Every finding on record at Pavilion Of Logan Square, The

Based on observation, interview, and record review, the facility failed to ensure that necessary services were provided to maintain personal hygiene and continence care for 1 of 3 sampled dependent residents (R2) who was unable to perform activities of daily living (ADLs) independently. Findings include:R2's face sheet documents R2 is a [AGE] year old admitted to the facility with diagnoses including, but not limited to: Hyperlipidemia, unspecified (too many fats or lipids circulating in blood), Essential (primary) hypertension (high blood pressure that has no single, identifiable medical cause), Gastro-esophageal reflux disease without esophagitis (chronic acid reflux symptoms, without physical damage, sores, or inflammation in esophagus) and Benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate blocking the flow of urine from the bladder).R2's MDS (Minimum Data Set of 7/15/2026) documents a BIMS (Brief Interview for Mental Status) of 5 indicating severe cognitive impairment. R2 is frequently incontinent of urine and feces.On 8/29/2026 at 3:30 PM, R2 was sitting in the dining room. V4 (R2's wife) said R2's brief was wet.On 8/29/2026 at 4:11 PM, V13 (CNA/Certified Nursing Assistant) said, I start at 3:00 PM. I saw R2 in the dining room. Surveyor asked V13 if he checked R2 for incontinence, V13 repeated, I saw him in the dining room.8/29/2026 at 4:15 PM, V4 brought R2 into his room and performed incontinence care. R2's brief was saturated from front to the rear with urine.8/29/2026 at 4:24 PM, V1 (Administrator) said, R2 is a heavy wetter. He should be checked (for incontinence) more frequently (than every two hours).8/30/2026 at 12:56 PM V10 (LPN/Licensed Practical Nurse) said, R2 is not able to tell you if he's wet. He sometimes won't let staff change him. Most of the times staff check every two hours. I think he should be checked more frequently.8/30/2026 at 1:36 PM via telephone, V8 (CNA/Certified Nursing Assistant) said, R2 is a heavy wetter. He should be checked at every hour to see if he is wet.R2's care plan is at risk for altered urinary elimination with episodes of incontinence documents the following intervention: Incontinence care after each incontinent episode.Incontinence Care Policy and Procedure (3/2014) documents, in part: 4. Bedridden, incontinent residents must be turned every two (2) hours and inspected for fecal incontinence. 5. Residents must be cleaned after each episode of incontinence.Policy does not address urinary incontinence.

Based on observations, interviews, and record reviews, the facility failed to practice infection control and prevention measures to:a. Ensure staff performed hand hygiene and wear appropriate Personal Protective Equipment (PPE) when caring for a resident (R209) on Contact Isolation Precautions.b. Educate family on hand hygiene procedure to follow for a resident (R103) on Enhanced Barrier Precautions (EBP). These failures have the potential to affect R209 and all 55 residents residing on the 3rd floor. c. Appropriately handle and transport linen to prevent potential contamination. These failures have the potential to affect all 202 residents residing in the facility. d. Follow their policy and post clear Enhanced Barrier Precaution (EBP) signage on the door or wall outside of a resident's (R20) room for 1 out of a total sample of 35 residents.e. Maintain food supply (ice cube) used by residents for consumption. These failures have the potential to affect all 54 residents with 1 resident on NPO or does not take food by mouth on maintaining clean food (ice cubes) for consumption.Findings include: On 08/19/2025 at 1:14 PM, observed Contact Isolation sign in English and Spanish posted on the outside of R209's door with adequate supply of PPE outside the door. On 08/19/2025 at 1:18 PM, observed inside R209's room hand sanitizer dispenser mounted to the wall filled with hand sanitizer. On 08/19/2025 at 1:22 PM, observed V17 (Certified Nursing Assistant) enter R209's room without performing hand hygiene and without putting on gown and gloves. V17 exited R209's room with R209's lunch tray in hand. On 08/19/2025 at 1:25 PM, V16 (Licensed Practical Nurse) stated R209 is on contact isolation because she has ESBL in her urine and that anyone going into R209's room should do hand hygiene and wear a gown and gloves and dispose of the gown and gloves inside the room before exiting. On 08/19/2025 at 1:29 PM, V17 stated he went into R209's room to collect her finished lunch tray. V17 stated he was not paying attention and did not see that R209 was on Contact Isolation Precautions. V17 said, I'm just seeing that now. I should have done hand hygiene and worn a gown and gloves. On 8/19/2025 at 12:18 PM, observed Enhanced Barrier Precaution (EBP) sign posted on the outside of R103's door in English and Spanish with stocked personal protective equipment (PPE) storage container outside R103's room. Observed hand sanitizer wall dispenser located on the inside wall of R103's room next to the door containing hand sanitizer. On 08/19/2025 at 12:24 PM, observed V15 (103's Family Member) leave R103's room without performing hand hygiene before leaving or after leaving the room in the hallway. On 08/19/2025 at 12:26 PM, observed V15 walk back into R103's room carrying his lunch tray and sit down and begin feeding R103. V15 did not perform any hand hygiene before entering or upon reentering R103's room. On 08/19/2025 at 12:26 PM, V8 (Registered Nurse) stated R103 is on EBP because he has a indwelling urinary catheter and the EBP guidelines are being followed for R103's protection. V8 stated anyone entering R103's room should use hand sanitizer or wash their hands and do it again after leaving the room. R103 stated staff/visitors only need to wear a gown and gloves if they directly touch the resident when providing care. V8 stated the resident's family is provided with education and given the rational of why the resident is on EBP so they understand what needs to be done and why it is important to do it. On 08/19/2025 at 12:40 PM, V15 stated she visits the facility almost every day, alternating with her other siblings. V15 stated she did not receive any education or instruction from the staff on EBP. V15 stated the staff did not tell her anything about handwashing or using hand sanitizer before and after entering the room and she is not aware of any of her family members receiving education on it either because none of them said anything to her about it. V15 stated as a matter of habit she washes her hands with soap and water when she first comes into R103's room but does not do it again for the rest of her visit or when she leaves the room and comes back into it. On 08/20/2025 at 12:00 PM, V5 (Infection Preventionist/Registered Nurse) stated R209 was admitted on [DATE] from the hospital where she was on isolation in for +ESBL urine and had completed her antibiotic course. V5 stated she will keep R209 on Contact Isolation Precautions for 72 hours in case she becomes symptomatic and that is why the signage for Contact Isolation Precautions is posted outside R209's room. V5 stated the staff should be doing hand hygiene and wearing a gown and gloves when entering R209's room and doing hand hygiene again when leaving the room and removing the gown and gloves before exiting the room. V5 stated the problem with staff not wearing PPE and doing hand hygiene is that they could contaminate other residents via cross contamination and that is how MDRO's are born. On 08/20/25 at 12:15 PM, V5 stated residents are put on EBP if they have medical devices such as indwelling urinary catheter. V5 stated those residents are more suspectable to acquiring an infection so the EBP are in place as a preventative measure. V5 stated if the staff or visitors are not following the EBP guidelines that could make the resident sick by introducing an infection to the resident. V5 stated anyone entering the room of a resident on EBP should do hand hygiene and do it when leaving the room including family/visitors. V5 stated education is done with family members to explain to them why the resident is on EBP and the preventative measures which should be followed. V5 stated educating the family is important for the protection of the