nursing student reported to his instructor that R3 was inappropriate with him by either saying things to him or touching him. On 5/1/26 at 12:32pm V4, RN, said we were monitoring R2's behavior. V4 said I did not see him actually do anything, but we had a task to monitor him daily. V4 said I was told R2 had touched someone inappropriately. The surveyor asked V4 about the progress note she had written. On 5/2/26 at 9:39AM V5, Administrator, I said spoke with the previous administrator and she said she had no knowledge of an incident of R2 touching a nursing student inappropriately. At 11:25AM The surveyor reviewed R2's progress note written on 12/5/25. V5 said that sounds like it should have been investigated. V5 said I would have sent R2 out to be evaluated, that is not normal. V5 said the purpose of an investigation is to determine the root cause of this inapprorpairate behavior. V5 said I can't say if we could have prevented the incident with R2 and R3 had the investigaiton for 12/5/25 been done.On 5/1/26 at 1:41PM V6 said I don't know about an incident between R2 and R3.R2 was [AGE] year old male with diagnosis (prior to incident), inlcuding but not limited to Peripheral Autonomic Neuropathy, Hypertenison, Anemia, Major Dperessive Disorder. R2 passed away in the faciilty on 2/20/26 following a stroke experienced on 1/20/26.R3 is [AGE] year old male diagnosis include, but are not limited to Hemiplegia following Cerebral Infarction affecting his Dominant side and Aphasia following Cerebral Infarction.A review of R3's Progress notes for 12/5/25-12/6/25 has no record of the incident documented by V2 in R2's record related to R2 touching R3 on 12/5/26.On 5/1/26 and 5/2/26 the surveyor asked V5 if they have a reportable or investigation for R3 and R2 on 12/5/26. No documentation was provided.The facility's undated abuse policy, in part states all incidents will be documented whether or not abuse occurred was alleged or suspected. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. Final abuse investigation report: the investigator will report the conclusions of the investigation in writing to the administrator or designee within 5 working days of the reported incident the investigation. Report shall contain the following: name, age, diagnosis, and mental status of the resident allegedly abused or neglected. The original allegation day, time, location, and specific allegation. Facts determined during the process of the investigation. Conclusion of the investigation: Attach a summary of all interviews conducted with the names, address, phone numbers and willing to testify of all witnesses. External reporting of potential abuse initial reporting of allegations if mistreatment has occurred the residents representative and Department of Public health shall be informed as soon as possible within 24 hours. The written report should contain the following information: name, age, diagnosis, and mental status of the resident allegedly abused or neglected type of abuse reported date, time, location, and circumstances of the alleged incident steps, the facility has taken to protect the resident. Within 5 working days after the report of the occurrence a complete written report of the conclusion of the investigation will be sent to the Department of Public health.

Based on interviews and records reviewed the facility failed to ensure one resident (R1) remained free from verbal and physical sexual abuse from a resident (R2) who had a history of inappropriate sexual behavior with another resident (R3) prior. This failure affected three of three residents reviewed for abuse on the sample list of five. Findings include: On 1/14/26 the facility reported an incident involving R1 and R2 on 1/14/26. R1 reported to staff he was in bed when R2 approached him, made inappropriate verbal comments and placed his (R2's) hand over R1's upper leg. R1 said he told R2 he did not want to engage in this type of interaction.R1 is [AGE] year old male with diagnosis, including but not limited to Difficulty Walking, Muscle Atrophy, Weakness, Need for Assistance with Personal Care, Blindness, Symptoms and Signs Involving Cognitive Functions and Awareness, and Major Depressive Disorder.R2 was [AGE] year old male with diagnosis (prior to incident), including but not limited to Peripheral Autonomic Neuropathy, Hypertension, Anemia, Major Depressive Disorder. R2 passed away in the facility on 2/20/26 following a stroke experienced on 1/20/26.On 5/1/29 R1 stated R2, my room mate, made verbal comments to me, about sex. He touched my leg with his hand and was running it up my leg. R1 said I didn't want R2 to do that, we were not in a relationship like that. R1 said R2 was trying to touch me with his hand, but I put my hand down to block him from touching me. The staff came in to help me; they moved me right away. R1 said I didn't want to go back to that room. R1 said it was not ok, what R2 tried.On 5/1/26 at 1:41PM V6 ,Social Service Coordinator, said I was told to see R1 because there was an incident with him and R2. V6 said I don't remember if I spoke to R2. V6 said R1 said he was good. V6 said R1said he did not want to go back to the room. V6 said R1 was alert and oriented, with confusion when he gets ill. V6 said R1 was at baseline when I spoke with him. V6 said R2's baseline at the time was confused at times but he could carry on a conversation, and he was usually in a wheelchair. V6 said at the time R2 was new to me. V6 said this was when I first heard about the incident, I think I had been off for a couple of days when it happened. V6 said I was not aware of an episode between R2 and R3. V6 said depending on the investigation the incident between R1 and R2 could be abuse. V6 said if abuse occurs or is reported we report to the administrator and we start an investigation.On 5/1/26 at 12:21PM V2, Registered Nurse, said there were multiple incidents with R2. V2 said I was told the first incident was with a nursing student. V2 said I didn't see that, I was told R2 touched a male student and the student reported it. V2 said I witnessed at dinner time, we were in the cafeteria and we were passing meal trays. R2 rolled up to R3, on R3's weak side. V2 said R3 had a stroke and has weakness. V2 said R2 was touching R3 inappropriately. V2 said R3 raised his good hand up in the air and was yelling hey, hey to get staffs' attention. V2 said we turned and immediately took R2 away and told him what he was doing was not allowed and he has to stop. A few minutes later R2 tried to do it again to R3, but we stopped him. V2 said the 3rd time R2 did something it was with his room mate, R1. V2 said when I came to work, I noticed R1 was in a new room and they told me because R2 was touching R1 at night. An additional interview with V2 on 5/2/26 at 10:19AM was conducted. V2 said I saw R2 had his hand on R3's upper thigh and moving his hand into R3's groin. V2 said R3 was waving his hand and calling out. V2 said when I spoke to R2 about he said it's fine. V2 said I moved R2 away from R3 and then about 5- 10 minutes later, R2 was going back to R3, so then we moved R2 back toward his room and R3 stayed in the dining room. V2 said the CNAs said this was not the first time R3 did something like that. V2 said the CNAs said that a nursing student reported to his instructor that R3 was inappropriate with him by either saying things to him or touching him. V2 said they said the instructor reported to someone here, but I don't know who. V2 said R3 was in a wheelchair at the time, but he could move around easily in it.On 5/1/26 at 12:32pm V4, RN, said we were monitoring R2's behavior. V4 said I did not see him actually do anything, but we had a task to monitor him daily. V4 said I was told R2 had touched someone inappropriately. The surveyor asked V4 about the progress note she had written. V4 said I saw R2 was sitting outside R3's room. R3 was in his bed. V4 said R2 was inching closer to R3's room. V4 said I told R2 to stop and redirected him, but then later on the same shift he was doing it again. V4 said I redirected him again. V4 said we kept watching R2. V4 said I told the CNAs to watch him and keep him away from R3. V4 said the managers were notified. V4 said I am not aware of his behavior prior to him coming to the unit, he was in the assisted living portion. V4 said R2 was not placed on 1:1, we will assign 1:1 if we need it.On 5/1/26 V3, RN, said when abuse occurs or is reported an investigation is done.On 5/2/26 at 11:47AM V6 said we do trauma Informed Consent assessment on admission, readmission, and quarterly. The assessments are not specifically related to abuse allegation made. Prior to this assessment, we did not have another assessment in place of it. The purpose of the assessment is to see if the resident has anything that triggers behaviors. V6 said they tell us their symptoms and if they ask for counseling we will assist. V6 we will develop specific interventions to address individual needs. V6 said after speaking with R1, he did not request anything special after the incident with R2.On 5/2/26 at 9:39AM V5, Administrator, I said spoke with the previous administrator and she said she had no knowledge of an incident of R2 touching a nursing student inappropriately. At 11:25AM The surveyor reviewed R2's progress note written on 12/5/25. V5 said that sounds like it should have been investigated. V5 said I would have sent R2 out to be evaluated, that is not normal. V5 said the purpose of an investigation is to determine the root cause of this inappropriate behavior. V5 said I can't say if we could have prevented the incident with R2 and R3 had the investigation for 12/5/25 been done. V5 said R2 and R3's incident report is not a substantiated case of abuse. V5 said I am not aware what a Trauma Informed Consent is. At 12:24PM V5 said R3 does not have a Trauma Informed Consent in his record. V5 presented an undated Abuse Policy titled Illinois Council of Long Term Care: Abuse Preventions Program. V5 said I am confident this abuse policy covers all areas we follow.R1's progress notes dated 1/14/16 read writer (V9, RN) told by CNA that resident (R1) informed her that roommate (R2) was engaging in inappropriate behavior toward him. Writer RN spoke directly with resident, who reported that roommate was rubbing his leg, attempting to touch his genital area, and made repeated sexual, vulgar, inappropriate verbal statements, including requests for resident to expose his genitals, and comments regarding sexual function.R1's Trauma Informed Consent dated 1/16/26 notes question 7. Has anyone ever made or pressured you nto some type of unwanted sexual contact? Yes Roommate verbal sexually inappropriate comments and touched [h]is leg.R1's care plan includes impaired vision to left and right eye. R1 is a trauma survivor-Unwanted inappropriate verbal sexual conversation by roommate. Date Initiated: 01/16/2026.R2's care plan date initiated 12/8/25 includes Resident with a behavioral concern. Resident inappropriately touching other male residents. Interventions inlcude: distract the resident when noting to approach other males or from entering other male rooms.R2's care plan date initiated 1/16/26 includes The resident is/has potential to demonstrate physical/verbal sexual behaviors Resident approached roommate related to Dementia. Poor Impulse Control telling roommate I want to see your c*** [additional questions]. I'll show you mine you show me yours, touching roommates leg while roommate told him to stop.R2's progress notes dated 12/5/25 written by V2 states writer notified residents attempted to touch another male inappropriately while both in the common area. Staff observed resident reaching towards other male resident leg and groin area. Staff noticed due to resident's distress and intervened. R2 proceeded to attempt multiple times after that. Writer notified administrator, POA, physician, and supervisor.R3 is [AGE] year old male diagnosis include, but are not limited to Hemiplegia following Cerebral Infarction affecting his Dominant side and Aphasia following Cerebral Infarction.On 5/1/26 at 1:08PM R3 observed in the dining room, in a wheelchair, has assistive devices for support of right leg and upper right body. Interviewed R3 in his room. R3 answers yeah, smiles, gives audible laughter for most responses can give thumbs up, shakes head left to right to say no. Noted facial expressions change depending on question. R3 says yes and visibly smiles when discussing staff care, changing him, bathing him, bringing medications, and assisting when needed. Visible change in facial expression when asked about R2 touching him in the dining room. He said yeah when asked if he remembers. Asked him if the person is still here R3 said die. When asked what happened R3 indicated the man (pointed outwards) touched towards his groin (pointing and gesturing towards groin area). R3 was asked if he consented to the touch he shook head left to right and made unpleasant face. Indicated it only happened 1 time (put hand up and held up 1 finger) and nodded yes when asked if staff took the person away from him. On 5/1/26 at 1:41PM V6 said I don't know about an incident between R2 and R3.A review of R3's Progress notes for 12/5/25-12/6/25 has no record of the incident documented by V2 in R2's record related to R2 touching R3 on 12/5/26.On 5/2/26 at 12:42PM V5 said R3 does not have a Trauma Informed Consent Assessment in his chart. [None in the record when the surveyor reviewed.]R3's cognitive assessment dated [DATE] identifies short and long term memory problems. Functional abilities identified R3 requires a minimum of 1 person assistance with all activities, except eating. R3's communication care plan identifies he has expressive aphasia related to a stroke. R3 has impaired thought process. R3's care plan does not identify he is at risk or has potential for abuse.The facility's undated abuse policy, in part states the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment neglect or abuse of our residents. Sexual abuse includes but is not limited to sexual harassment sexual coercion or sexual assault.

Based on interviews and records reviewed the facility failed to report an allegation of abuse to the state agency. This failure affects two of three residents (R2/R3) reviewed for abuse in the sample of five. Findings include: R2's progress notes dated 12/5/25 written by V2 states writer notified residents attempted to touch another male inappropriately while both in the common area. Staff observed resident reaching towards other male resident leg and groin area. Staff noticed due to resident's distress and intervened. R2 proceeded to attempt multiple times after that. Writer notified administrator, POA, physician, and supervisor.On 5/1/26 at 1:08PM R3 observed in the dining room, in a wheelchair, has assistive devices for support of right leg and upper right body. Interviewed R3 in his room. R3 answers yeah, smiles, gives audible laughter for most responses can give thumbs up, shakes head left to right to say no. Noted facial expressions change depending on question. R3 says yes and visibly smiles when discussing staff care, changing him, bathing him, bringing medications, and assisting when needed. Visible change in facial expression when asked about R2 touching him in the dining room. He said yeah when asked if he remembers. Asked him if the person is still here R3 said die. When asked what happened R3 indicated the man (pointed outwards) touched towards his groin (pointing and gesturing towards groin area). R3 was asked if he consented to the touch he shook head left to right and made unpleasant face. Indicated it only happened 1 time (put hand up and held up 1 finger) and nodded yes when asked if staff took the person away from him. On 5/1/26 at 12:21PM V2, Registered Nurse, said there were multiple incidents with R2. V2 said I was told the first incident was with a nursing student. V2 said I didn't see that, I was told R2 touched a male student and the student reported it. V2 said I witnessed at dinner time, we were in the cafeteria and we were passing meal trays. R2 rolled up to R3, on R3's weak side. V2 said R2 was touching R3 inappropriately. V2 said R3 raised his good hand up in the air and was yelling hey, hey to get staffs' attention. V2 said we turned and immediately took R2 away and told him what he was doing was not allowed and he has to stop. A few minutes later R2 tried to do it again to R3, but we stopped him. V2 said the 3rd time R2 did something it was with his room mate, R1. An additional interview with V2 on 5/2/26 at 10:19AM was conducted. V2 said I saw R2 had his hand on R3's upper thigh and moving his hand into R3's groin. V2 said R3 was waving his hand and calling out. V2 said I moved R2 away from R3 and then about 5- 10 minutes later, R2 was going back to R3, so then we moved R2 back toward his room and R3 stayed in the dining room. V2 said the CNAs said this was not the first time R3 did something like that. V2 said the CNAs said that a nursing student reported to his instructor that R3 was inappropriate with him by either saying things to him or touching him. V2 said they said the instructor reported to someone here, but I don't know who.On 5/1/26 at 12:32pm V4, RN, said we were monitoring R2's behavior. V4 said I did not see him actually do anything, but we had a task to monitor him daily. V4 said I was told R2 had touched someone inappropriately. The surveyor asked V4 about the progress note she had written. V4 said I saw R2 was sitting outside R3's room. R3 was in his bed. V4 said R2 was inching closer to R3's room. V4 said I told R2 to stop and redirected him, but then later on the same shift he was doing it again. V4 said I redirected him again. V4 said we kept watching R2. V4 said I told the CNAs to watch him and keep him away from R3. V4 said the managers were notified.On 5/2/26 at 9:39AM V5, Administrator, I said spoke with the previous administrator and she said she had no knowledge of an incident of R2 touching a nursing student inappropriately. At 11:25AM The surveyor reviewed R2's progress note written on 12/5/25. V5 said that sounds like it should have been investigated. V5 said I would have sent R2 out to be evaluated, that is not normal. V5 said the purpose of an investigation is to determine the root cause of this inappropriate behavior. V5 said I can't say if we could have prevented the incident with R2 and R3 had the investigation for 12/5/25 been done.On 5/1/26 at 1:41PM V6 said I don't know about an incident between R2 and R3.R2 was [AGE] year old male with diagnosis (prior to incident), including but not limited to Peripheral Autonomic Neuropathy, Hypertension, Anemia, Major Depressive Disorder. R2 passed away in the facility on 2/20/26 following a stroke experienced on 1/20/26.R3 is [AGE] year old male diagnosis include, but are not limited to Hemiplegia following Cerebral Infarction affecting his Dominant side and Aphasia following Cerebral Infarction.A review of R3's Progress notes for 12/5/25-12/6/25 has no record of the incident documented by V2 in R2's record related to R2 touching R3 on 12/5/26.On 5/1/26 and 5/2/26 the surveyor asked V5 if they have a reportable or investigation for R3 and R2 on 12/5/26. No documentation was provided.The facility's undated abuse policy, in part states all incidents will be documented whether or not abuse occurred was alleged or suspected. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. Final abuse investigation report: the investigator will report the conclusions of the investigation in writing to the administrator or designee within 5 working days of the reported incident the investigation. Report shall contain the following: name, age, diagnosis, and mental status of the resident allegedly abused or neglected. The original allegation day, time, location, and specific allegation. Facts determined during the process of the investigation. Conclusion of the investigation: Attach a summary of all interviews conducted with the names, address, phone numbers and willing to testify of all witnesses. External reporting of potential abuse initial reporting of allegations if mistreatment has occurred the residents representative and Department of Public health shall be informed as soon as possible within 24 hours. The written report should contain the following information: name, age, diagnosis, and mental status of the resident allegedly abused or neglected type of abuse reported date, time, location, and circumstances of the alleged incident steps, the facility has taken to protect the resident. Within 5 working days after the report of the occurrence a complete written report of the conclusion of the investigation will be sent to the Department of Public health.

Based on interview and record review, the facility failed to supervise one resident (R1) who was a high risk for falls. This failure resulted in R1 falling to the floor and sustaining a broken clavicle. This failure affected one of three residents reviewed for falls.Findings include:R1's diagnoses include but are not limited to epilepsy, muscle weakness, difficulty walking, lack of coordination, muscle wasting and atrophy, dementia.R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 11, indicating R1's cognition is moderately impaired. R1's progress note dated 02/25/26 at 5:39pm documents in part, Late Entry: Root cause: Poor safety awareness.R1's rehab progress note dated 02/20/26 documents in part, Chief complaint: mobility and ADL (Activities of Daily Living) dysfunction. Picking up object = partial/moderate assistance.R1's progress note dated 02/25/26 at 11:47pm documents in part, Resident noted laying on the floor, on her back in front of the nurse station. Upon assessment noted with quarter sized bump at the back of her head. Complained of pain on the left shoulder.R1's after visit summary discharge note dated 02/26/26 documents in part, Diagnoses: Displaced fracture of shaft of left clavicle, initial encounter for closed fracture.On 03/30/26 at 11:25am R1 stated that she remembers falling. R1 stated that she was in the hallway by herself and dropped something on the floor. R1 stated that she attempted to pick up the object from the floor and fell to the floor. R1 stated that she broke her clavicle when she fell. R1 stated that after she fell, the nurse picked her from off the floor.On 03/30/26 at 1:08pm V18 (Registered Nurse/RN) stated that she was R1's nurse at the time of the fall. V18 stated that she did not witness R1's fall. V18 stated that R1 was at the nurse's station when she fell. V18 stated that it was medication time and was attending to other residents down the hall when R1 fell. V18 stated that R1 is always trying to pick up things from off the floor. On 03/31/26 at 1:10pm V23 (Certified Nursing Assistant/CNA) stated that R1 sits at the nurse's station for most of the day. V23 stated that R1 is a fall risk and needs a constant eye on her because R1 does not always communicate her needs and would just start doing things on her own. On 04/01/26 at 10:21am V26 (Nurse Practitioner/NP) stated that R1 should have assistance when trying to pick up objects from off the floor. V26 stated that R1 should definitely be supervised because staff are aware that R1always tries to pick up objects from the floor. R1's fall risk data collection form dated 01/16/26 has a score of 16, indicating R1 is a high risk for falls and documents in part, Instructions: Evaluate the resident's condition and determine the most appropriate response. When resident's total score is 10 or more interventions should promptly be put into place. F. Balance: Observe resident's balance while standing, sitting and during transitions. 4. Not able to attempt without physical help.R1's fall risk data collection form observed with no interventions checked.R1's care plan dated 01/18/26 documents in part, Resident at risk for Falls d/t (due to) impaired mobility, hx (history) of right hip fracture s/p (status post) hemiarthroplasty, glaucoma and gait/balance problems. See fall risk assessment. The resident will be free of fall through the review date. Monitor between meals to ensure safety/prevent falls.On 04/01/26 at 12:37pm V17 (Assistant Director of Nursing/ADON) stated that R1's fall risk score of 16 makes R1 a high risk for falls. V17 stated that R1 should have had interventions filled out on the fall risk form and is not sure why R1's fall interventions were not in place before R1's fall. V17 stated that a resident that is high risk for falls should not be left in the hallway unsupervised and leaving them unsupervised could result in a fall with injury. V17 stated that a resident that is known for always bending down to pick things up and is a high risk for falls should not be left unsupervised. Facility's policy titled Safety and Supervision of Residents dated 07/2017 documents in part, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation: Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff;. d. Ensuring that interventions are implemented;. e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently. Facility's undated policy titled Fall Prevention Program documents in part, Policy Statement: Fall prevention program will be implemented to assure that safety of all residents in the facility whenever possible. This program should include measure which determines the individual needs of each resident by assessing the risks for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.

Based on observation, interview, and record review the facility failed to have an effective pest control program by having gnats flying around residents room and kitchen area. This failure has the potential to affect all 107 of the residents in the facility. Finding includes:On 03/30/2026 at 9:05 am, the other surveyor at facility stated she observed gnats in the hallway flying around upon her entrance to the facility, surveyor had to swat the gnats away to avoid the gnat from touching her face.On 03/30/2026 at 10:22 AM, V3 (MDS coordinator) stated she has seen a few gnats in her office. V3 stated her office is on the second floor in the office building, I have only been working here for the last three weeks.On 03/30/2026 at 11:00 AM,V4 (Cook) stated he has seen gnats flying around in the kitchen everywhere, and I am not sure what will help with get rid of the gnats.On 03/30/2026 at 11:03 AM, V5(Cook ) stated he has worked here for a year now and previously observed gnats flying around daily we use to use vinegar to contain the drains and keep the gnats contained but the gnats stayed in the drains which made it worse. I have not seen the gnats as much anymore in the last few weeks.On 3/30/2026 at 11:07 AM, V6 (Dining Service director) stated he works five days a week and the last time he has observed gnats in the kitchen was about a week ago. During interview with V6 a gnat flew pass his face and he attempted to swat it.V6 stated gnats can infect the food and contaminate food items and spread disease.On 03/30/2026 at 11:10 AM, V6 toured the walk-in freezer and observed with this surveyor multiple dead gnats on top of 5 galloon, crosscut crinkle pickle container inside the walk-in freezer.V6 stated he would discard the pickle container.On 03/30/2026 at 11:14 AM, V7 (Maintenance director) observed in kitchen area and stated the facility is working on gnats the exterminator comes weekly, bug repellent machines are used in hallways to trap the gnats, we do not have any bug repellent machine in the kitchen yet, but they should be installed. V7 stated drains harbor gnats, the drain in the kitchen is clogged and was just observed today we are trying to resolve the issue. V7 stated the drain in the kitchen is full to the top with water and we have been trying to rod and open the drain. The area in the kitchen is called the Steamer/Kettle drain area. On 03/30/2026 at 11:17 AM,V8(Maintenance tech) was observed attempting to rod the drain in the steamer/kettle kitchen area, V8 stated the drain is very slow and gnats live in drains.V8 stated he has been working to rod the drain for an hour and the water is not going down yet but he will continue to try.On 03/30/2026 at 11:21 AM, V9 (Registered Nurse) on the 2nd floor stated the facility had an issue a while back with gnats flying all over the place and gnats can spread infection and lay eggs. In the last month the gnat issue has gotten better even though gnats continue to fly around in the facility they are worse on the 2nd floor.On 03/30/2026 at 11:23 AM, V10 (Registered Nurse) on the 3rd floor stated she has worked here since September 2025 and has observed black bugs with wings flying around by the nursing station, V10 stated the bugs are called gnats, gnats should not be touching on the resident's food, and I do not know where the gnats are coming from.On 03/30/2026 at 11:27 AM, V11 (Certified Nursing assistant) on the 3rd floor stated she has been working here for the last two years and she has observed the gnats in the residents' room on the window seals and on the beds. Gnats can make the residents sick, the last time I saw the gnats on the unit last week.On 03/30/2026 at 11:42 AM, V13 (House keeper) on the 3rd floor stated the facility has bug lights now on the units that get rid of gnats, gnats are attracted to the lights and g and die on the light.V13 stated the gnats use to be observed flying throughout the facility, the housekeepers make sure we clean the rooms and windows daily to remove the dead gnats.On 03/30/202 at 11: 45 AM, R3 was observed sitting in her room and stated she is visually impaired but feels the gnats flying and hitting her skin and face and the gnats even touch my mouth. R3 stated that V7 informed her that the facility has treated the gnats through the drains but they gnats still are flying around in my room. On 03/30/2026 at 11:50 AM, R4 was observed sitting in her room and stated the gnats were on her bedside table, and the gnats aggravate R4 because they fly on my table near my food and on my clothes, I swat the gnats away.On 03/30/2026 at 11:55 AM, V14 (Licensed Practical Nurse) stated she has been working here since December 2025, and gnats have been on the units and flying around everywhere. Gnats can contaminate the resident's food.V14 stated several times when she was passing medications gnats make her feel nasty and cause her to itch her skin because the gnats fly all around the area.V14 stated she use to have to swat the gnats off her clothing and near her face. The gnat issue has been horrible for the last three months, the gnats use to fly by your nose, ears and mouth.On 03/30/2026 at 12:00 PM, V15(Licensed Practical Nurse) stated about a month or so ago the gnats were flying around everywhere in the facility. The facility treated the drains, and the gnats were gone for about a month and now they are coming back around per the residents.V15 stated she did not like, when she was passing medications and had to swat away the gnats all the time. On 03/30/2026 at 12:10 PM, this surveyor observed two gnats flying in the conference room and one gnat landed on my left arm and I had to swat the gnat dead.On 3/30/2026 at 2:10 PM, V1 (Administrator) stated when he interviewed and toured the facility about a month and half ago the gnats were really bad, the facility has done some work and cut the pipes to repair the issue because the gnats were observed laying in the water pipes, but the gnat issue has decreased drastically.V1 stated he was not made aware that the kitchen drain was clogged this morning.On 03/30/2026 at 2:30 PM, V7 stated the drain company will be in facility on 03/31/2026 to attempt to resolve the clog drain issue because V7 feels the issue is clogged deeper within the pipes.On 03/30/2026 at 2:00PM, V1 ( Administrator) presented Illinois Long term care Ombudsman program titled Residents rights with a revision date of ; 02.2025 which documents in part that the facility must be safe, clean ,comfortable and homelike.Facility policy with revised date of May 2008 titled Pest control documents in part; Our facility shall maintain an effective pest control program;1).this facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents; 6.) maintenance services assist, when appropriate and necessary, in providing pest control services.Reviewed the facility's plumbing and sewer treatment receipts dated 03/10/2026 and 03/19/2026 which documents in part; pipe in the living/recreation room was full of gnats as observed on the camera, treatment of gnats on the third floor in room [ROOM NUMBER].Reviewed facility's document titled facility and investigation and response concern log dated 02/10/2026 at 10:26 AM, documents in part that resident requested a room move due to bugs in room; pest control/plumber following to rectify situation with bugs.