resident. V5 stated family education is done verbally, not necessarily documented. V5 stated R103 is on EBP because he has an indwelling urinary catheter. V5 stated she spoke with R103's son in the past to let him know about the EBP precautions but does not remember when specifically. V5 stated R103 has a big family; she did not talk directly to R103's daughters about EBP. On 08/21/25 at 9:34 AM, V2 (Director of Nursing) stated residents who have a physician order for contact isolation have signage posted outside their room to let the family/staff know that the resident is on contact isolation and what they need to do before entering/exiting the room. V2 stated anyone entering the room of a resident on contact isolation needs to preform hand hygiene and put on a gown and gloves before entering the room and before exiting the room the gown and gloves should be discarded and thrown out inside the resident's room and hand hygiene needs to be performed again before leaving the room. V2 stated it is important for staff to follow these precautions so as not to spread the infection to others. V2 stated R209 is on contact isolation for ESBL urine and anyone entering her room should have followed the guidelines as posted on the signage On 08/21/25 at 9:43 AM, V2 stated EBP barrier precautions are in place to prevent the spread infection. V2 stated everyone including visitors/family members entering a room of a resident on EBP should perform hand hygiene before and after leaving the room. V2 stated Infection Prevention Nurse provides this information to the family and documents when the education is provided in progress notes under education. V2 stated it is important to provide education to family/visitors, so they know to do hand hygiene before entering and when leaving the room. V2 stated the potential problem if family/visitors are not doing hand hygiene is they could be spreading infection. R209's diagnosis included but not limited to Hemiplegia and Hemiparesis Following Cerebral Vascular Disease, Type 2 Diabetes Mellitus, Acute Kidney Failure, Heart Failure, Ileus, Epilepsy, Iron Deficiency Anemia, Long Term Use Of Antithrombotics/Platelets, Cutaneous Abscess Of Right Lower Limb, Contracture To Left Knee, Contracture To Left Hand. R209's Order Summary Report dated 08/19/25 documents in part single room strict contact isolation for ESBL of the urine every shift for infection control. R209's care plan documents in part R09 has a diagnosis of ESBL in urine. Single room strict contact isolation for ESBL of the urine. Single room prophylactic for contact isolation of ESBL in the urine with goal of ESBL will colonize without complications. R103's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease, Acute And Chronic Respiratory Failure With Hypoxia, Interstitial Pulmonary Disease, Dementia, Centrilobular Emphysema, Moderate Protein-Calorie Malnutrition, Asthma, Cholecystitis, Encounter For Fitting And Adjustment Of Urinary Device Foley Catheter, Bilateral Inguinal Hernia, Hypotension, Neuromuscular Dysfunction Of Bladder, Retention Of Urine, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Calculus of Gallbladder Without Cholecystitis Without Obstruction, Other Specified Disorders Of Kidney And Ureter, Nodular Prostate With Lower Urinary Tract Symptoms, Adult Failure To Thrive, Obstructive And Reflux Uropathy, Unspecified Cyst Of Epididymis. R103's Order Summary Report dated 08/19/25 documents in part Enhanced Barrier Precautions (Foley) every shift for EBP and Foley Catheter size 16 French; balloon 10 ml for diagnosis of neurogenic bladder. R103's Minimum Data Set (MDS) dated [DATE] documents R103 has indwelling catheter. R103's care plan documents in part R103 has indwelling (Foley) catheter and interventions include but not limited to EBP. R103's electronic health record (EHR) progress note titled Education Note entered by V5 dated 08/21/25 at 10:44 documents in part EBP and hand washing education given to (R103's son) and verbalized understanding the reason of EBP as well of the importance of hand washing. There were no other education notes found in R103's EHR progress note section indicating education on EBP guidelines were provided to any of R103's family members between the dated 07/29/22 to 08/20/25. Facility provided policy titled, Contact Precautions dated 05/2022 which documents in part, contact precautions are intended to prevent transmission of infectious agents, like MDROs that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room and transmission occurs by contaminated hands of staff. The single most effective means of reducing the potential transmission is hand antisepsis before and after contact with residents. Facility provided copy of Contact Precaution sign from the U.S. Department of Health and Human Services Center for Disease Control and Prevention which documents in part, everyone must clean their hands, including before entering and when leaving the room and providers and staff must also put on gloves before room entry and put on gown before room entry. Facility provided policy titled, Enhanced Barrier Precautions (EBP) dated 05/2022 which documents in part, this precaution is in use in long term care facilities to prevent the spread of novel or MDRO infections and everyone must clean their hands before entering and when leaving a room. Facility provided copy of Enhanced Barrier Precaution sign from the U.S. Department of Health and Human Services Center for Disease Control and Prevention which documents in part, everyone must clean their hands, including before entering and when leaving the room. Findings Include: On 8/19/25 at 12:08 PM, surveyor observed V35 (Laundry Aide) on the second floor delivering clean residents' clothing in an uncovered cart. On 8/20/25 at 11:14 AM, V5 stated that Dirty linens are bagged, and have a chute. Clean clothing and clean linen come from the lower level to the floor. The laundry person put them in the cart and transport them on the floors. The cart should be closed or covered and transport clean personal clothing directly to the floors and to the resident's rooms. Linens are from the basement to the floors the laundry will transfer to the big cart. Clean carts should almost be closed. To prevent cross-contamination and keep them clean free from germs or dirt. On 8/21/25 at 10:07 AM, surveyor did laundry service walk-through with V34 (Maintenance Director) and found a large, gray bin filled with linens and residents' gown not contained in bags and the bin was not covered. On 8/21/25 at 10:21 AM, V5 stated that all soiled linens in the soiled room should be bagged and covered due to risk for cross contamination and risk for infection. V5 stated that the residents and staff could potentially be affected. V5 stated the staff works with the residents so everyone in the facility could potentially be affected. The staff could get sick, and the residents could get sick. The facility's LINEN and LAUNDRY policy and procedures dated 5/22 documents in part: Personnel to bag contaminated linen at the point of use, and not sorting or pre-rinsing in resident care areas. All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Place any linen saturated with blood or body fluids into a bag before placing it into the hamper. Clean linen will be transported from the laundry to the linen room in a clean, covered cart with a solid bottom. Linen is covered during transport to prevent contamination while being moved through the facility. Linen must remain covered at all times until it is placed into the residents' room. The facility's residents' roster dated 8/19/25 documents a total of 202 residents residing in the facility. ---------------------------- Findings include: R20's 'Order Summary Report' documents in part active wound orders to R20's left and right ischium. There is also an order for Enhanced Barrier Precaution (wound) every shift for Wound Care. Order active since 8/06/2025. R20's 'Care Plan Report' documents in part skin issues, wounds, and risk for impaired skin integrity (page 10, 28-32); however, it does not contain a focus for EBP (Enhanced Barrier Precautions) related to wounds. On 8/19/2025 at 11:40 AM, there was no EBP signage on R20's door or wall outside of the room. R20 stated having wounds that require treatment