Based on observation, interview, and record review, the facility failed to a.) provide adequate supervision and monitoring for fall risk residents and b.) follow their policy to ensure accident prevention measures were in place by not ensuring a dependable locking mechanism on a soiled utility room door. These failures affect R22, R34, R55, R60, R63, R67 and all residents residing on the second floor. Findings include: 1.On 07/22/2025 at 10:37AM, inside the solarium (identified as the fourth-floor dining room) R22, R34, R55, R60, R63, and R67 were observed sitting inside of the fourth-floor dining room unsupervised and unattended. R55, and R22 were sitting in wheelchairs. R34, R60, R63, and R67 were sitting in geriatric chairs. R63, R22, and R60 observed with seat pad alarms in their seats. On 07/22/2025 at 10:38AM, V7 (Registered Nurse/RN) walks inside of the dining room and administers medications to a resident and exits the dining room at 10:39AM leaving the residents unsupervised and unattended again. All six residents were unsupervised and unattended until 10:42AM, when two staff members (identified as V8/Life Enrichment Associate (LEA) and V9/LEA) entered the fourth-floor dining room to perform activities with the residents. On 07/22/2025 at 10:50AM, V6 (Restorative Nurse/Fall Coordinator) was located inside of the fourth-floor dining room and states all residents in the facility are at risks for falls including R22, R34, R55, R60, R63, and R67. V6 states the seat pad alarms are placed underneath the resident and alerts the staff if a resident has positional movement. V6 states seat pad alarms do not prevent a resident from falling but can help reduce the risk of a resident falling. V6 states he is in the process of updating the resident's fall risk assessments because they do not generate a fall risk score upon completion. V6 states he has been educating the staff on watching and monitoring the residents because this helps better meets the resident's needs. V6 states there should be someone in the dining room monitoring the residents at all times, especially residents who are at risk for falls. V6 states if there is no one monitoring the residents inside the dining room, then residents can potentially fall and injure themselves. On 07/22/2025 at 11:21AM, V7 (Registered Nurse/RN) states there is supposed to be someone inside of the dining room monitoring the residents at all times. V7 states the CNAs/certified nursing assistants are not assigned designated times to monitor the dining room. V7 states the CNAs take turns going in and out of the dining room to check on the residents. V7 states if a staff member is not located inside of the dining room to monitor residents, then the residents could potentially fall and sustain injuries. V7 states she is not sure why a staff member was not inside of the dining room monitoring the residents when she arrived in the dining room previously at 10:38AM. V7 states she did not assign any of the CNAs to monitor the dining room after she was made aware that fall risk residents were inside of the dining room unsupervised and unattended. Facility Policy dated 06/15/2024, titled Fall Protocol and Prevention documents in part, Standard: Residents will be free from falls and injury. Interventions: 4. Resident assessed at risk for falls will be monitored. 11. All departments are encouraged to assist in the prevention of accidents and falls. 2. On 7/23/25 at 1:45 PM, observed the soiled utility room door not locked/secured on floor 2. There was a five-button locking system on the door. Writer opened/accessed the room without utilizing a code to unlock the locking mechanism on the door.Located inside of the soiled utility room:-four sharps containers with visible syringes/needles, razors inside-a one-gallon bottle with liquid inside, with a label that read Disinfectant-a large rolling trash can/dumpster with bags of trash inside-a hopper with standing water-a toilet plunger-approximately nine glass vases-a smaller room with a door, with a sticker that read Bio-Hazard on the door. There was no lock on the door.Located inside of the smaller room inside of the soiled utility room:-approximately twelve red trash bins with labels on them that read Only for Isolation Trash-two filled sharps containers On 7/23/25 at 1:51 PM, V26 (Registered Nurse) stated this is he soiled utility room. It locks automatically usually. There is no door handle. Maybe with a door handle people can make sure it shuts. It has happened before where it does not lock all the way. We call maintenance to fix it. Maybe it sticks, malfunctions. Residents should not be in here. Isolation trash cans and filled sharps containers are stored here. We take the sharps containers off the medication carts when they fill up and store them in here. Housekeeping then disposes of the filled sharps containers. I assume the disinfectant is used to clean. There is potential harm to the residents to cut themselves with the glass vases if they become broken. There is potential harm to the residents if they drink the disinfectant. There is potential harm for the residents to get stuck and infected by the used needles and razors in the sharps containers. On 7/23/25 at 4:45 PM, V3 (Director of Nursing) stated the soiled utility room should be closed. Stored in the room are waste products, biohazard/infectious material, sharps containers with sharps in them that are for disposal. The room should not be accessible to the residents. The door should be kept always locked. There is a risk for potential harm depending on the type of resident. If they are alert and strong enough to open the bottle. The second floor has mostly confused residents. Residents in wheelchairs that are able to propel themselves. Residents that need assistance. The residents in wheelchairs can go anywhere, any room on the unit if they can propel themselves. There is potential for the residents to be injured by the items in the soiled utility room. They could get stuck by used needles. We have a sufficient number of nurses and CNAs (Certified Nursing Assistants) to get the needs of the residents met. We have adequate staffing. We do nursing and CNA competencies, online lessons. We do in-services including infection control, procedures. Facility policy Biohazards, 6/2024, documents in part: Standard: To protect residents, staff, and visitors from exposure to biohazardous materials and ensure compliance. Facility policy Accident Prevention, 1/2025, documents in part: Standard: Ensure the safety and wellbeing of residents, staff and visitors by minimizing risks of accidents. Facility ensures accident prevention measures are in place (i.e. clutter free hallways, available handrails, proper lighting, equipment inspections, etc) Facility Sharps Policy, 11/15/24, documents in part: Standard: To establish protocols for the safe handling, disposal, and prevention of injuries from sharps (e.g. needles) in order to protect residents, staff, and visitors from exposure to bloodborne pathogens.

Based on observation, interview and record review, facility failed to provide medication in compliance with standards of professional practice for five residents (R19, R32, R39, R58, R77) out of 7 residents reviewed for medication administration in a sample of 24 residents.Findings include: On 07/22/2025 at 10:11AM, V4 (registered nurse) during medication administration, V4 had 5 residents (R19, R32, R39, R58, R77) that did not receive their scheduled 9:00 AM medications. Per the standards of professional practice, scheduled medications may be administered one hour before or one hour after of the medication schedule and are considered late when given more then an hour past the scheduled time. On 07/24/2025 at 10:12 AM, V4 (registered nurse) stated, I have 5 residents remaining to administer medications to. Per the standards of practice, you have one hour before the scheduled time and an hour after the scheduled time to pass the medications. Anything after one hour past the scheduled medication time is considered late, so the 5 residents are going to receive their medications late. Sometimes residents ask for things, and I assist them, which is why I am late with the medications administration. On 07/22/2025 at 11:10 AM, V3 (director of nursing) stated, The expectation is that medications are to be passed on time. The window for medication administration is for it to be passed an hour before and an hour after. Anything given more than an hour past the scheduled time is considered late. Typically, the medications are passed on time. It depends what the situation is why the nurses could not pass the medications on time, but the expectation is that medications are to be given on time. R19's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Dementia with other behavioral disturbance, hyperlipidemia, generalized anxiety disorder, urinary tract infection. Care plan (dated 05/09/2025) documents that R19 uses psychotropic medication (Seroquel) due to a diagnosis of dementia and psychosis. R19's scheduled 9:00 AM Medication as per the physician orders are:Aspirin 81mg Extended-Release tablet; 1 tabletAzelastine HCL Nasal Solution 137 MCG/Spray; 1 spray in both nostrils Cephalexin Oral Capsule 500mg, 1 capsule.Namenda Tablet 5mg; 1 tablet. R32's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Atrial fibrillation, nonrheumatic aortic valve disorder, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance. Care plan (dated 06/19/2025) documents that R32 has impaired cognitive function/dementia or impaired thought processes impaired decision-making, long-term memory loss, and short-term memory loss. R32's scheduled 9:00 AM Medication as per the physician orders are:Eliquis Tablet 2.5mg; 1 tablet. Lasix Oral Tablet 20mg; 1 tablet. R39's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Atrial fibrillation, insomnia, essential (primary) hypertension, muscle weakness (generalized), lack of coordination. Care plan (dated 06/27/2025) documents that R39 at risk for FALLs d/t impaired mobility, Deconditioning, Gait/balance problems, Incontinence, Psychoactive drug use, and diagnoses of A-Fib, dementia, and insomnia. R39's scheduled 9:00 AM Medication as per the physician orders are:Eliquis Tablet 2.5mg; 1 tablet.Ferrous Sulfate 325mg tablet; 1 tablet. R58's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Sequelae of unspecified cerebrovascular disease, pneumonia, unspecified organism, acute upper respiratory infection, malignant neoplasm of unspecified site of left female breast. Care plan (dated 05/28/2025) documents that R58 is on anticoagulant medication (Apixaban) due to atrial fibrillation. R58's scheduled 9:00 AM Medication as per the physician orders are:buspirone HCL 5mg oral tablet; 1 tablet. Clopidogrel Bisulfate 75mg tablet; 1 tablet. Gabapentin 300mg oral tablet; 1 tablet. Hydralazine 100mg oral tablet; 1 tablet. R77's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Metabolic encephalopathy, type 2 diabetes mellitus with other specified complication, chronic systolic heart failure, osteo-arthritis. Care plan (dated 07/18/2025) documents that R77 resident uses antidepressant medication (Sertraline 100mg) depression. R77's scheduled 9:00 AM Medication as per the physician orders are:Jardiance oral tablet 10 MG, 1 tablet.metformin HCl oral tablet 1000 MG; 1 tablet. Nifedipine ER oral tablet extended release 90 MG; 1 tablet. Potassium Chloride ER 20 MEQ. oral tablet; 1 tablet.

Based on observation, interview and record review, the facility failed to follow standards of practice by failing to label medications when opened; and (b) failing to label medications with an expiration date an (c) dispose of expired medical supplies. This failure affects residents receiving medications from the second and third floor medication cart. Finding Include: On [DATE] at 10:43 AM, during a certification and licensure survey, the surveyor audited the 2nd floor odd side Medication Cart with V26 (registered nurse). The surveyor found: a bottle of R17's Humalog insulin vial with an open date of [DATE] and no marked date when the medication expires; a bottle of Gas Relief (Simethicone) 100 chewable tablets with no marked date when the medication was opened and no marked date of when the medication expires; a bottle of Vitamin B-12 1000mcg (micrograms) 130 tablets with no marked date when the medication was opened and no marked date of when the medication expires; a bottle of Vitamin D 50mcg 100 tablets with no marked date when the medication was opened and no marked date of when the medication expires; a bottle of Ibuprofen 200mg (milligrams) 100 tablets with no marked date when the medication was opened and no marked date of when the medication expires; a bottle of Melatonin 1mg 90 tablets with no marked date when the medication was opened and no marked date of when the medication expires; a bottle of Acetaminophen 325mg 100 tablets with no marked date when the medication was opened and no marked date of when the medication expires. On [DATE] at 11:49 AM, during a certification and licensure survey, the surveyor audited the 2nd floor even side Medication Cart with V4 (registered nurse). The surveyor found: a bottle of Zinc 50mg 100 tablets with no marked date when the medication was opened and no marked date of when the medication expires; a bottle of Vitamin D 25mcg 100 tablets with no marked date when the medication was opened and no marked date of when the medication expires; a bottle of B-12 500mcg 100 tablets with no marked date when the medication was opened and no marked date of when the medication expires; R80's Novolin Insulin 70-30 3ml flex pen with no marked date when the medication was opened and no marked date of when the medication expires. On [DATE] at 12:20 PM, surveyor inspected the 2nd floor medication storage room. Surveyor found: 6 Medical Protective IV (intravenous) Safety Catheters that were labeled with an expiration date of 11-29-2021 and were not discarded. On [DATE] at 10:49 AM, during a certification and licensure survey, the surveyor audited the 3rd floor odd side Medication Cart with V17 (registered nurse). The surveyor found: R53's Novolin 70/30 flex pen marked with an open date of [DATE] and no marked expiration date; R102's Lantus insulin 100 units/ml 10 ml vial marked with an open date of [DATE] and not marked with the expiration date; R102's Insulin Lispro 100 unit/ml marked with an open date of [DATE] and not marked with an expiration date; R5's Lantus 100 units/ ml 10 ml vial marked with an open date of [DATE] and not marked with an expiration date. On [DATE] at 11:39 AM, surveyor inspected the 3rd floor medication storage room. Surveyor found: 8 Female Luer Lock Caps marked with an expiration date of [DATE] and not discarded; 1 Secondary Medication Set IV tubing 10 drops/ml marked with an expiration date of 02/2025 and not discarded. On [DATE] at 1:10 PM, V3 (director of nursing) stated, Insulin must be labeled with the date it was open and the date the insulin expires. I will check our policy for labeling for over-the-counter minerals and vitamins and I will check if it should be labeled with an open date and an expiration date. I know all the liquid medications should be labeled with an open date. I will check the policy to see if all the medications bottles should be labeled with the open and expiration dates. Expired syringes and supplies should be discarded. At 1:53 PM V3 stated, The policy is that we follow the expiration dates that are labeled on the bottles by the manufacturer. We don't label the over-the-counter medication bottles with the date the medications were opened. Medication Storage Policy (revised 04/2024) documents in part: If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to practice infection control and prevention and ensure the appropriate personal protective equipment (PPE) was worn by staff caring for a resident on enhanced barrier precautions. This failure affects one (R6) reviewed for infection control on the sample of 24. Findings include: On 07/22/2025 at 1:20PM, surveyor located on the fourth floor of the facility and observes a sign posted on R6's door that reads in part Enhanced Barrier Precautions Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting. Do not wear the same gown and gloves for the care of more than one person. On 07/22/2025 at 1:21PM, V14 (Certified Nursing Assistant/CNA) observed inside of R6's room providing incontinence care and changing R6's diaper. V14 is observed without a gown on and wearing gloves. Surveyor inquires to V14 about the appropriate PPE that should be worn while providing care for R6. V14 states he forgot to put a gown on because he got so busy. V14 observed picking R6's soiled diaper up from the floor while wearing gloves. V14 states he placed a clean gown inside the resident's clean linen cart to use for himself. V14 observed throwing R6's soiled diaper in the trash and walking outside R6's room door and retrieving a clean gown from the resident's clean linen cart wearing the same soiled gloves he used to throw R6's diaper in the trash. Surveyor inquires to V14 about hand hygiene and the appropriate infection control protocol when handling clean and soiled items. V14 states he did not touch any other clean items on the clean linen cart while wearing the soiled gloves. V14 then states there is a potential for cross contamination if he does not wear the appropriate PPE and practice infection prevention protocols. Facility policy dated 04/30/2025 titled Infection Control documents in part, Standard: The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of one resident (R56) reviewed for ADL care in the sample of 24. Findings include:R56's face sheet documents resident is an [AGE] year-old admitted to the facility with diagnoses including but not limited to: Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Need for Assistance with Personal Care, Lack of Coordination, and Muscle Weakness.R56's MDS (Minimum Data Set, 7.16.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R56 is cognitively intact. R56's MDS documents a functional status of 1 for toileting hygiene/toilet transfer denoting R56 is dependent-helper does ALL of the effort. Resident does not complete the activity. The assistance of 2 or more helpers is required for the resident to complete the activity.R56 's bowel and bladder incontinence care plan (initiated/revised 2.20.24) documents in part, INCONTINENT: Check the resident every 2-3 hours for incontinence and assist with toileting if needed.On 7/22/2025 at 10:50 AM, R56 was observed awake, alert sitting up in bed. R56 said, I am okay, I can be better. I feel that there is a lack of communication around here. I let them know that I want to get up and get dressed. I have a doctor's appointment that I have to be at. They said they would come back at 10:00 AM. Surveyor offered to activate R56's call light. R56 said, I don't know, I might be wet by now. I just want to get up and get dressed and ready for my doctor's appointment. I don't want to get anyone in trouble, I don't want to be a tattle tale. I already called them; they know I have a doctor's appointment.On 7/22/2025 at 11:20 AM, V5 (Registry Certified Nursing Assistant) entered R56's room. V5 said she was going to change R56, she has an appointment today. A blue stripe was noted down the front of R56's brief. V5 said that means she's wet. R56 brief was saturated with urine in the front and the back. The incontinent pad was wet with urine. V5 said, I checked R56 at 7:00 AM, she was dry. This is the first time I'm changing her.On 7/23/2025 at 4:39 PM, V3 (Director of Nursing) said, the importance of prompt incontinence care is to maintain skin integrity and to ensure the resident is kept clean and dry. V3 said some residents should be checked more frequently than others, residents with heavy incontinence should be checked at least every two hours.

Based on observation, interview and record review, the facility failed to provide 1:1 feeding assistance in a timely manner for one (R2) resident out of seven residents in a total sample of 24. Findings include: On 07/23/2025 at 12:31 PM, R2 lying in bed, awake, head of the bed slightly elevated. R2 stated in Spanish si, yes, when asked if he wanted to eat. When asked in Spanish if he ate, R2 stated no. R2's meal contents on the food tray is untouched, uneaten, and was sitting at R2's overhead bedside table.On 07/23/2025 at 12:40 PM, V22 (Certified Nursing Assistant/orientee) sitting on a chair, touching screen on the wall. On 07/23/2025 at 12:43 PM, R2's food tray is still untouched, uneaten sitting at R2's overhead bedside table.On 07/23/2025 at 12:46 PM, V20 (Certified Nursing Assistant) walked into R2's room. V20 stated that she will be changing R2's incontinence brief at this time and after will provide feeding assistance to R2. V20 stated that V20 was feeding another resident prior to attending to R2. V20 stated I don't know what time lunch is but probably at 12:00 PM. V20 stated that she placed R2's lunch tray in R2's room. V20 stated that R2 should not have waited that long for lunch. V20 stated I am from agency, I thought someone would have fed him by now, because yesterday someone did. V20 stated that she didn't ask any staff to assist V20 in feeding R2. V20 stated that she did feed R2 breakfast this morning but cannot recall at what time V20 fed R2.On 07/23/2025 at 12:51 PM, V21 (Registered Nurse) stated that she is surprised that no one else fed R2. V21 stated residents' lunch time is at 12:00 PM. V21 stated R2 should eat when lunch arrives despite R2 being a feeder. V21 stated that when V21 returned from her break between 12:15 PM-12:20 PM, V21 conducted rounds and did observe R2's lunch tray on R2's overhead bedside table. V21 stated but I was not made aware that he needed to be fed if not I would ask someone to assist R2 with his meal. V21 stated that the time she was making rounds, V21 noticed that staff were collecting trays. V21 stated that there are no issues with staffing because they are fully staffed.On 07/23/25 at 12:55 PM, V11 (Assistant Director of Nursing) stated we can all help feed a resident. That is not allowed to have someone waiting that long. V11 stated that if she would try to feed a resident, V11 would go in and ask the resident if they are hungry and in the event the resident is confused, V11 stated that she would physically try to feed the resident. V11 stated that this surveyor can speak to this floor's manager, V23 (Registered Nurse).On 07/23/25 at 1:07 PM, V23 (Registered Nurse) stated that the assigned CNA (certified nursing assistant) will ask for help if the CNA can't keep up with the time, she will need to ask for help from another CNA.R2's current face sheet documents that R2 is a [AGE] year-old individual with diagnoses not limited to: need for assistance with personal care, unspecified dementia, unspecified severe protein-calorie malnutrition, pressure-induced deep tissue damage of sacral region.R2's current care plan documents in part R2 is at risk for compromise in nutrition/hydration status. Interventions documents in part provide 1:1 feeding assistance.R2's active physician order set documents in part regular diet, pureed texture, nectar consistency, double portion; 1:1 feeding assist with order date 06/11/2025. Nursing assignment sheet dated 07/23/25 documents that R2 requires meal assistance.Facility document not dated, titled dining room mealtimes documents that lunch time is at 11:45 AM. Facility document not dated titled resident rights for people in long-term care facilities documents in part your rights to dignity and respect. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source.

Based on observation, interview, and record review the facility failed to ensure a pressure relieving device was functioning properly for one (R20) who is at risk for pressure ulcers out of seven residents in a total sample of 24.Findings include:On 07/22/2025 at 11:39 AM, R20 lying in bed, wearing a hospital gown, asleep, and in no apparent distress. R20's bed with an air loss mattress and the machine pump (electronic controller). The display screen on the pump (electronic controller) is dark, no items displayed, and no sound heard from the air mattress pump noted. R20's mattress appeared/felt slightly flat and lumpy. The air mattress pump (electronic controller) model noted. On 07/22/2025 at 11:47 AM, V15 (Infection Prevention) pressed the lock button, on and off button on the air mattress pump (electronic controller) but nothing appeared on the screen. V15 stated the pump should be on, it is probably locked. Let me go get the person in charge of handling the mattress pump. On 07/22/2025 at 11:51 AM, V6 (Restorative Nurse/Fall Coordinator) pressed a lot of the buttons on the air mattress's pump and the screen did not appear on. V6 plugged in a hose/tube from the pump (electronic controller) tighter. V6 stated I just pulled it out and pressed it back in, and as you can see it is inflated up. The electronic controller's screen displayed a light, air loss mattress settings, and able to hear sound coming from the pump (electronic controller). V6 stated that R20 does not have any pressure sores. V6 stated that the importance of a functioning air loss mattress is to assist in prevention of wounds, and some are ordered to assist in helping wound healing. V6 stated that the purpose of this alternating low air loss mattress is to change and distribute the area based on the weight distribution. Facility document provided dated 07/22/2025, documents in part, the low air loss alternating pressure mattress is not designed to stay inflated indefinitely during a power outage. If the power goes, the pump will stop functioning, and the mattress will gradually deflate. The mattress is designed with a foam base that provides cushioning and support, but it will not maintain its full inflation without power. R20's current care plan documents in part R20 is at risk for pressure ulcer/skin breakdown d/t (due to) impaired mobility, right pelvic fracture, and incontinence. Intervention notes air mattress.R20's active physician order set documents in part air mattress dated 02/17/2023.R20's air mattress manufacturer manual documents in part controller is inoperable. May be caused by a power surge substantial enough to overload the internal circuitry. May be caused by other internal damage/failure. Patient is uncomfortable or mattress feels lumpy. May be caused by excess or insufficient pressure. Solution notes make sure controller is plugged in and turned on, i.e.: LED (light-emitting diode) is on and solid green.

Based on observation, interview, and record review the facility failed to ensure medications were not left at bedside for one (R2) resident and failed to ensure a treatment cart was locked when not in visual proximity of the nurse and not in use. This failure has the potential to affect all 36-residents residing on the 4th floor of the facility. Findings include: 1. On 02/24/25 at approximately 11:12am, R2 noted in bed, on the cabinet in the room a bottle of Fluocinonide topical solution with instruction to apply to scalp topically@ bedtime with a pharmacy label to Avoid contact with eyes. In addition, a tube of Econazole nitrate cream 1% left on the table. When V4 ADON (Assistant Director of Nurse's) was shown and was asked about the facility policy/protocol on medication storage at the bedside. V4 stated no medicine should be left at bedside without an order (referring to physician order) but let me check if there is an order to leave at the bedside. V4 then took the medications to V5 RN (Registered Nurse) assigned to R2. Both V4, V5 and the surveyor checked the EPO (Electronic Physician Order) for R2 there was no written order for R2 to keep those medication at the bedside or self-administer the medication. V5 asked the surveyor whether topical medications can be kept at bedside. The surveyor asks V5 about the professional standard of medication storage/ administration. V5 stated I don't know, can we move to the next question. V4 who was present at the time stated, I will have to educate the nurses on medication storage when there is no order (Physician Order) to do so. On 02/24/25 at 11:58am V2 DON (Director of Nurse's) stated that all medication should be locked in the medication cart unless the physician ordered it to be kept at bedside. The facility policy and professional standard of medication administration is that any medication should be prescribed by the doctor (physician). Any one on elf-administration program will be evaluated and see if they are able to self-administer the medication. 2. On 02/24/25 at 10:57am, on the 4th floor upon getting on the floor treatment cart with treatment medications noted unlocked with no licensed nurse or any staff at the nurse's station. When this was shown to V5 RN (Registered Nurse) and was asked about the facility policy on medication storage and cart policy. V5 stated it is not my cart, but the treatment cart should always be locked when not in use. On 02/24/25 at 11:05am, V4 ADON (Assistant Director of Nurse's) who was present on the floor was asked about the facility policy on carts storage, medication storage and expectation of the licensed nurse staff responsibility. V4 stated that the medication carts that includes treatment cart should be locked always when the nurse is not in view of the cart. It should not be left unlocked. On 02/24/25 at 11:22am, the surveyor asks V6 (RN) assigned to the treatment cart about the treatment cart that was left unattended and unlocked. V6 stated that when she got to work this morning (02/24/25, she did not look (check) at the treatment cart, but it should be locked (treatment cart) when not visual few. On 02/24/25 at 11:56am, V2 DON (Director of Nurse's) stated that medication cart and treatment carts should be locked. Nurses has the key to the treatment cart and the medication cart for each side assigned so they are to make sure the carts are locked when not in few of the nurse. On 02/25/25 at 11:50am, on the 2nd floor treatment cart noted unlocked on the (odd side) of the floor. V16 CNA (Certified Nurse's) stated that the nurse on this side (odd) is on lunch break but the other nurse (referring to V5) is in the dining room passing medicine. V5 was shown the treatment and she stated it should be locked always. V12 IP (Infection Preventionist) nurse who was on the 2nd floor was asked about the facility policy on medication and cart storage. V12 stated that the carts should be locked always when not in the nurse view. On 02/25/25 at 11:55am, when the surveyor made V11 RN (Registered Nurse) assigned to the odd side aware the observation and was asked about the facility policy on medication storage and treatment cart storage. V11 stated I was so sure I locked the treatment cart, V5 then told V11 that it was not locked. then V11 stated it (referring to the treatment cart) should be locked every time is not in use or leave it. On 02/25/25 at 12:03pm, V12 RN (Registered Nurse) / IP (Infection Preventionist) stated that all carts containing any medication should be locked when not in use and in view of the nurse. The facility policy on Medication Storage presented with revised date 04/2024 documented that the standard is medications will be stored correctly. Listed procedure includes but not limited to nursing staff is responsible for maintaining medication storage and compartments that includes carts containing medications and biologicals are locked when not in use and carts used in transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review the facility failed to properly log refrigerator and freezer temperatures in the facility kitchen; and failed to properly log the checking of the dating and labeling of food items and removal of expired items in the facility kitchen. These failures have the potential to affect all 104 residents receiving an oral diet in the facility. Findings include: On [DATE] at 12:06pm, with V4 (Director of Dietary Services), during observation of the facility's main walk-in freezer, walk-in refrigerators (coolers), and Ice Cream freezer, the following was observed: 1. The walk-in freezer's temperature log titled, Freezer/Refrigerator Temperatures, dated February 2025, documents, in part, -10 degrees Fahrenheit on [DATE] AM shift. This was observed on [DATE] which indicates the temperature of the walk-in freezer was documented for a future date. 2. The Ice Cream freezer's temperature log titled, Freezer/Refrigerator Temperatures (with the word Ice cream written at the top right corner of the document), dated February 2025, documents, in part, 5am 3.2 (degrees Fahrenheit) on [DATE] AM shift. This was observed on [DATE] which indicates the temperature of the Ice Cream freezer was documented for a future date. 3. The Refrigerator #1 (Cooler #1) temperature log titled, Freezer/Refrigerator Temperatures (with the words Cooler #1 written at the top right corner of the document), dated February 2025, documents, in part, 5am 37 (degrees Fahrenheit) on [DATE] AM shift. This was observed on [DATE] which indicates the temperature of Refrigerator #1 (Cooler #1) was documented for a future date. 4. Refrigerator #2 (Cooler #2) temperature log titled, Freezer/Refrigerator Temperatures (with the words Cooler #2 written at the top right corner of the document), dated February 2025, documents, in part, 5am 36 (degrees Fahrenheit) on [DATE] AM shift. This was observed on [DATE] which indicates the temperature of Refrigerator #2 (Cooler #2) was documented for a future date. 5. Facility document titled, (Facility Name) Dietary Audit Form: Dating and Labeling of Food Items and removal of expired items in the main kitchen, dated February 2025, documents, in part, that the ice cream freezer, produce, dairy, freezer, dry storage was checked for dating and labeling of food items as well as removal of expired items in the main kitchen on [DATE]. This was observed on [DATE] which indicates the checking for dating and labeling of food items as well as removal of expired items in the main kitchen was done on a future date. On [DATE] at 12:10pm, when asked what the facility's expectations on documenting temperatures for the refrigerators and freezers in the kitchen; and documenting the checking of the dating and labeling of food items and removal of expired items in the facility kitchen, V4 (Director of Dietary Services) replied, I'm (V4) going to talk to this employee about this documentation. This should be done on am shift and pm shift. This is a mistake. It should not for the following day. When asked the purpose for properly documenting refrigerator and freezer temperatures and the checking for dating and labeling of food items, V4 replied, To make sure the coolers and freezers are working good so the food doesn't go bad. If the food goes bad the residents can get sick. We (kitchen staff) actually checking the expirations on the food twice a day. Same thing. Expired food can cause the residents to get sick. I (V4) think she was just confused on the date. The facility's document, titled (Facility) Diet Type Report, dated [DATE], shows that the facility has 1 resident that does not have an oral diet. Facilities policy titled, Food Storage, dated ,d+[DATE], documents, in part, . Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination . A thermometer will be present in the storeroom and will be monitored on a regular basis . Refrigerators should maintain food temperatures at or below 41 F and freezer temperatures to keep food frozen solid . Temperatures for refrigerators should be between 35 to 39 F. Thermometers should be checked at least two times each day . Freezer temperatures should be checked at least two times each day . Facility's job description titled, Food Service Manager, revised date [DATE], documents, in part, . Manage all kitchen staff and front of the house operations to ensure the highest quality of customer service to residents . Ensures that all services and programs are in compliance with federal, state, and/or local regulations, laws and statues . Facility's job description titled, Dining Service Manager, revised date [DATE], documents, in part, . manage all kitchen staff and front of the house operations to ensure the highest quality of customer service to residents . Ensures that all services and programs are in compliance with federal, state, and/or local regulations, laws and statues . Facility's job description titled, Kitchen Supervisor, revised date [DATE], documents, in part, . manage all kitchen staff and front of the house operations to ensure the highest quality of customer service to residents . Ensures that all services and programs are in compliance with federal, state, and/or local regulations, laws and statues . Facility's job description titled, Dietary Aide, revised date [DATE], documents, in part, . To assist the Clinical Dietitian with food service to the skilled nursing patients, so that each receives the correct diet at the specified time .

Based on observation, interview and record review the facility failed to ensure that one resident (R1) was treated in a dignified manner. This failure affected one resident (R1) out of four residents reviewed for dignity. Findings include: On 02/19/25 at 11:36am V6 (Registered Nurse/RN) stated that she placed signs on R1's wall to remind other nurses to change R1's wound dressing. On 02/19/25 at 11:50am observed 3 handwritten paper signs taped to walls in various locations of R1's room. Signs document in part, 7-3 shift nurse: AM (morning) nurse please do wound care dressing on left lower leg on Tuesday and Saturday mornings. Resident will call DON (Director of Nursing)/Supervisor if it's not being done!! Foot doctor do not do resident dressing or his wound. On 02/20/25 at 11:40am, V3 (DON) stated that instructions should not be posted on resident walls because of confidentiality not so much dignity. Facility's policy dated 12/2024, titled Dignity documents in part, Policy and Procedure: 1. Residents are treated with dignity and respect at all times .10. Staff are to follow HIPAA (Health Insurance Portability and Accountability Act) guidelines at all times to maintain residents' privacy. Facility's undated policy titled Resident's Rights documents in part, Your rights to dignity and respect .Your facility must treat you with dignity and respect .Your rights to privacy and confidentiality .You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private.