by the nurses. On 8/19/2025 at 2:53 PM, V5 (Infection Preventionist) stated any resident with an open area such as a wound should be on EBP. On 8/20/2025 at 1:50 PM, R20's room remained without EBP signage. V27 (Laundry Aide/Housekeeping) was in the room cleaning R20's area. V27 stated [V27] did not know whether R20 was on EBP or not. V27 stated there's no sign. On 8/20/2025 at 1:52 PM, V12 (Nurse) stated R20 is on EBP and should have a sign on the door to inform staff. Facility's 5/2022 'Enhanced Barrier Protection' policy documents in part: This precaution is for use in long term care facilities to prevent the spread of novel or [Multi-Drug Resistant Organism] infections. When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required [Personal Protective Equipment] (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. ----------------------- Findings include: On 08/19/2025 at 11:48 AM at the hallway near entrance of dining room a cooler colored blue and white was seen with resident scooping ice cubes from inside the cooler with plastic scooper. Then putting ice cubes inside plastic pitcher. V28 (Certified Nursing Assistant) after seeing resident stated that residents do not need to do that taking ice from the cooler. Scooper was then placed at the bottom of the cart where on top the cart, cooler was located. Scooper was uncovered and exposed to environment. On 08/20/2025 at 3:20 PM V5 (Infection Preventionist) stated that it is the staff that needs to scoop the ice. But because some residents are highly independent, they (residents) scoop ice cubes in the cooler. V5 said, we try not for them to do that because contamination happens. Scooper supposed to have a little bin and needs to have a top cover. There is cooler on each floor and only residents on that floor can use ice cubes in the cooler. Infection Control Plan dated 06/2022: Policy and Practices, this facility's infection control policies and practices are intended to facilitate maintaining, a safe, sanitary and comfortable environment and help prevent and manage transmission of diseases and infections. The facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and general public. The objective of our infection control policies and practices to provide guidance to ensure a safe, sanitary food operation to prevent food borne illness. To provide guidance to ensure safe, sanitary water supply.

Based on observations, interviews and review of records the facility failed as follows: Failed to maintain refrigerated food labeled, dated and without signs of deterioration. Failed to ensure food stored on dry storage that was opened are labeled and dated, canned food follow first in first out policy. Failed to maintain clean environment with shelves use to accommodate plates, fans used circulating air on unclean condition. Failed to follow policy on handwashing/hand hygiene prior to food preparation on the tray line and after touching high touched areas. These failures are not in accordance with their policy and can affect all 200 residents living in the facility with two (2) residents on NPO or not taking food by mouth on the quality of food received during meals. Finding includes: On 08/19/2025 at 09:29 AM, V6 (Dietary Aide) informed writer that V7 (Dietary Director or Food Service Manager) will not report today. And she (V6) will help with the review on the kitchen. During initial tour shelves near the tray line was found with dirt when scrapped by finger. V6 stated that cleaning usually is done Mondays and Fridays. At dry storage room, a transparent bag of bread ends from multiple loaves of bread was seen on top of the shelf that has loaves of bread stored on other level of the shelf. V6 stated it was not dated and it needs to be discarded. Upon checking the shelves with large can food. Dice tomato cans dated 07/20/2026 was in front of 08/07/2025, [NAME] orange cans 07/10/2026 was in front of 08/11/2026. V6 stated that it was not arrange in accordance with first in first out policy they follow. Inside walk in cooler, transparent bag of cilantro without a date or almost vanishing marker written that cannot be read found visually discolored like deterioration was seen. V6 took the bag saying, these needs to be discarded. Onions inside a large box without label or date. V6 stated that onions usually is not dated. V6 was asked how staff determines when onions are still good? V6 replied, it needs to have a date. Prepared super cereal was marked with date of 08/16/2025 with use by date 08/20/2025. V6 stated super cereal can only last 2 or 3 days. V6 said, I do not know why they put that date. At stove / oven area there is a floor fan that was used. V6 turned off the fan, and saw dirt on the fan blades, and fan guards after swiping with finger. V6 stated, I see what you mean, the fan may circulate around. On 08/20/2025 at 11:25 AM, during tray line review. There are three (3) kitchen staff present during review. Included on food preparation at the tray line was V6 and V20 (Cook), prior to start of food preparation V20 did not perform hand hygiene, put on his gloves and started to prepare food touching with his gloves. V20 was seen went to microwave touched multiple times the handle to heat food. Took the food out of the microwave by his gloves. And resume touching food during preparation. At 11:50 AM, V7 (Dietary Director or Food Service Manager) arrived at the kitchen stated that staff needs to perform hand washing before food preparation on the tray line. V7 was made aware about V20 holding microwave handle during food preparation. At about the same time V7 saw V20 again opening microwave by pulling the handle. V7 called V20 attention to perform handwashing. V7 made aware about concerns that was seen the day before. V7 stated that cilantro needs to be taken out of the refrigerator. V7 breads ends need to be labelled and dated, and it is being used for puree. V7 to a plastic container that have bread ends inside. V7 confirmed that she was notified about the shelf and fan being used that was not cleaned. V7 stated that onions do not need to be labeled. V7 reviewed refrigerated food policy that reads: Food in the refrigerator will be covered, labeled and dated. V7 stated that best practice is to date and label food in the fridge per policy. V7 presented document that reads: Suggested Guide for Dating Fresh Fruit and Vegetables. Under the list onions suggest being dated for seven (7) days. The following policies are provided by facility: Storage of Refrigerated Foods dated 2010: Food supplies received will be stored in a manner that will ensure preservations of nutritive value and quality. Food in the refrigerator will be covered, labeled and dated. Labeling and Dating Foods dated 2010: Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste. For dry stores, cans will be labeled with the date received when unpacked from cases. Newer cans will be placed behind previously received product on the shelf or in the can rack. For refrigerated stores, food prepared on the premises to be held cold will be labeled with the date of preparation and time as required for cooling purposes. This food will also be labeled with date to discard or use by. The discard / use by date will be a maximum of 6 days after preparation. Storage of Dry Goods / Food dated 2010: Non-refrigerated foods, disposable dishware and other dry goods will be stored in a clean, dry area, which will be free from contaminations. Cans will be removed from cartons, dated and stored behind shelves products (FIFO method). First-In-First-Out dated 2021: To ensure food quality and food safety, food products are rotated. The first food product placed in storage is the first one to removed and used. New products are placed on the shelf behind the food products on hand. Products with the earliest expiration date are stored in front of product with later dates so that the older food is used first. Handwashing dated 2021: Food and nutrition services employees will practice safe food handling to prevent foodborne illness. Food and nutrition services employees will thoroughly wash their hands and exposed areas of their arms with soap and water in the designated hand-washing sink at the following times: Before engaging in food preparation. After handling soiled equipment and utensils.