Based on interview and record review, the facility failed to ensure that one resident (R1) with a venous stasis ulcer received the necessary treatment and services to promote wound healing. This failure affected one resident (R1) out of four residents reviewed for wound care. Findings include: R1's medical diagnoses include but are not limited to myositis, hypertensive heart disease with heart failure, nonrheumatic aortic stenosis, non-pressure chronic ulcer of unspecified part of left lower leg, muscle weakness, peripheral vascular disease. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 15, which indicates R1's cognition is intact. R1's care plan dated 11/13/24 documents in part, R1 at risk for pressure ulcer/skin breakdown due to impaired mobility and bilateral leg edema. Bilateral lower leg venous statis ulcers .Administer treatments as ordered and monitor for effectiveness. R1's physician orders dated with a start date of 12/14/24 documents in part, Left heel apply bordered foam dressing every day shift every Tuesday, Thursday, Saturday for DTI (Deep Tissue Injury) R1's physician orders dated with a start date of 01/21/25 documents in part, Left lateral lower leg wound, cleanse wound with saline, pat dry, apply Aquacel Ag, cover with gauze and abdominal pad and wrap with roll gauze and secure tape. Apply single tubugrip on left leg only per resident request .every day shift every Tuesday, Thursday, Saturday. R1's Treatment Administration Record shows no documentation for the completion of R1's left heel or left lateral lower leg wound care on Tuesday 01/21/25. R1's physician order dated with a start date of 12/07/24 documents in part, Left lateral lower leg wound cleanse wound with saline, pat dry, apply prisma and xeroform, cover with gauze and abdominal pad and wrap wit roll gauze and secure tape .every day shift every Tuesday, Thursday, Saturday. R1's Treatment Administration Record shows no documentation for the completion of R1 left lateral lower leg wound care on Tuesday 01/14/25. R1's physician order with a start date of 01/25/25 and discontinue date of 02/06/24 documents in part, left lateral lower leg wound cleanse wound with saline, pat dry, apply prisma cover with gauze and abdominal pad and wrap with roll gauze and secure tape .every day shift every Tuesday, Thursday, Saturday. R1's Treatment Administration Record shows no documentation for the completion of R1's left lateral lower leg wound care on Tuesday 01/28/25. On 02/19/25 at 11:36am, V6 (Registered Nurse/RN) stated that R1 went to the wound clinic every Thursday and the facility was responsible for changing R1's wound care dressings on Tuesdays and Saturdays. V6 stated that R1 had complained to her about not having his wound dressing changed on some Tuesdays. V6 stated that she told R1 to remind the staff to change his wound bandage because he is alert and oriented. V6 stated that she put an order on R1's physician orders to make sure staff are changing R1's wound. V6 stated that she placed signage on R1's bedroom walls to remind staff to change R1's wounds. R1's physician order dated 02/06/25 documents in part, AM (morning) nurse to do wound dressing on the left lateral lower leg, foot doctor do not do the dressing on the leg every day shift every Tuesday, Saturday .FYI (for your information) resident goes to wound care clinic (WCC) on Thursday. On 02/20/25 V3 (Director of Nursing/DON) stated that if there is no documentation then it may not have been done. V3 stated the facility has a podiatrist that comes to the facility to see residents on Tuesdays. V3 stated that there was a mix up and the nurses thought that R1 was being seen by the podiatrist on Tuesdays, so the nurse was not changing the bandages of R1. V3 stated that if wounds dressings are not changed that the wounds could get worse. R1's left lateral lower leg wound measured 2.8 centimeters length by 1 centimeter width by 0.1 centimeter depth on 12/12/24. R1's wound for pre debridement and post debridement measured 5 centimeters length by 2 centimeters width by 0.2 centimeters depth on 2/6/25. Facility's job description for Registered nurse dated 04/2013 documents in part, Essential Duties and Responsibilities: .Perform treatments in a timely manner, using proper techniques.

Based on interviews and record reviews, the facility failed to provide adequate supervision for one resident [R5] who is a high fall risk out of three residents reviewed for falls. This failure resulted in R5 experiencing an unwitnessed fall and sustaining an acute nondisplaced fracture of the L5 superior endplate with extension to the left L5 transverse process (Lumbar Fracture). Findings Include, R5 clinical record indicate in part; R5 is a sixty-nine year old with the Medical diagnosis includes but not limited to malignant neoplasm of right main bronchus, secondary malignant neoplasm of brain, severe protein calorie malnutrition, atrial fibrillation, osseous and subluxation, major depressive disorder, wedge compression fracture of fifth lumbar vertebra, subsequent encounter for fracture with routine healing, muscle weakness, difficulty in walking, need for assistance with personal care, malignant neoplasm of unspecified part of unspecified bronchus or lung , adult failure to thrive, and presence of left artificial hip joint. R5's minimum data set section [C] dated 11/27/24 indicates R5 is cognitively impaired. R5's care plan documents in part: 11/27/24, R5 has anemia, metastatic small cell lung cancer. Intervention: Complete fall risk assessment and increase vigilance for falls. 11/27/24, R5 needs a safe environment with a working and reachable call light. 11/27/24, R5 requires maximum staff assist with transfers. 12/9/24, place R5 by the nurse station for closer monitoring. R5's hospital document dated 12/9/24, indicates: R5 was brought in for unwitnessed fall at the nursing care facility. CT scan results: Acute nondisplaced fracture of the L5 superior endplate with extension to the left L5 transverse process. R5's progress notes documented in part: V7 [Registered Nurse] Note: 12/9/24 at 9:01 AM, Note Text: R5 has been anxious this morning trying to get out of bed. Writer and CNA [V11-Certified Nurse Assistant] redirected R5 multiple times as she kept dangling her legs off the bed. Writer and CNA [V11] on duty transferred the resident to the wheelchair so that she could be supervised at the nurse's station. V7 [Registered Nurse] Note: 12/9/2024 11:16 am Nurses Notes Note Text: Writer hears yelling coming from R5's and quickly went in to assess the scene and found R5 laying supine position on the floor next to her bed. R5's head was facing towards the foot of the bed, and her feet were facing towards the head of the bed. The R5 began to adjust her arms and bend her knees to try and get up, and the writer and another RN on duty assisted the R5 off the floor back into the wheelchair. The R5 began pointing to her head where the writer observed a small hematoma on the right side of the rear of her head. RN assessed the resident for additional injuries and the assessment was with in normal limits. Vital signs: BP (blood pressure) 111/74, HR (heart rate) 79 BPM (beats per minute), 99%O2 (oxygen) saturation, 97.1F temperature, and respirations 22. Parties notified: AM supervisor, director of nursing, physician, and family. Carried out doctor's orders to send the resident to the hospital emergency department for evaluation. 12/10/2024 04:34 am Nurses Notes Note Text: R5 admitted to hospital with L5 Vertebral fracture. R5's Illinois Department of Public Health Report Notification dated 12/10/24, indicated: On 12/9/24 at 11:12 AM, R5 was noted laying on the floor in her room. Noted with elevated area to the back of R5's head. On 1/25/25 at 12:41 PM, V11 [Certified Nurse Assistant] stated, I was R5's certified nurse assistant on 12/9/24 day shift. R5 is alert but confused and needs close monitoring. When I came in to work and observed R5 trying to get out of bed and anxious. I assisted R5 with ADL (activities of daily living) care and dressed. R5 was transferred out of bed into her wheelchair. Then R5 was taken nurse's station for close monitoring. At 11AM, I told V7 [Registered Nurse] I was going to lunch and to monitor R5 at the nurse station. Upon my return back from lunch, V7 told me that R5 fell , when I left for lunch. On 1/25/25 at 1:30 PM, V7 [Registered Nurse] stated, I was R5's nurse on 12/9/24, day shift. R5 is alert but confused and is a high fall risk resident. R5 has diagnosis of lung and brain cancer. R5 needed close monitoring and supervision especially when she becomes anxious. Early that morning, I noticed R5 was anxious trying to get out of bed. Multiple times I redirected R5 to place her legs back into the bed so she would not fall. I assisted V11 in transferring R5 into the wheelchair so she could be monitored and supervised closely at the nursing station. A little past 11AM, I was in the hallway and heard yelling from R5's room, I observed R5 laying on the floor on her back. R5 started to move and was trying to get herself up, after me and another registered nurse assessed R5 then we assisted her up off the floor back into her wheelchair. At that time R5 pointed to her head and noted a hematoma. R5's physician gave an order to send R5 to the emergency department for further evaluation. I did not see when R5 left the nursing station, I had other residents to give medication and assistance. Around 11AM I started the noon medication pass and checking blood sugar levels during that time. I do not remember if V11 told me she was going to lunch around 11AM. I did not notify the director of nursing that I needed assistance to monitor R5. On 1/26/25 at 11:25 AM V12 [Nurse Practitioner] stated, I am familiar with R5, I been working at the facility for several years. R5 is alert and confused due to lung cancer that spread to her brain. R5 requires close supervision and monitoring due to her confusion and brain cancer diagnosis. I made rounds and saw R5 on 12/9/24. R5's pain was managed well. R5 needed to supervise and monitored closely due to the fact R5 needed frequent queuing and redirection for her safety. R5 was able to stand and walk but with a weak unstable gait. However, due to R5's brain cancer she did not have safety awareness, not to walk, therefore needed close supervision. R5 had an unwitnessed fall on 12/9/24 and sustain a L5 fracture. On 1/25/25 at 2:40 PM V3 [Director of Nursing/Fall Coordinator] stated, R5 is alert but confused and is a high fall risk resident. R5 has diagnosis of lung and brain cancer. R5 needed close monitoring and supervision. During my investigation related to R5's fall on 12/9/24, V7 [Registered Nurse] observed R5 being restless and trying to get out of bed. R5 was dressed and transferred to the wheelchair and taken to the nurse's station for close monitoring. When V11 [Certified Nurse Assistant] notified V7 that she was leaving the unit for lunch, V7 should have monitored R5 closely. If V7 had to take care of other residents, then V7 should have notified me so I could have assisted in making sure R5 was supervised closely. R5 fell and sustained a fracture that could have been avoidable due to lack of supervision. Policy documents in part: Fall Prevention dated 6/15/24. Residents assessed at risk for falls will be closely observed. Residents will be free from falls and Injury. Diagnosis is evaluated for those that may predispose a resident. Residents exhibiting mental or physical changes are evaluated for the increased risk of falls.