Based on observation, interview and record review the facility failed to a.) ensure expired medications and fiber fortified formula were removed from 1 of 2 medication rooms b.) ensure expired medications were removed from 2 of 4 medication carts and c.) ensure medications were properly labeled and dated in 1 of 4 medication carts reviewed for medication storage and labeling.Finding Include:On 08/19/25 at 09:53 AM the Second Floor Short End Medication Cart was reviewed with V9 (Registered Nurse). R98's Erythromycin 0.5 % eye ointment and Azelastine HCL 0.05% 1 drop both eyes Twice a day was observed in the medication card drawer with an open date of 05/11/25 and expiration date of 06/07/25 written on the boxes. V9 stated they should have been discarded. They were opened on 05/11/25 and expired 06/07/25. R174's lispro insulin multi dose vial was observed in the medication cart drawer with an open date of 07/21/25 and a discard date of 08/18/25. Surveyor asked V9 the dates that were written on the insulin vial label. V9 responded, 07/21/25 and it look like a 6 for 06/18/25. I guess it's an 8. The medications should have been removed from the medication cart drawer. If the resident receives expired medications, there is a potential they could have adverse side effects.On 08/19/25 at 12:38 PM the Fourth Floor Medication Room was reviewed with V10 (Registered Nurse). One open box with an undated vial of Tuberculin Purified Derivative Mantoux 5 tu (tuberculin units) 0.1 ml intradermal was observed in the refrigerator. V10 stated the tuberculin is good for 30 days from the date when it was opened. Ten 8-ounce cartons of Osmolyte 1.5 cal. With an expiration date of 09/24 was observed on a shelf in the medication room. V10 stated we use it in the g (gastric) tube, and we discard them when they expire. If a resident receives the Osmolyte they will probably get an upset stomach.On 08/21/25 at 10:47 AM the 1st floor medication cart was reviewed with V12 (Licensed Practical Nurse) R19's Basaglar insulin pen was observed in the medication cart drawer with no name or dated and R19's Aspart insulin flex pen was observed in the medication cart drawer with no open date. V12 stated they should have been labeled when they were opened, to know when we opened it and to know when we should discard it. R167's Lantus insulin vial was observed in the medication cart drawer with a label documenting opened 07/20/25, expiration date 08/20/21. V12 stated the Lantus insulin vial is expired as of 08/20/25. V12 then removed the Lantus insulin vial from the box and placed it in the sharp's container.On 08/21/25 at10:02 AM V3 (Director of Nursing) stated for the Tuberculin they supposed to be labeling the PPD (Purified Protein Derivative) when they open it with an open date so they can properly discard it. Outside of the discard date it is a medication error, but I am not sure if it causes any adverse reactions. I will take a look. I don't know why the Cartons of Osmolyte were there. There are no residents on that floor that is on Osmolyte. If the Osmolyte is expired, it should not be there. There is a potential adverse reaction-like diarrhea, and I already started education. My expectations for the Insulin Multi Dose Vial are that it has an open and expiration date. If it is past the expiration date, we should remove the vial and we should not be using the vial that is expired. Most insulin is good for 28 days once opened. If used after the discard date, there is a potential that the medication will not be as effective. Eye Drops with an open date of 05/11/25 and a discard date of 06/07/25 should have been removed because the Erythromycin eye ointment was completed and expired. The Azelastine eye drops should have been removed because it was expired. There is a potential that the eye ointment and eye drops would not work the same way and could irritate R98's eyes.Email presented to the surveyor on 08/21/25 11:22 AM document in part: Please see attached requested package insert for Tubersol solution. A vial of Tubersol which has been entered and in use for 30 days should be discarded.Document titled Tuberculin Purified Protein Derivative (Mantoux) Tubersol undated document in part: A vial of Tubersol, which has been entered and in use for 30 days should be discarded. Do not use after expiration date.PolicyTitled Storage of Medication and Medical Supplies revised 12/17 document in part: The facility shall store all drugs [NAME] biologicals and medical supplies in a safe, secure and orderly manner. 2. Medical supplies are to be stored in order of their expiration date and in original packaging or container. 3. Damaged or expired medical supplies are not to be used. These supplies are to be discarded. 6. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 14. Multiple dose vials such as insulin shall e dated the day they are opened and with the expiration date. 17. Expired medications are to be disposed of.Titled Administering Medications revised 11/20 document in part: 9. The expiration/beyond use date on the medication label must be checked before administering. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on observation, interview and record review the facility failed to administer medication according to the physician's order for 1 (R107) of 4 (R6, R147, R202) residents reviewed during medication administration.Findings Include:R107 has diagnosis not limited to Epilepsy, Delirium due to Known Physiological Condition, History of Falling, Disorders of Brain, Muscle Weakness (Generalized) and Cognitive Communication Deficit. R107's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 09 indicating moderate impairment.Order Summary Report document in part: Dilantin Oral Capsule 100 MG (Phenytoin Sodium Extended) Give 4 capsule by mouth in the morning for Epilepsy.R107's Care Plan document in part: Focus: R107 has a seizure disorder, Epilepsy. Is at risk for potential complications; fall, injury, abnormal labs Date Initiated: 06/24/25. Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness.On 08/19/2025 9:43 AM RN V8 (Registered Nurse) prepared Resident #107 medication. Surveyor asked V8 how many pills were in the medication cup. V8 responded there are 8 pills in the medication cup. V8 entered R107's room and administered the medications. 