Based on interviews and record reviews, the facility failed to obtain monthly weights and recognize, evaluate, and address weight loss for three (R17, R66, and R61) residents out of a total sample of 22 residents. This failure resulted in R17 having a 15.7 percent decrease in weight in six months between 12/4/2023 (121 pounds) and 6/4/2024 (102 pounds). Findings include: 1. On 6/11/2024 at 10:48 AM and at 1:26 PM, R17 was observed sleeping in bed with an intravenous (IV) in the left hand and 0.9 percent Dextrose with Sodium Chloride running at a rate of eighty milliliters per hour. On 06/11/24 at 2:47 PM V9 (Registered Nurse) stated that R17 felt weak, threw up and had diarrhea the morning of 6/11/2024. R17's blood pressure was also low. V9 called the doctor who ordered intravenous (IV) fluid. R17 was interviewed and stated that she was dizzy the morning of 6/11/2024. R17 stated I don't like the food here. R17 stated that she felt better after receiving the IV fluid and resting. On 06/11/24 at 03:17 PM R17's weights were read in the electronic health record as: 124 pounds on 7/22/2023, 125 pounds on 8/2/2023, 126.8 pounds on 8/7/2023, no weight was obtained in September 2023 or October 2023, 122 pounds on 11/8/2023, 121 pounds on 12/4/2023, no weight obtained in January 2024, 104.8 pounds on 2/5/2024, 105 pounds on 2/16/2024, 104.8 pounds on 2/26/2024, 98.6 pounds on 3/7/2024, 107 pounds on 3/16/2024, 107 pounds on 3/23/2024, 98.6 pounds on 4/14/2024, 105 pounds on 5/9/2024, 102.6 pounds on 5/23/2024 and 102 pounds on 6/4/2024. R17 had a 7.85 percent weight loss and an 8.4 pound weight loss in one month between 3/16/2024 (107 pounds) and 4/14/2024 (98.6 pounds). R17 had a 15.7 percent decrease in weight in six months between 12/4/2023 (121 pounds) and 6/4/2024 (102 pounds). On 6/12/2024 at 10:05 AM V12 (Registered Dietician) was interviewed and stated that facility policy is that residents are weighed monthly. The facility has a weekly Nutrition-At-Risk meeting. The purpose of the meeting is to discuss any weight concerns or any other nutrition concerns that staff may have about a resident. Residents are discussed at the Nutrition-At-Risk meeting if the resident is newly admitted , is readmitted to the facility, or if nursing staff, dietary staff, the resident, or the family have concern about the resident's weight or nutritional status. If there are concerns about a resident's weight or nutritional status, V12 stated we then get weekly weights. Weekly weights are documented in the weight section of the electronic health record. V12 stated that she would be concerned about a resident's weight if there was a five percent decrease in one month, a seven and a half percent decrease in three months or a ten percent decrease in six months. V12 stated that if there was a concern about a resident's weight or nutritional status, V12 would assess the resident's food intake, supplement intake, diet order, any concerns about fluid retention and any use of diuretics. V12 would also speak to the resident, physician, and nursing staff to assess for any change in the resident's medical status or food intake. V12 stated that she speaks to the resident about food preferences and the possible need for supplements. Sometimes V12 encourages family to bring food in if that might be helpful. V12 considers appetite stimulants and if there are any chewing or swallowing issues, V12 considers a diet change. V12 reviewed R17's dietary progress note dated 2/24/2024 and stated that the resident had a weight warning because of significant weight loss at three and six months. The plan was for weekly weights and to continue same diet. V12 stated that R17 was again seen by the dietician on 3/16/2024. At that time, R16 continued weekly weights and R17's weight was trending back up. There was a concern about a weight that was low and that she was not eating all three meals a day. V12 reviewed R17's weights documented in the electronic health record. V12 stated the weekly weights were not documented. V12 stated There was significant weight loss in April. It doesn't look like anything was documented on that significant weight loss of 107 pounds on 3/23/2024 to 98.6 pounds on 4/14/2024. It also looks like the weight of 105 pounds on 5/9/2024, 102.6 pounds on 5/23/2024 and 102 pounds on 6/4/2024 triggered in the electronic health record as a significant weight loss, but no dietary assessment was completed. V12 stated that R17 should have had a dietary assessment after the 4/14/2024 weight of 98.6 pounds. V12 stated R17 is due for her quarterly assessment. She is on my list today so I will be seeing her. There may not have been follow up on R17's weight loss because there were several dieticians who were covering the Dietician position; some part time and some remotely, before V12 was hired. V12 stated now knowing that R17 has this weight loss, I will do her assessment today. On 6/11/2024 at 3:30 PM, the dietary progress note of R17 written by V20 (Dietician) dated 2/24/2024 was read and stated in part: Weight review/weight warning: 105 pounds. Body mass index (BMI) 17.5 underweight. Significant weight loss at 3 and 6 months noted, resident weight overall stable this month. Added to weekly weights for monitoring of weight loss. The dietary progress note of R17 written by V20 (Dietician) dated 3/16/2024 stated in part: R17 continues on weekly weight with interdisciplinary team following. Weight trending back up but question other weights of 90 pounds. Will continue supplements and weekly weights. The electronic health record had no dietary progress notes after 3/16/2024. Policy titled 3.01 Philosophy and Standards of Clinical Care, Section: Clinical Nutrition revised 1/2024 stated in part: Procedure: This area provides state of the art nutritional care and education to the patients, residents, medical staff, associates and the communicate. The Registered Dietician Nutritionist (RDN) will follow the standards of clinical care including: 3. The RDN will assess the nutritional status of those patients/residents identified at risk and will communication information that impacts care to the health care team. Procedure: 1. The RDN should be alerted to significant weight changes including loss/gain of 5% in a month and/or three points/week through communication with nursing staff. In addition, monthly weight charts should be monitored closely for weight loss trends. 3. The resident should be placed on weekly weights and monitored for one month until weight change is resolved. Nutrition Risk Criteria for the Geriatric Resident: Nutritional High-Risk Indicators: Significant weight loss over 6 months (180 days) or 5% in 30 days. Policy titled Weights and Heights with revision date of October 6, 2011, stated in part: Standard: Accurate weight and height of each resident will be obtained and monitored. Policy and Procedure: Bullet 1: Monthly weights will be completed by the tenth weekday of each month. Bullet 2: Weekly weights will be completed each week for applicable residents. Bullet 9: All information will be discussed at the weekly weight monitoring meeting and followed up with physician if indicated. 40061 2. R66's weights are as follows: 10/20/2023 - 178 lbs (pounds) 12/07/2023 - 161 lbs 1/29/2024 - 175 lbs 2/22/2024 - 164 lbs 5/14/2024 - 165 lbs There was a severe weight loss of 6.28% from January to February. Dietary progress note dated 2/24/2024 9:20 AM documents in part R66's weight change. It also states in part that facility will obtain new monthly weight and continue to monitor weights monthly and as needed. Facility failed to obtain new weight and monthly weights for March and April. No other recent Dietary Note as of 6/11/2024. On 6/12/2024 at 11:41 AM, surveyors interviewed V12 (Registered Dietitian) in-person with V13 (Regional Nutrition Director) on the phone. Both stated V12 was new to the facility and prior to that there were different consultants in the previous months. When asked about R66, V12 stated [V12] has not evaluated R66 and staff did not notify V12 that R66 had weight loss. V13 stated R66's most recent weight was from 5/14/2024 and prior to that it was from 2/22/2014. V12 stated significant weight loss is 5% in a month, 7.5% in three months, and 10% in six months. V13 stated when staff notify Dietitians of weight loss, then Dietitians will consult to add weekly weights for the residents. V13 stated at the minimum, staff should weigh residents monthly. V13 did not see documentation as to why staff did not do R66's weights. V13 also stated that if there is a questionable weight or weight loss, the Dietitians will request a re-weigh. V13 stated there was no re-weigh after 2/22/2024 weight. On 6/13/2024 at 11:35 AM, V2 (Director of Nursing) stated the Certified Nurse Aides (CNAs) weigh the residents. At the minimum the staff must weigh all residents monthly. If they cannot weigh the resident, the CNAs must notify the nurse so that the following shift can follow-up or staff can attempt the next day. V2 stated Dietary is supposed to do the weight calculations and address the weight loss. Facility's Policy: 3.01 Philosophy and Standards of Clinical Care Section: Clinical Nutrition, last revised 1/2024, documents in part: The Registered Dietitian Nutritionist (RDN) will assess the nutritional status of those patients/residents identified 'at risk,' and will communicate information that impacts care to the health care team. All nutritional care is recorded in the medical record in accordance with facility policy/protocol. Timely and periodic assessments of patients'/residents' tolerance, acceptance and appropriateness of their prescribed diet will be conducted. Facility's Policy: 3.14 (LTC/AL) Unintentional Weight Change Monitoring Section: Clinical Nutrition, last revised 1/2024, documents in part: The Registered Dietitian Nutritionist (RDN) should be alerted to significant weight changes including loss/gain of 5% in a month and/or three (3) pounds/week through communications from the nursing staff. In addition, monthly weight charts should be monitored closely for weight loss trends. Prior to initiation of a nutrition intervention, weight change should be validated by a reweight. Once actual loss/gain has been established and determined to be a nutritional concern, a nutrition reassessment/progress note is completed. The resident should be placed on weekly weights and monitored for one month until the weight change is resolved. Facility's Weights and Heights, last revised 10/06/2011, documents in part: Monthly weights will be completed by the 10th weekday of each month. Staff to request assistance if needed for completion. If there is a weight discrepancy the resident will be reweighed to ensure accuracy. Monthly weights will be documented on weight flow sheet. 44103 3. R61's electronic health records (EHR) show an admitted [DATE]. R61's Minimum Data Set, dated dated dated [DATE] shows R61 has impaired cognitive skills and requires substantial/maximal assistance with eating. R61's weight records show the following readings: 5/31/24 134.0 pounds, 4/24/24 135.0 pounds, 2/26/24 133.0 pounds, 12/2/23 145.0 pounds, and 11/26/23 144.0 pounds. No weights were obtained in January and March 2024. R61's weights show R61 had a 12 pounds weight loss from 12/2/23 to 2/26/24. R61's records do not show any documentation that R61's weight loss was recognized, evaluated, and addressed. R61 was evaluated by V33 (Registered Dietician) not until 5/2/24 and did not address the weight loss. On 6/12/24 at 11:52 AM, a phone interview was conducted with V13 (Regional Nutrition Director). V13 stated that R61's January and March weights are missing. V13 stated that the December and February weights show a significant weight loss and that should have been triggered and should have been addressed by the Dietician. V13 stated that V13 was not the consultant that was in the facility at that time and does not know if the weight loss was referred to a Dietician. V13 stated that V13 does not see any notes or assessment completed addressing the weight loss. V13 stated that an annual assessment was done on 5/2/24 and the last progress notes was in September 2023. V13 stated, I don't see any further interventions were put into place addressing the weight loss. V13 stated V13 would benefit for a nutritional supplement that would increase R61's calories and protein intake. V13 stated that it would at least maintain R61's weight. V13 stated that the goal is for R61 to have no more weight loss.

Based on interviews and record reviews the facility failed to provide adequate supervision and failed to follow their fall policy by failing to develop and implement indivualized fall prevention interventions for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 sustaining a closed displaced fracture of the left femoral neck requiring surgical intervention. Findings Include: R1's clinical record documents: R1's medical diagnosis of displaced intertrochanteric fracture of left femur, Alzheimer's disease, dementia with behavior disturbances, anxiety, essential hypertension, unsteadiness on feet, reduced mobility, need for assistance with personal care, and history of falling. R1's minimum data set [MDS] assessment Brief Interview Mental Status score= 99, which indicates R1 is severely cognitively impaired. R1's MDS section G documents R1 is total dependence for self-performance. Surface to surface transfer R1 is not steady, only able to stabilize with staff assistance. MDS section GG documents R1 is dependent with toileting needs. R1's care plan indicated R1 had falls on the following dates: 1/7/23- R1 was observed sitting on the bathroom floor. R1 said she lost her balance. Intervention: Physical and occupational therapy. 4/29/23-R1 was observed on the floor near the dining room laying on her left side, with the walker on the floor next to R1. Right thumb swollen. Intervention: X-ray of right thumb and physical and occupational therapy. 5/8/23-R1 was observed in another resident's room on the bathroom floor. 911 was called. R1 was admitted with diagnosis of a closed displaced fracture of the left femoral neck, left hip ORIF [open reduction and internal fixation] proximal femur peri-trochanteric fracture. R1 received surgical repair. Intervention: Physical and occupational therapy. 7/11/23-R1 observed on the floor in the hallway. R1 reported she fell and hit the back of her head. Intervention-start bowel and bladder program and will toilet her after meals and as needed. The facility did not put any new interventions in place to prevent R1's falls. R1's Fall Risk assessment dated [DATE] documents: - takes psychotropics, - occasionally has urinary incontinence - moving from seated to standing position R1 is not steady, only able to stabilize with staff assistance - walking, R1 is not steady, but able to stabilize without staff assistance R1's Facility reported incident final report form dated 5/15/23 documents: Resident alert oriented with forgetfulness and confusion. Resident ambulates with a walker with unsteady gait. Resident able to make needs known and uses the toilet with assist. Resident with diagnoses of bilateral osteoarthritis of the knee, Alzheimer's disease, Osteoporosis, Anxiety, Depression, HTN (hypertension) and GERD (Gaston esophageal reflux). On 5/8/23 resident noted on the bathroom floor with the walker next to her after hearing resident calling for help. Full body assessment completed. No change in LOC (level of consciousness) with limited ROM (range of motion) to the left hip. Resident complaining of left hip pain. MD (physician) made aware and ordered the resident to transfer to ER (emergency room ) for evaluation and treatment. Hospital completed x-ray of the left hip and revealed comminuted [NAME] cervical fracture of left femoral neck. Interview with the staff completed regarding the incident. Resident observed in the bathroom floor of another resident. The call light was not on, and resident used the toilet by herself. Resident did not ask or call for assistance. After the fall incident, resident noted confused and not able to give details of what happened. Resident not soiled and bathroom floor dry. Vitals remained stable. Resident's fall incident caused by her non-compliance of toileting herself without assistance and confusion. Plan of care will be updated upon resident's return to facility. On 8/1/23 at 4:56 PM, V11 [Registered Nurse] stated, On 7/11/23 I was (R1's) nurse. I made sure (R1) was in the dining room before I went on my break. I returned and (R1) had fallen in the hallway. The certified nurse assistant told me that she was in another room providing care when she heard (R1's) wheelchair alarm. The certified nurse assistant ran to the hallway, but it was too late, (R1) was on the floor. (R1) is confused and need close monitoring and reminders. (R1) also need to be taken to the bathroom after meals, but the certified nurse assistant was helping another resident. (R1) wanders around the unit all the time in and out of other resident's room, it's hard to keep up with (R1). On 8/1/23 at 2:45 PM, V12 [Licensed Practical Nurse] stated, I was (R1's) nurse on 5/8/23. I was assisting another resident when I heard the other nurse yell out for help. I saw (R1) in another resident's bathroom on the floor crying out in pain holding her right hip area. I did not move (R1), and phoned 911. Physician, family, and director of nursing was made aware. (R1) is forgetful and wanders around the unit in other resident's room. Some of the nursing fall interventions is we have to monitor and supervise (R1) closely, and verbally re-direct her as much as possible, low bed, and keep the call light in reach. R1's progress notes documents on 4/29/23 at 1:15 PM by V13 [Agency-Registered Nurse], found resident [R1] on the floor on her left side by the solarium [Dining room] with the walker laying by her side. Head to toe assessment done. v/s [vital signs] (blood pressure) 132/71 P [pulse] 67 T [temperature]-97.2 o2 sat [ oxygen saturation] 95@RA [room air] R [Respirations]18, range of motion rendered to both lower and upper extremities, no pain noted, no shortening noted on either extremity, right thumb slightly swollen. Resident [R1] complained of pain on the back of her head, head assessed-no bump nor swelling nor redness noted. LOC [level of conscious] intact, denies dizziness nor vomiting. Resident gotten up on the floor via Hoyer lift and sited back on the chair and taken in front of the nurse's station. Ice pack applied at the back of her head. R1's progress notes dated 1/7/2023 3:40 PM documents, Resident [R1] noted sitting on bathroom floor, feet outstretched in front in seated position, res sitting on her buttocks. Resident wearing nonskid socks, resident's walker in front of her. Resident stated she lost her balance. Resident assessed and no cuts or bruises noted. Denied hitting her head, no bump or redness noted. Res able to move all extremities WNL (within normal limits). On 8/1/23 at 11:40 AM, V4 [Certified Nurse Assistant] stated, I been working with (R1) since her admission to the facility. (R1) tries to get up out of her chair to use the bathroom. (R1) will tell staff if they are around that she has to go to the bathroom. I automatically take (R1) to the restroom when she gets up in the morning, before and after breakfast, lunch and one more time before I get off work. (R1) has not fallen with me, because I make sure she goes to the bathroom, and in closely monitored. (R1) wanders around the unit in and out of other resident's room. On 8/1/23 at 11:46 AM, V5 [Registered Nurse] stated, I been working here for [AGE] years, and familiar with (R1). (R1) needs close monitoring by nursing staff, because (R1) random wandering around the nursing unit in and out of other resident's room. I asked her was she trying to find her room, (R1) told me no. (R1) does not know to ask for help. Before her fall in May, she would use her walker to ambulate through the unit. Now (R1) is in a wheelchair and continues to wander the unit by propelling herself. Sometimes it's hard to keep up with (R1), when all the staff has other residents to take care of. On 8/1/23 at 11:50 AM, V6 [Agency Registered Nurse] stated, I am (R1's) nurse today. The last time I saw (R1) was around 8AM. (R1) ate breakfast and took her medication, then she went to therapy. I am not sure if she is back from therapy. When I received report this morning, the nurse told me (R1) was a high fall risk and need to make rounds on (R1) every two hours on the evening shift, not day shift. During the day shift she is okay. During the evening shift [3PM-11PM] (R1) has sun downing and need closely monitoring not now during my day shift. On 8/1/23 at 1:02 PM, V2 [Director of Nursing/Fall Coordinator] stated, I was the fall coordinator around March this year until June 2023. I hired a new fall coordinator, but I still oversee the fall incidents. I started last year in November 2023. (R1) is Spanish speaking, confused and impulsive getting up on her own. (R1) wanders around the nursing unit on her floor. On 7/11/23, (R1) fell in the hallway coming from the dining room after lunch. The nurse observed (R1) sitting on the floor next to her wheelchair. Fall intervention for 7/11/23 was to place (R1) on bowel and bladder program and after meals. (R1's) wheelchair alarm sounded, but staff was not close around. On 5/8/23 fall, (R1) fell around dinner time 5:30PM. The nurse heard (R1) yelling out for help. (R1) was in another resident's bathroom and complained of right hip pain, 911 was phoned. (R1) was transported to the emergency department. (R1) was admitted to the hospital for fracture and surgical repair. Upon (R1) re-admission to the facility, (R1) care plan was updated. The nursing intervention for 5/8/23 fall was physical therapy and occupational therapy to treat and evaluate. (R1) fell on [DATE] (R1) outside the solarium, which is the dining room, while ambulating with her walker. The fall intervention was physical therapy and X-ray of her right thumb, with negative results. (V8 - R1's Power of Attorney-Family Member] refused therapy because she wanted to save (R1's) therapy days. That was only fall intervention, also the nursing staff to supervise, and give verbal reminders. (V8) did not agree with the fall intervention, and I did not replace the fall intervention. Those were the only nursing interventions for 4/29/23 and 5/8/23 falls, honestly, I could not think of any more fall interventions due to (R1's) frequent falls. The staff continues to monitor (R1) by keeping her near the nursing station. The nurses and certified nurse assistances take care of other residents. In June (R1) was given a wheelchair and bed alarm, per the request of (V8). On 1/7/23 (R1) was observed sitting on the bathroom floor. (R1) said she lost her balance. Fall intervention was physical and occupational therapy. For 1/7/23 and 4/29/23 falls (V8) was notified of the fall interventions, and she declined both times. (V8) did not want physical therapy, because she wanted to save (R1's) therapy days. I did not know any other fall interventions to use for (R1). 8/1/23 at 2:40 PM, V9 [Medical Director] stated, I am the facility's medical director. I am familiar with (R1's) care. I was the physician phoned on 5/8/23 due to (R1's) fall and she complained of hip pain, I gave orders to send resident to the emergency department. (R1) did obtain a fracture. (R1) is forgetful with poor safety awareness and should be on the memory care unit. The nursing staff should provide supervision close as possible. The facility is not able to provide one-to- one care. The facility Policy documents: Fall Protocol dated 6/20/23. -Facility fall protocol is to decrease the number of falls and the severity of falls. -The director of nursing and assistant director of nursing will review and investigate each fall. - The director of nursing, assistant director of nursing, and restorative nurse will do periodic checks on all the units to ensure that interventions have been individualized for each resident and put in place.