1. Aspirin 81 mg chewable2. Depakote 500 mg bid 3. Phenytoin 4 capsules 100 mg daily V8 only administered 1 capsule 4. Sertraline 50 MG5. Januvia 100 MG6. Magnesium Oxide 400 mg 7. Metformin 500 mg8. Gabapentin 300 mg On 08/21 at 08:47 AM V8 (Registered Nurse) was observed standing at the medication cart on the second floor. Surveyor asked V8 if he would administer R107's medication how many pills would be given. V8 looked into the computer then counted the number of pills that showed on the screen. V8 responded, I would give 8 pills. Surveyor asked V8 to read R107's order for the Phenytoin. V8 said, I gave 1 pill and should have given 4 pills. R107 need the Phenytoin for his seizures and if you don't give right amount R107 could have a seizure.On 08/21/25 at 10:02 AM V3 (Director of Nursing) stated Prior to given medications the nurse should take a look at the 5 rights. The right order, right dose, right time, right patient and right route. V107's order for Dilantin (Phenytoin) is give 100 mg, give 4 capsules by mouth in the morning. If the correct dosage of the Dilantin is not given it is a missing medication and there is a potential if not receiving the correct dosage it will affect the Dilantin level and by not receiving the right dosage R107 could have seizures.Policy:Titled Administering Medications revised 11/20 document in part: Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications are administered according to physician's orders unless otherwise specified. 7. The individual administering the medication must check the label THREE (3) times to verify right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation, interview and record review, the facility failed to ensure call light was within reach and accessible based on resident's abilities for one resident (R118) reviewed for reasonable accommodation of needs out of a sample of 35. Findings include:On 08/19/2025 at 11:53 AM, observed R118 lying in bed wearing splints to right and left hands with finger deformities. Some of R118's fingertips appear to be bent backwards. Observed call light switch on the wall attached to a string and the end of the string was tied around a large stuffed thick circular object toy and the toy was located behind and above R118's shoulder. Observed R118's cell phone on her over the bed table turned upside down with a red plastic stand attached to the back of her phone. R118's phone was out of R118's reach. On 08/19/2025 at 11:56 AM, R118 stated due to the arthritis in her hands she cannot reach the call light where it is right now. R118 stated that the staff added the large stuffed toy to the end of the call light string to help her access the call light, but the object is too thick and heavy for her to be able to move it. R118 said, I don't have the strength to move it and pull it hard enough to push down the call light switch. R118 stated because of this she has been having to pull the call light cord using her mouth because that is the only way she can move the string hard enough to activate the call light. R118 said, having to put that call light string in my mouth is nasty because it is dirty. R118 stated the staff is aware of the problem and they have not tried any other type of call light device for her to use. R118 stated this has been an issue for approximately six months. R118 stated she has a cell phone, but she is no longer able to make calls using her cell phone because of her fingers which are deformed from arthritis. R118 stated she can answer her cell phone but only if her cell phone is set up directly in front of her using a plastic stand she has attached to her phone. R118 said, see where my phone is now? I cannot reach that to use it. On 08/19/2025 at 12:33 PM, V8 (Registered Nurse) observed R118's call light attached to the stuffed toy located above her right shoulder on her bed. V8 stated he was not aware that she did not have the strength to grab on to the stuffed toy and pull it to activate the call light switch. V8 stated that means if R118 needs hep she cannot get it. V8 stated the call light string is not clean because everyone touches it and putting her mouth on that string is a high risk for infection. On 08/20/2025 at 12:44 PM, V21 (Restorative/Rehab Licensed Practical Nurse Manager) stated R118 has contractures in both of her hands and some of her fingers are extended backwards. V21 stated R118 wears hand splints six to seven days out of the week for three hours per day. V21 stated she was not aware that R118 was having difficulty pulling the call light. On 08/20/2025 at 1:05 PM, V24 (Therapy Director/Occupational Therapist) stated Occupational Therapy (OT) evaluated R118 in 06/2025 because of worsening hand contractures and provided recommendations for her to wear bilateral hand orthotics. V24 stated she is familiar with R118 but was not the OT who did her eval in 06/2025 but the OT did not evaluate R118 for ability to use her call light. V24 stated R118 was referred to her yesterday due to concerns over R118's ability to pull her call light. V24 stated R118 used to be able to pinch and grasp items using her thumb and index finger but yesterday she could not do that anymore due to worsening hand contractures and more limited finger dexterity. V24 stated R118 does not enough external rotation of her shoulder to be able to reach behind her so the call light system needs to be directly in front of her for her to be able to access it. V24 stated the call light string attached to the thick stuffed toy she saw set up for R118 yesterday was not working for her because she could not grasp it and it was too heavy for her to move. V24 stated she removed the stuffed toy and set up a different system which R118 was able to use independently to activate her call light.On 08/21/2025 at 9:50 AM, V2 (Director of Nursing) stated all residents should have access to a call light and the call light should be near the bed and accessible to the resident. V2 stated it is important for the resident to have access to a call light so they can call for assistance. V2 stated if a resident cannot reach the call light or use the call light then it will be hard for the resident to communicate with the staff and call for assistance. V2 stated the facility should be providing a call light system that is functional for the resident and individualized to the resident's abilities. R118 has diagnosis which includes but not limited to Type 2 Diabetes Mellitus, Severe Morbid Obesity, Contracture Right Hand, Contracture Left Hand, Contracture Right Elbow, Contracture Right Ankle, Contracture Left Ankle, Muscle Wasting and Atrophy, Fatigue, Tremor, History of Falling, Unspecified Osteoarthritis, Venous Insufficiency (Chronic), Lymphedema, Chronic Kidney Disease, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity. R118's MDS (Minimum Data Set) dated 06/11/25 documents in part, functional limitation impairments to both sides of upper and lower extremities, dependent for activities of daily living and mobility. R118's activities of daily living self-care documents intervention in part, encourage the resident to use bell to call for assistance. R118's fall risk care plan documents intervention in part, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Facility provided document titled Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities dated 11/2018 which documents in part your facility must treat you with dignity and respect and your facility must be safe, clean, comfortable, and home-like. Facility provided policy titled, Answering the Call Light dated 11/2013 which documents in part when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review the facility failed to a.) ensure the Code status matched on the Physician Orders, POLST (Practitioner Order for Life-Sustaining Treatment) and Care Plan and b.) update the care plan to reflect the correct code status for 1 (R8) resident reviewed in a sample of 35.Finding Include:R8 has diagnosis not limited to History of Falling, Transient Ischemic Attack (Tia), and Cerebral Infarction, Anemia, Dementia, Essential (Primary) Hypertension, Schizophrenia, Generalized Anxiety Disorder Osteoarthritis, Nicotine Dependence, Pain in Unspecified Knee, Mild Cognitive Impairment, Chronic Kidney Disease, Multiple Fractures of Ribs, Left Side, Displaced Fracture of Proximal Phalanx of Right Little Finger, Severe Protein-Calorie Malnutrition, Dysphagia, Adult Failure to Thrive, Hyperlipidemia and Gastrostomy. R8's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03 indicating severe cognitive impact. Practitioner Order for Life-Sustaining Treatment form dated [DATE] document in part: No CPR (Cardiopulmonary Resuscitation): Do No Attempt Resuscitation. Comfort-Focused Treatment: Primary goal is maximizing comfort through symptom management. Allow natural death. Use medication by any route as needed. Use oxygen, suction and manual treatment of airway obstruction. Do not use treatment listed in Full and Selective treatment unless consistent with comfort goal. Transfer to hospital only if comfort cannot be achieved in current setting.Progress note dated [DATE] 15:04 document in part: The care plan was reviewed and updated accordingly. POA/POLST (Power of Attorney/Practitioner Order for Life-Sustaining Treatment) in file. R8's Advance Directives document in part: DNR (Do No Resuscitate) DNR, Full Code (discontinued as of [DATE] 16:42). R8's Care Plan document in part: Focus: Advance Directives POA (Power of Attorney), and R8 will receive education on advance directives. At this time R8 will remain a full code and all life saving measures must be utilized. Date Initiated: [DATE]. Goal: R8's wishes will be respected, and staff will take the appropriate measures in the event of an emergency Date Initiated: [DATE]. Focus: R8 is a Full Code requiring all life saving measures be utilized Date Initiated: [DATE]. Goal: R8's wishes will be respected, and staff will take the appropriate measures in the event of an emergency Date Initiated: [DATE]. Interventions: Assess and notify medical staff of changes. CPR (Cardiopulmonary Resuscitation), O2 (Oxygen), IV (Intravenous), AED (Automated External Defibrillator) as needed. Notify EMS (Emergency Medical Services), 911, and hospitalization as needed, Date Initiated: [DATE].Updated care Plan presented to surveyor on [DATE] document in part: Focus Advance Directives: POA (Power of Attorney), and R8 will receive education on advance directives. At this time R8 Code status DNR. Date initiated [DATE]. R8's wishes will be respected, and staff will take the appropriate measures in the event of an emergency Date Initiated: [DATE].On [DATE] at 10:02 AM V3 (Director of Nursing) stated Social Service is responsible for uploading the Advance Directives POLST (Practitioner Order for Life-Sustaining Treatment) form and updating the Advance Directives care plan. If there is a POLST form the nurse enters the order. The Advance Directives physician order, POLST form and care plan should match. If the care plan does not match the Advance Directives order and POLST form, there will be a conflict of care. Nurse assumes the resident is a full code if there is no proper paperwork as a DNR (Do Not Resuscitate). When we do have the DNR form the resident may still want to go to hospital.[DATE] at 11:21 AM V11 (Director of Social Service) stated social services are responsible for Advance Directives. We explain to the family what the form is and have them fill it out. Administration and the Director of Nursing update the file in the system where it says advance directives and they code it in the system. We upload the POLST form, update the care plan and make sure the POLST forms are signed. Rather Do No Resuscitate or Full Code we upload the file. The care plan is updated the same day the POLST form is signed. R8's care plan should be dated [DATE] when the POLST form was signed. The physician order, care plan and POLST form should match. If they do not match R8 would be incorrectly resuscitated if he is a DNR.Policy:Titled Advance Directives) revised 11/20 document in part: Advance Directives will be we respected in accordance with state law and facility policy. 10. A plan of care for each resident will be consistent with his or her document treatment preferences and/or advance directive. 17. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. 19. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment and care plan. 20. The Director of nursing services or designee will notify the attending physician of advanced directives so that appropriate information can be documented in the plan of care.Titled Medical Emergency (Code Blue) revised 06/22 document in part: Purpose: To provide care and services to residents in accordance with Advance Directives that have been discussed with the resident or resident' legal representative in advance of medical emergencies.Titled Care Plans, Comprehensive Person-Centered revised 04/17 document in part: comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The Interdisciplinary Team, in conjunction with the resident and resident representative or family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: j. Reflect the resident's expressed wishes regarding care and treatment goals. 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change.