Based on observation, interview and record review the facility failed to ensure the resident received adequate supervision and assistive devices to prevent serious injury to the resident. This failure affected one (R2) of three residents (R1, R2 and R8) reviewed for accident prevention by not using proper transfer practices. This failure resulted in R2 sustaining a skin tear during transfer, which required sutures at the local hospital. Findings include: R2 is a [AGE] year-old female resident with diagnoses including Heart Failure, Dementia with Psychotic Disturbance and History of Falls. R2's BIMS (Brief Interview for Mental Status) score indicated R2 is not able to be interviewed. Minimum Data Set scores R2 at 3 (Extensive Assistance) with 2 (One-person physical assist) for transfer. R2 is care planned as a high risk for falls due to impaired mobility, strength and cognition related to Dementia, Urinary Tract Infection, Dysuria, arthritis, malaise and fatigue and history of falls. Facility Incident Report dated 3/2/23 states that on 3/2/23 at 13:15, R2 was transferred to the bed from her wheelchair by V13 (Certified Nursing Assistant/CNA) and sustained a skin tear. Wheelchair was beside bed with chair legs still attached. V13 stated that resident was not letting go of the wheelchair during transfer and her leg brushed against the bedframe causing the skin tear. A gait belt was not used during transfer. The bedframe was noted to have missing covers over the aspects of the frame. Skin tear measures 7X3 cm. Bleeding at site noted. Resident denied pain at this time. ROM (Range of Motion) to BLE (Bilateral Lower Extremities) is at baseline. Noted no swelling or bruising at site. MD was notified and ordered to send to emergency room for evaluation. Following evaluation, writer notified that resident received sutures to site and they are to be removed in 10-14 days. Conclusion: It was concluded that resident sustained a skin tear during transfer due to resisting care. Interventions: Bedframe covers to be installed on bed. V13 was educated to remove wheelchair leg rests, use a gait belt during transfer, and to go at resident pace during transfers, thus decreasing chance of injury. Going at the resident pace will decrease chance of resident resisting care and holding onto the wheelchair during transfers. Resident is now a 2-person transfer. On 3/13/23 at 12:50PM, R2 was observed in corridor being assisted with lunch directly outside her room. R2's bed was against the wall. A floor matt was next to the bed. The metal bed frame directly under the mattress protrudes approximately 2 inches out from bottom of mattress. At this time the exposed metal bedframe was observed with foam padding on outside frame rail. This was done after the 3/2/23 incident. Hospital record dated 3/2/23 shows R2 was diagnosed with a left lower leg laceration of 9 centimeters in length which required 8 sutures. On 3/14/23 at 3:06PM, V13 (Agency CNA) with V2 (Director of Nursing/DON) present stated, I have been a CNA almost 4 years. I am a certified CNA. On the day of incident, I was about to take my break; the nurse told me I had to transfer R2. I had to use rest room. I finished and went to R2's room. I needed to transfer R2 into the bed from the wheelchair. I put my arms under R2's armpits. I lifted R2. As I lifted R2 she held onto the arms of wheelchair. It became clumsy. I managed to pivot R2 to the bed. R2's legs hit the metal sides of the bed. When she was fully in bed, I saw she was injured on R2's right leg. There was an open wound. The skin was cut open; you could see the flesh behind the skin. I went to tell the nurse. We went back to the room. The nurse went to tell V16 (Assistant Director of Nursing/ADON). R2 did not cry or anything. V16 came. V16 asked me what happened, and I told her. V16 told me I shouldn't have proceeded to transfer when I saw the condition of R2 holding the arms of wheelchair. R2 wasn't combative. V16 told me I should have used a gait belt to do the transfer. I have worked in the facility several times. I haven't had any incidents during transfers at this facility before. The facility trained me in transfer. When transferring you should check the assistance needed and whether it's one, two or three-person transfer. R2 was a one-person transfer. This is displayed on the entrance of room. I am supposed to use a gait belt. If the person is not able to stand then you use a gait belt. When you do a one person transfer you are supposed to use a gait belt. R2 needed a gait belt. I didn't have the gait belt on me. I forgot the gait belt when I went in her room. I am familiar with the facility transfer policy which states to use a gait belt. I am familiar with the policy by inservices given regularly. On 3/16/23 at 9:50AM V16 (Assistant Director of Nursing) stated, I was with R2 after the incident happened. I saw the skin tear. R2 was assessed and sent to the hospital. I told V13 (CNA) that he shouldn't have proceeded with the transfer from wheelchair to bed if she was holding onto the arms of the wheelchair. I told V13 that he was supposed to use a gait belt for the transfer. V13 did not have his gait belt. On 3/14/23 at 1PM, V11 (Registered Nurse/RN) stated, I take care of R2. She had her stitches taken out today. I wasn't here when the accident happened. I heard that a CNA was transferring R2 from wheelchair to bed. The CNA bumped R2's leg on the bedframe and caused a skin tear. She had to go to the hospital. R2 was a 1-person transfer. Since the accident she is now a two-person transfer. The CNAs are supposed to use a gait belt for all transfers. I don't think the CNA used a gait belt. On 3/14/23 1:10PM, V12 (RN) stated, R2 was injured during a wheelchair to bed transfer. R2 hit her leg on the bedframe. She got stitches out today. All staff are supposed to use a gait belt when transferring a resident. The staff who transferred R2 did not use a gait belt. On 3/15/23 at 11AM, V2 (DON) stated, All staff are to use a gait belt during transfer of a resident. This is facility policy. V13 (CNA) was supposed to use a gait belt during the transfer of R2. V13 failed to use a gait belt. If V13 used a gait belt it could have prevented injury to R2. On 3/15/23 at 1:35PM, V7 (Medical Director) stated R2 sustained a skin tear from bumping her leg on the metal bedframe of her bed. It is very possible that the accident could have been prevented if the CNA used a gait belt for a better transfer. R2 has skin that is very thin and brittle due to age. Her skin is easily injured. Facility Resident Handling Policy documents, Gait belt usage is mandatory for all resident handling with exception of bed mobility and medical contraindications. The gait belt will be considered a part of the certified nursing assistants' uniform.

Based on interview and record review, the facility failed to 1) safely transfer a resident (R4) & 2) failed to monitor a dementia resident (R1) for toileting assistance. These failures affected two residents (R4 and R1) of three residents reviewed for falls with serious injury. R4 sustained laceration to the occipital (back) of the head and a nondisplaced corner fracture of the right T12 (back fracture) that required hospitalization . R1, with history of falls, sustained a closed left hip fracture after a fall. Findings include: Hospital medical records dated 08/19/2022, notes R4 presented to the hospital after a fall. The fall caused a scalp laceration to the back of R4's head (required 6 staples) and a back fracture. R4 is a [AGE] year-old female. R4's diagnoses are but not limited to irregular heartbeat, heart failure, diabetes, heart disease, high blood pressure, right side body paralysis, kidney disease, and altered mental status. R4's BIMS (Brief Interview for Mental Status) dated 07/03/2022, notes R4 is alert. R4's MDS (Minimum Data Set) documents that R4 requires two people when R4 is being transferred. R4's care plan notes that R4 is a high risk for falls. Progress note dated 08/19/2022, notes while passing evening medication, V7 (CNA) assigned to R4, called out for help in R4's room. Staff approached R4's room and observed R4 on the floor lying across the base of the mechanical lift. The head of R4 rested on the side of the bed frame. R4 was alert, conscious, and verbally responsive to commands. R4 had a laceration on the occipital area of head (back of head) with moderate bleeding. V7 stated the sling on the mechanical lift malfunctioned while attempting to transfer R4 from wheelchair to bed. V7 called for assistance from other nursing staff. R4's physician and family were notified. Staff received orders to send R4 to the emergency room for immediate attention. Staff called 911 emergency service for transportation assistance for R4. On 08/25/2022, at 12:50PM, V1 (Administrator) stated, The sling, which I have, tore. The straps tore. Otherwise R4 was perfectly transferred. The sling was under R4. R4 stated R4 must go to the bathroom really bed. When V7 started to transfer R4, V7 noticed the sling broke, and everything happened so fast. V7 stated V7 heard a strap tear. R4 landed on R4's bottom on the floor and hit R4's head. R4 was awake and alert through the whole thing. R4 was screaming for help. V7 stated V7 moved R4 alone because the nurse was right there. On 08/25/2022, at 1:04PM, V4 (Registered Nurse) stated, I came to the facility around 3:00PM. I was starting with the afternoon medication passage. I saw R4 sitting in the doorway. I told R4 to go to the bathroom. The aide that was assigned to R4's room was right behind me. I was down the hallway. I heard a call for help. I stopped medication pass. I saw R4 on floor with R4's head resting towards the bed frame. I could see that R4 had a gash. I asked the aides to help while I called for the other nurses. I did not witness anything. I only saw that R4 was on the floor. I did ask the aide what happened. The aide stated the sling gave away. I did not talk to R4, but I did determine that R4 was conscious and alert. On 08/25/2022, at 1:22PM, V6 (Corporate Nurse) stated, V7 stated that V7 transferred R4 by himself. V7 stated that R4 was screaming for help and that is why the V7 transferred R4 by himself. On 08/25/2022, at 1:50PM, V8 (Medical Doctor) stated, The fracture of the vertebrae (back)is from the fall. R4 was admitted to the hospital with a vertebrae fracture. On 08/25/2022, at 2:06PM, R4 stated, I was coming back to the room. I was in the wheelchair. There was one aide that was there. I ended up falling at the end of the bed and hit my head. I needed five stitches in my head. The aide was using the lift and I was in a sling. I did not black out. I was fully with it. I was taken to the hospital. They usually use two people when they move me. After it happened, I was in pain, and my back is sore. The neurologist confirmed that I have a small fracture in the vertebrae. On 08/26/2022, at 1:58PM, V7 (Certified Nursing Assistant) stated, I was working sitting at the desk. The nurse was saying that R4 was trying to ambulate to go to the bathroom and R4 cannot stand. R4 had a mechanical lift sling underneath R4 already. I went in R4's room and the nurse asked if I could help R4 to the toilet. I asked R4 if R4 could stand. R4 tried and could not stand. I asked if R4 had on an incontinence brief and R4 said yes. I told R4 I would put R4 back in bed. I went to get the lift. I got it and came back to the room. I transferred R4 without any issue from chair to the bed. I proceeded to give R4 direct care and put a new incontinence brief on R4. I got the mechanical lift ready. I went to grab lift and I heard the strap break. I heard a thud. I turned around instantly. R4 hit R4's head against the bed frame and the rest of R4's body hit the floor. The nurse came in and assessed R4. The other nurses came in. Another nurse brought another sling. R4 was put into the bed with the lift. Two people are required to move residents when transferring with a mechanical lift. There was no one else to transfer R4 with me because I could not find anyone. This was first time working in this facility. There was no in servicing or expectation training before I started. The risk of transferring by myself is the residents falling and hurting themselves. I would say getting another person would have helped the situation and the sling should be checked. Facility policy titled Resident Handling Policy Limited Lift, undated, notes the policy exists to ensure a safe working environment for resident handlers. Any transfer with a mechanical lift requires two-person assistance. R1 is an [AGE] year-old female. R1's diagnoses are but not limited to left leg fracture, dementia with behaviors, Alzheimer's disease, anxiety disorder and cognitive communication deficit. R1's MDS (Minimum Data Set) dated 07/24/2022, notes R1 is not alert and needs total assistance from staff. Review of R1's falls note that R1 has had three falls in the facility. R1's fall on 07/09/2022, resulted in a major injury. Progress note dated 07/09/2022, notes R1 sitting on the floor, legs straight facing the bedside table. R1 is alert and verbally responsive. R1 complained of pain to the left knee, femur and hip. R1 is unable to raise leg, put weight on it or bend knee. No swelling or bruising noted at this time. R1 denies hitting R1's head and denies losing consciousness. R1 states R1 doesn't know why or how R1 fell out of bed. Vitals assessed and were normal. R1 was sent to the local hospital after R1's physician was notified. Injury was documented as a closed fracture of the left hip. On 08/25/2022, at 12:29PM, R1 was seen in the dining room. R1 could not answer any questions and was not alert. R1's had a winged mattress in R1's room. The facility informed the surveyor that the facility does not have a fall coordinator. On 08/25/2022, at 1:15PM, V5 (Certified Nursing Assistant) stated, R1 was on the floor when I came in the room. I had to call the nurse's attention. I do not recall the nurse's name. I do not remember the time. R1 was on the floor mat by the bed. I remember providing incontinence care to R1 before R1 went to bed. I check on the residents at 1:00AM and at 4:00AM. R1 requires hourly rounding. On 08/25/2022, at 1:22PM, V6 (Corporate Nurse) stated, Whenever there is a reportable, I make sure that things are being identified. The root cause of the fall is R1 woke up and had to urinate. R1 is confused and got up without assistance. R1's care plan lists interventions before and after R1's fall. Before R1's 07/09/2022, R1's interventions were staff escort R1 to and from meals, remind R1 to use walker, anticipate R1's needs. Interventions after R1's 07/09/2022 fall are providing a winged mattress, fall mats, hourly rounding and low bed.

Based on interview and record review, the facility failed to provide adequate supervision to R1. This failure resulted in R1 sustaining a fall which required R1 to go to the hospital due to sustaining a closed displaced supracondylar fracture of the distal end of right femur (thigh bone, or femur, is broken at the knee). and 6 staples to R1's head. Finding includes: R1's Face sheet documents that R1 has a diagnosis which include but not limited to: Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, unspecified injury of head subsequent encounter, history of falling, Alzheimer's disease with early onset, and [CONDITION(S)]. R1's Brief Mental Status Interview (BIMS) dated 12/09/21 documents that R1 is moderately impaired. R1's Brief Mental Status Interview (BIMS) dated 03/11/22 documents that R1 is severely impaired. R1 was not interviewable for this investigation. Facility's document dated 03/07/22 and titled Unexplained Accident/Incident Investigation documented in part: R1 was observed next to the bed on the mat on the floor, supine with R's head towards the radiator and feet towards the bed. R1 was with the Certified Nursing Assistant (CNA) at the time of fall . R1 was noted with a raised area to the back of R1's head with small opening. R1 was sent to the hospital for evaluation. Facility's fall incident report dated 03/08/22 documents that R1 sustained a laceration to the back of R1's head. R1's progress note authored by V23 (Registered Nurse, RN) documents that R1 had swelling to the right upper leg and 6 staples to the back of R1's head. R1's progress note authored by V24 (Registered Nurse, RN) documents that R1 returned from local hospital with a brace on her right lower extremity. On 03/30/22 at 2:54 pm, V21 (Certified Nursing Assistant, CNA) was interviewed regarding R1's incident on 03/07/22 and V21 stated that V21 provides care to R1 frequently and is familiar with R1's care. V21 stated that R1 is a total body lift and stays in the bed for the 3:00 pm - 11:00 pm shift. V21 stated that on 03/07/22 around 9:00 pm, V21 was providing perineal care to R1 and that R1 was not able to help V21 with turning and repositioning. V21 also stated that R1's legs are contracted in a bent position and that R1's hands are contracted in a fist position. V21 stated that V21 stood on R1's right side and turned R1 to the edge of the bed towards the window onto R1's left side which was the opposite side of where V21 was standing. V21 stated that R1's hands remained contracted into a fist position and that R1 was not able to assist with the turning and repositioning, or able to hold onto the half side rail on R1's bed. V21 had V21's left hand on R1's shoulder supporting R1. V21's right hand was wiping R1 with a cleaning wipe, while R1 was laying on R1's left side at the edge of the bed. V21 stated as V21 reached for an incontinence brief for R1, V21 removed V21's left hand from R1's shoulder, no longer holding R1, leaving R1 unsupported at the edge of the bed. R1's feet began to slip off edge of the bed first then R1's entire body landed on the floor mat on the floor next to R1's bed. V21 also stated, I usually keep my hands (V21 referring to V21's hands) on a resident to prevent them (referring to a resident) from falling or ask for help. On this day with R1, I didn't feel R1 had any declines, so I (V21) did her (R1) by myself (V21). On 03/31/22 at 10:49 am, V2 (Director of Nursing, DON) was interviewed regarding residents who are one person assist for bed mobility. V2 stated that residents who are 1 person assist should have the ability to help with turning and positioning in bed as well as be able to hold their (the resident's) position by placing hands and holding onto the half side rail if the resident has good trunk control. V2 stated residents who cannot assist with bed mobility should have a 2 person assist for safety. Surveyor asked V2 if a staff is having difficulty turning and repositioning a resident in bed what should the staff member do? V2 stated, If a staff is having difficulty turning and repositioning a resident in bed staff should return the resident to the original position if they notice a resident is not helping with the repositioning. V2 also stated that residents should not be rolled or turned to the edge of the bed during turning and repositioning. Residents should be turned to the center of bed because it is not safe for a resident to be on the edge of the bed. On 03/31/22 at 12:58 pm, V17 (Registered Nurse, RN) was interviewed regarding the incident related to R1 on 03/07/22. V17 stated that R1 is a resident who has contractures to bilateral hands and unable to straighten fingers, contractures to bilateral lower extremities, non-ambulatory and requires total assistance with care. V17 also stated that R1 is unable to use R1's side rails to assist with repositioning and that R1 receives total care from staff for bed mobility. V17 stated that V21 (Certified Nursing Assistant, CNA) did not ask for assistance with R1's care or report any changes with R1's status prior to R1 falling from the bed on 03/07/22 when V21 was providing R1 with care. On 03/31/22 at 1:08 pm, V19 (Physical Therapist, PT) was interviewed regarding R1's care. V19 stated that when V19 assessed R1 in November 2021, that R1 could not follow commands and was totally dependent on staff for bed mobility. V19 explained that R1 could not help with bed mobility, positioning and needed total assistance for changing, dressing, and transfers. V19 was asked regarding turning and repositioning residents who could not assist with bed mobility. V19 stated, I would not recommend turning a resident to the opposite side of where you are standing to reposition them to the edge of the bed because a person cannot use their body to help prevent the resident from falling. The resident can roll out of bed and hurt themselves if the person assisting is standing opposite from the side the resident is turning and unable to assist. 03/31/22 at 2:59 pm, Surveyor requested R1's Assessment for Minimum Data Set (MDS) dated [DATE] section G. A. Bed mobility from V2. V2 stated there is no restorative program for turning and repositioning for R1 for the 12/09/21 MDS, and that the facility did not have a restorative nurse at that time. R1's progress notes authored by V17 (Registered Nurse) dated 03/07/22 documents that V21 (Certified Nursing Assistant, CNA) reported R1 fell off the side of the bed and sustained a bump to the back of R1's head and that 911 was called at 9:47 pm for R1. R1's progress notes authored by V17 (Registered Nurse) dated 03/08/22 documents that an x-ray was performed to R1's right lower extremity, pelvis, and right foot and the results showed a fracture to distal right femur with orders to send resident to emergency room for follow up. R1's hospital records documents that R1 was sent to the emergency room (ER) on 03/08/22 with x-ray imaging performed to the right knee that confirmed that R1 sustained a comminuted fracture of the distal femur with slight anterior angulations and 6 staples to R1's head. Facility's Reportable Incidents from January 2022 through March 2022 reviewed and documents that R1 sustained a fall with injury on 03/07/22. Facility's Accident and Incident Reports from January through March 2022 reviewed and documents that R1 sustained a fall with injury on 03/07/22. R1's Fall Care plan dated revised on 11/29/21 documents in part that R1 is at risk for falls due to impaired mobility, confusion, incontinence, psychoactive drug use, [CONDITION(S)] and unaware of safety needs. R1's Fall Activities of Daily Living (ADL) care plan dated initiated 03/29/18 documents in part: R1 has ADL self-care performance deficit secondary to impaired mobility, decrease in ADL's. Physical limitations: Balance problems, gait strength, endurance. Facility's Certified Nurse Assistant, C.N.A. job description, documents in part: Cooperate with inter-departmental personnel, as well as other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of residents.

Based on record review and staff interview, the facility failed to supervise one resident of 14 residents on the 4th floor requiring mechanical soft diet meals. On [DATE] at 5:25PM, R3 was found choking on food. R3 expired in the hospital on [DATE] of Aspiration and Cardiovascular Collapse. This failure resulted in an Immediate Jeopardy which was determined to have started on [DATE] at 5:25PM when the incident occurred. On [DATE] at 9:55 AM to E1, (administrator) was informed of the Immediate Jeopardy The Immediate Jeopardy was removed on [DATE] at 4pm, but the facility remains out of compliance at a level 2 until all in-services are completed, and new policy changes are evaluated for effectiveness. Findings include: R3's [DATE] Physician order [REDACTED]. She had a [DIAGNOSES REDACTED]. A mechanical soft diet was ordered. The resident resided on the 4th floor of the facility. R3's Minimum Data Set ( MDS ) dated [DATE] assesses R3 as "needing supervision/oversight, encouragement or cueing during meals". R3 has dentures. On [DATE]( onset date ) R3 was evaluated for treatment for [REDACTED]. The recommendations were as follows; "Continue mechanical soft diet and thinned liquids. Compensation strategy training , Patient/Caregiver/staff education and Patient will require assistance at meals". The plan for swallow precautions were: "One bite at a time, small bites, slow pace and alternate liquids and solids". R3's quarterly nutrition review dated [DATE] documents "difficulty swallowing, self feeding but needs assistance". No care plan was found to address the resident's swallowing problem or swallowing recommendations, or that the resident needed assistance during meals. Document review of the facility incident report states the following: [DATE] at 5.25 PM, R1 was eating her dinner in the hallway on the 4th floor next to the dining room. E4 ( Registered Nurse ) observed resident was up in chair when E4 noticed R1 with a large amount of bread sticking out of her mouth. Her face was red. R1 could not speak . E4 performed the Heimlich maneuver several times with no success. Resident was placed on the floor and Heimlich thrusts were done. 911 was called . A small amount of food was removed from mouth. An Ambu bag was used to increase oxygenation. Resident coughed and expelled a small amount of undigested food. Paramedics arrived and suctioned resident, an IV was started and R1 was transported to the hospital. The hospital discharge summary dated [DATE] documents the resident was admitted for a choking episode with altered mental status . The documentation shows R3 was found choking while eating a piece of orange in the nursing home. Heimlich maneuver was initiated by the nursing staff , but unsuccessful. Paramedics were called and the orange piece was removed with forceps. Z1 ( Medical Director) stated on [DATE] that R1 expired from Aspiration and Cardiovascular Collapse in the hospital. Z1 did not provide any further information. R3's Certificate of Death, issued on [DATE], documents Cardiovascular Collapse and aspiration as the cause of death on [DATE]. E4 ( Registered Nurse ) stated on [DATE] she was passing meds when she saw R1 choking. She did a mouth sweep and a Heimlich twice with R1 in her chair. She called out to E5 (Certified Nurse Aid ) for help. E5 did the Heimlich but could not get any results. Both E4 and E5 lowered R1 to the floor, took her dentures out, and did abdominal thrusts. At this time paramedics arrived. E5 ( Certified Nurse Aid ) stated on [DATE] "I was with another resident assisting him to his bed. E14 (Certified Nurse Aid ) called out for me to help. E14 was doing Heimlich on R1 . I tried to do the Heimlich 4 or 5 times with no results. E4 was there at this time with other CNA's . The nurse was called and 911 was called. We lowered her to the floor and did abdominal thrusts. Some food came out. R1 was unresponsive. E3 came with the crash cart. Oxygen was administered. Paramedics arrived". E3 ( Registered Nurse ) stated on ,[DATE] that a CNA called her on the phone and said R3 was choking. :When I arrived E4 was doing the Heimlich on R1. E5 and E4 lowered R1 to the floor and did a mouth sweep. E4 did abdominal thrusts. They turned R1 to her side and did another mouth sweep. R1 was still unresponsive We used an Ambu bag and put her on oxygen. The ambulance rescue team arrived. They pulled out a piece of food that was orange in color. R1 was taken from the facility". E14 ( Certified Nurses Aid ) stated on [DATE] the following: "We were passing trays when I heard E4 say: "spit up come on spit it up." E4 started doing the Heimlich maneuver. R1 was unconscious and blue in the face. I also attempted to do Heimlich . We yelled out to dial 911. Other staff arrived . E5 attempted to do the Heimlich with no results. We lowered her to the floor and attempted to do thrusts with no results. She was still unconscious. E5 was also there trying to help. Paramedics arrived". The facilities dietary spread sheet week 3, day 5, ([DATE]) documents that a fresh orange wedge was included in the dinner menu for the mechanical soft diets. Per facilities standardized recipe, a fresh orange wedge with the rind is included in the mechanical soft diet. The diet manual for the facility recommends only canned citrus sections should be served to mechanical soft diets, and to avoid fruits with a tough skin. The facility failed to correctly prepare a menu to avoid fruits with a tough skin in its mechanical soft diets. There were 14 residents residing on the 4th floor at the time of this survey on prescribed mechanical soft diets. E13 (dietician) stated on ,[DATE] at 11:55am that it was all right for R3 to have a fresh orange wedge and "was fine to eat by herself." E13 also said that fresh orange wedges were allowed for mechanical soft diets. The facility took the following actions to remove the Immediate Jeopardy: Norwood Crossing immediately conducted a full audit to ensure that all resident dining needs were assessed , documented , and implemented appropriately . In order to ensure the safety of all residents the following occurred on [DATE]. Nursing administration , MDS Coordinator , Speech Therapist , Dining Services manager and Dietician reviewed all Residents in Skilled Nursing Auditing charts including Care Plan , Dietary Assessment , Nursing Documentation , POS , Speech Therapy Documentation ( if applicable) and tray ticket to ensure that all Residents were assessed for the appropriate diet consistency and that dining needs were identified. Meal service will continue to be adequately staffed and actively supervised , with floor nurses, certified assistants , nursing administration and dining services supervisors ( including the Dietician ) rounding during all meals. Supervision goals include making sure that the residents are dining in an appropriate setting and that orders are being followed. Floor staff breaks do not coincide with resident dining times. To ensure future compliance , the following modifications to the facilities ongoing quality improvement program were assigned by the Administrator on [DATE]. The Dietician and Nursing Administration will review/audit the Nursing Monthly Summaries every four weeks at the facilities weekly weight meeting to ensure the residents individual needs are updated on the care plan , MDS and POS. The Director of Nursing will report on these audits as part of her Quarterly Improvement project. Additionally as of [DATE] the Director of Food Services will begin listing any special interventions regarding residents dining/meal needs on the meal ticket ( i.e. Resident needs to be fed ; meal set up verbal cues to encourage eating - this will serve to reinforce the existing , similar nursing documentation of the same directives). This will also provide an additional cue to ensure that the resident receives the appropriate support and level of supervision. The Food Services Director will audit tray ticket compliance , including the new tray ticket language discussed in 4 above , monthly. The Dining Services Director will report on these audits as part of her quality improvement project. The Certified Nursing Accountability Record was updated on [DATE] to reflect in a detailed manner the individual residents identified care plan needs during meal service. This form requires the Certified Nursing Assistant to initial daily at each meal that the identified Resident dining needs were addressed. In addition , the facility has updated the posted lists of residents receiving therapeutic diets with care plan interventions regarding specific dining needs , these documents will be reviewed weekly at the facility weight meeting. The Registered Dietician will be responsible for auditing ( and updating accordingly ) and will communicate changes to the MDS Coordinator to ensure care plans are appropriately updated. The Dietician will report on these audits as part of her quarterly quality improvement project. The Director of Human Resources will monitor all training and CPR records to ensure compliance with facility standards and will report on these audits as part of her quarterly quality improvement project. The facility Administrator will monitor these programs to ensure all identified Resident dining needs are met including appropriate level of supervision.