Based on interview and records review, the facility failed to follow their policy and procedure to develop and implement a comprehensive person-centered care plan that includes measurable objectives with timeframe and interventions to address a resident's language barrier and communication needs for one (R5) out of one resident reviewed for communication in a final sample of 35. Findings Include:On 8/19/25 at 12:12 PM, R5 was sitting up in her wheelchair alert and verbally responsive. Surveyor attempted to interview R5 but started talking in a foreign language. R5 stated, Spanish. Surveyor asked V33 (Certified Nursing Assistant) to interpret. R5 stated that if no one speaks Spanish, they can't explain to R5 the medications that they are giving. R5 stated that not all the time there is someone in the facility to interpret in Spanish. On 8/21/25 at 11:09 AM, V11 (Director of Social Services) stated that language barrier and communication needs are assessed upon admission and reevaluated quarterly. V11 stated that language barrier needs should be addressed in the care plan so that the staff who takes care of the resident is aware of the needs and what to do for the resident. V11 stated that the communication books are accessible in the nurses' station on each floor so they can use it whoever needs them. V11 stated R5 only speaks and understands English, and it should be addressed in her care plan. V11 stated she must have missed including it in R5's care plan.R5's clinical records show a re-admission date of 3/15/25. R5's Quarterly Minimum Data Set (MDS) dated [DATE] shows R5's preferred language is Spanish. It also shows R5 has moderate impairment with cognition. R5's comprehensive care plan does not address R5's language barrier.The facility's Communication Program policy dated 6/7/22 documents in part: Resident is assessed during the completion of the MDS and appropriate CAA (Care Area Assessment) reviews. Deficits in the areas of hearing, vision, speech, foreign language and/or dementia will be documented and discussed at the care plan conference. The IDT (Interdisciplinary Team) will develop sensible approaches designed to facilitate expressive and/or receptive communication. The approaches will be documented in the plan of care. The Care Plan will indicate what deficits exist and are being addresses. The facility's Care Plans, Comprehensive Person-Centered policy dated 4/17 documents in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observations, interviews, and record reviews, the facility failed to maintain an environment as free from potential accidents hazards as is possible by failing to (a) ensure that a resident (R153) did not have a retractable blade in their possession, (b) implement interventions to properly supervise a resident (R14) with a history of multiple falls, and (c) follow interventions for fall prevention for a resident (R15) who had multiple falls. These failures have the potential to affect three residents reviewed for accidents hazards. Findings include: R153's 'admission Record' documents in part diagnoses of major depressive disorder, single episode, moderate; tremor; generalized anxiety disorder; schizophrenia; unspecified psychosis not due to a substance or known physiological condition; and hallucinations. R153's 7/28/2025 MDS (Minimum Data Set) assessment documents in part that R153 is cognitively intact. It also documents in part that R153 had moderately severe depression. During the look-back period, R153 had delusions and hallucinations. R153's 'Care Plan Report' documents in part that R153 may have some controlling behaviors due to R153's diagnosis of schizophrenia (12/16/2024). On 8/19/2025 at 11:00 AM, R153 was alert and oriented to person, place, and year. R153 had an orange and pear on the bedside table. R153 was using a red, retractable blade to cut the fruits. While holding the blade upright, R153's hands were shaking. R153 stated [R153] got the retractable blade from a friend a while ago. R153 stated [R153] hasn't told anyone [R153] has it. R153 stated using it to cut [R153's] food. R153 stated locking up the retractable blade in the top drawer of [R153's] dresser. R153 washed the retractable blade in the sink, placed it in the top drawer, and locked it. R153 kept the key to self. At 11:14 AM, V12 (Nurse) stated didn't know R153 had a retractable blade. V12 stated R153 is not supposed to have a blade. V12 stated it is not safe for anyone to have it. V12 went to R153's room to retrieve the retractable blade but R153 did not want to hand it over. R153 stated [R153] keeps the retractable blade locked in the drawer. V12 stated will get social services involved. At 11:21 AM, V13 (Social Worker) stated not knowing that R153 had a retractable blade. V13 went into R153's room and asked for the retractable blade. R153 did not want to hand it over. R153 stated [R153] had it locked in the upper drawer each time. V13 called the nurse over. At 11:24 AM, V12 and V13 entered R153's room to retrieve the retractable blade. R153 unlocked the top drawer and handed the blade over to V12. Surveyor used a wound measuring tape from V12 to measure the blade. When fully engaged, the blade measured to 7.5 cm (centimeters). At 12:26 PM, V14 (Nurse Practitioner) stated R153 is alert and oriented but can get confused with active infection but does not have a current infection. V14 stated in the past, R153 would hallucinate but has not done that in years. V14 stated R153 does have Parkinson's. V14 stated [V14] does not see a need for R153 to have the retractable blade. V14 stated R153 probably wouldn't do anything harmful with the blade. At 12:47 PM, V2 (Assistant Administrator) stated did not know R153 had the blade. V2 stated R153 and R198 (R153's roommate) are alert and oriented with no behaviors. At 12:55 PM, V3 (Director of Nursing) did not know R153 had a blade. V3 stated R153 is alert and oriented to person, place, and date. V3 stated R153 does not have behaviors and is not a danger to self or others. V3 stated [V3] would not be afraid of R153 doing harm to anybody. V3 stated regardless, a blade is a blade, and residents aren't allowed to have blades because it wouldn't be safe. V3 stated a blade can be misplaced and anybody can take it. V3 stated the facility must make sure it doesn't get into the wrong hands. V3 stated no wanderers on the first floor with most being alert and oriented. At 1:06 PM, V4 (Assistant Director of Nursing) did not know R153 had a blade. V4 stated R153 is alert and oriented to person, place, and date. V4 stated R153 hasn't had any behaviors in years. V4 stated R153 has been pleasant and there are no concerns for self-harm or harm to others. V4 stated residents aren't allowed to have blades because they can injure themselves even if not intentionally and can injure somebody else. On 8/20/2025 at 3:03 PM, V1 (Administrator) stated staff turned over R153's retractable blade to V1 yesterday. V1 stated staff also searched the remainder of R153's possessions and no other contrabands found. V1 stated when V1 questioned R153, R153 stated getting the blade from the garbage can. V1 stated educating R153 to not have blades or knives. V1 stated instructing R153 to inform facility if R153 needs assistance cutting fruit. V1 stated the blade looked like a box cutter. V1 stated not knowing if R153 obtained it somehow due to facility's current remodeling construction on the first floor. V1 stated educating staff and contractors to not leave sharp objects such as blades unattended. V1 also educated them that if sharp objects need disposal, staff and contractors need to do it properly and not within residents' access. V1 stated if facility suspects a resident from bringing in contrabands, they will usually search their items, but facility has not suspected R153 of it. During the follow-up interview with R153 at 3:14 PM, R153 stated finding the retractable blade in a garbage can in the hallway almost 10 years ago. R153 stated having the blade for years and always locking it up in the drawer after use. Facility provided a copy of their admission Packet which includes the Illinois Long-Term Care Ombudsman Program 'Resident Rights' for People in Long-Term Care Facilities document. In documents in part residents' rights to safety. Your facility must be safe, clean, comfortable, and homelike. Facility's 'Accidents and Incidents: Supervision, Investigating and Reporting' policy (rev 06/2022) documents in part: The facility provides an environment that is free from accident hazards over which the facility has control. The facility provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazard and risk, evaluating and analyzing hazard and risk, implementing interventions to reduce hazard and risk, monitoring for effectiveness and modifying interventions when necessary. Facility's 'Search and Confiscation Policy' (4/24/2022) documents in part that prohibited items include sharps, razors, knives, weapons, or items considered a possible danger. ---------------------------- Findings include: On 8/19/25 at 11:36 AM, R14 was sitting up in his wheelchair in his room. Surveyor asked if R14 remembers falling in the last six months. R14 stated [R14] does not remember falling. R14 was noted with forgetfulness and bouts of confusion, was unable to verbalize R14's current location, time, and day. On 8/19/25 at 11:39 AM, R173 was lying in bed alert and verbally responsive. R173 stated [R173] remembers R14 falling a couple of months ago. R173 stated R14 was yelling for help. R173 stated it happened in the afternoon but does not remember the exact date and time. R173 stated [R173] pulled the call light to get help and the nurse (does not remember nurse's name) came in right away. On 8/19/25 at 3:45 PM, V10 (Registered Nurse) stated, I was called by [R173]. I answered the call light, and I saw [R14] sitting on the floor next to the bathroom by his wheelchair by the bathroom door. [R14] was trying to go to the bathroom. [R14] said he had to use the bathroom. I asked why [R14] didn't call for help and he said he could do it himself. The wheelchair was unlocked. [R14] was wearing his shoes. [R14] was not in bed. [R14] could propel himself on the wheelchair, but he needs extensive assist with one person to go to the washroom. [R14] is continent of bowel and bladder. I cannot remember off the top of my head the last time [R14] was toileted. I can't remember who the CNA [Certified Nursing Assistant] at that time was. [R14's] call light was clipped on his bed. [R14] needs constant cuing and re-direction. [R14] was educated how to use the call light. [R14] is forgetful and gets confused. [R14] is at risk for fall due to poor cognition. [R14] used to be independent so he tends to not call for help at times. [R14] would get up by himself without asking for help. I've seen [R14] last in the day room about an hour and half before the fall. When he's [R14] up on the chair someone has to always watch him [R14] and monitor him constantly. I can't recall how [R14] got to his room by himself. I did a full body assessment, and he was noted with no visible injuries. He didn't complaint of pain. On 8/20/25 at 12:17 PM, V21 (Restorative/Rehab Licensed Practical Nurse Manager) stated, The falls interventions are developed depending on their progress notes, the root cause of the fall and interview of the patient. For residents who are forgetful and have the tendency to not ask for help, we do a lot of redirections and varies from patient to patient. It's individualized. The staff do a lot of supervision. The staff provides constant monitoring. They must be supervised at all times to go to the toilet for safety and to prevent them from falling. For [R14] he requires extensive one person assistance for toileting. Transfer [R14] requires supervision. [R14] is able to propel himself on the wheelchair, but he still needs supervision because [R14] has the tendency to get up by himself. Since February [R14] had three falls. The 3/11/25 fall [R14] was attempting to get out bed. On 3/12/25, [R14] had another fall trying to go to the toilet by himself. On 3/25/25 [R14] was also found on the floor in his room. [R14] slid out of the wheelchair. Prior to the 3/25/25 fall [R14] was placed on falling star program it's a yellow sticker by the door. It tells the staff that [R14] is high risk for falls that staff should always assist him and not to leave him alone when [R14] is up on his wheelchair because [R14] is a frequent faller. [R14] needs constant monitoring. R14's clinical records show an original admission date of 3/30/16 with listed diagnoses but not limited to unspecified dementia, muscle weakness, generalized anxiety disorder, and history of falling. R14's Minimum Data Set, dated [DATE] shows R14 has moderately impaired cognition and requires supervision or touching assistance with transfers and toileting. Facility's Post Fall Evaluation dated 3/25/25 revealed R14 was observed on the floor in his room attempting to self-toilet. The facility's Fall Star Program Policy dated 11/2013 documents in part: To ensure that all residents determined to be at risk for falls or who have fallen are properly monitored the facility may initiate the falling star protocol. The facility's Falls – Clinical Protocol dated 6/22 documents in part: Based on the preceding assessment, the staff and physician or LIP will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. ---------------------------- Findings include: R15 is [AGE] years old, initial admission date of 03/04/2024. R15 medical diagnosis includes Parkinson's disease, syncope and collapse and bipolar disorder. Per R15's clinical notes, resident (R15) has multiple falls on 02/03/2025, 03/01/2025 and 03/23/2025. Review of R15's care plan intervention documents that R15 needs non-skid under mattress dated 03/01/2025 and personal items within reach among other. On 08/21/2025 at 10:00 AM V21 (Restorative Rehab Manager/Licensed Practical Nurse) stated that R15 mostly dependent on her ADLs (Activity of Daily Living). V21 confirmed that R15 fell three (3) times on 02/03/2025, 03/01/2025 and 03/23/2025. And intervention that was placed to prevent R15 from falling is to place non-skid pad underneath the bed, place the bed in low position and personal items within reach. V21 stated that the fall dated 03/01/2025 was due to mattress moved or slid off the bed. Nursing notes dated 03/01/2025 by V5 (Registered Nurse/Infection Control) documents that the bed slightly sliding to the floor when R15 fell. On 08/21/2025 at 10:00 AM with V21 inside R15's room. R15's mattress was seen without non-skid pad underneath. There were straps on the mattress that was not attach to the bed. Mattress on the bed was light weight that can be moved with one hand. V21 said that there needs to have non-skid pad, and strap needs to be attached for bed not to move. V21 then lowered the bed on its lowest position. V21 stated that the bed needs to be lowered as part of fall prevention. Side table with cabinet where all personal items (bottle of lotion, personal toiletries) of R15 was seen out of reach/hard to reach. V21 stated that bed needs to move closer to the side table cabinet to reach the items. And the bed was light in its weight that it can moved and make R15 fell. Nursing notes dated 03/23/2025 by V8 (Registered Nurse) documents that R15 fell when she was reaching for item(s). Falling Star Program Policy dated 11/2013: To ensure that all residents determined to be risk for falls or who have fallen are properly monitored that facility may initiate the falling star protocol. Recommendation and updating of individualized interventions will be implemented and documented on the resident's care plan.

Based on observation, interviews, and record review the facility failed to place oxygen in use signage on the door of one (R159) resident out of five residents reviewed for respiratory care in a sample of 35. Findings include: On 08/19/2025 at 12:15 PM, observed R159 lying in bed with oxygen infusing via nasal canula. R159 did not have an oxygen in use sign or no smoking sign posted in or outside his room.On 08/19/2025 at 12:30 PM V8 (Registered Nurse) stated if a resident is on oxygen, then they have to have an oxygen in use/no smoking sign posted outside their door to alert people that oxygen is in use. V8 stated the sign is a safety precaution. V8 stated if there is a fire the resident's doors are closed but the oxygen in use sign posted outside the door would still be visible which is important for staff and fire personnel to be able to quickly identify who is at risk. V8 stated R159 is on continuous oxygen. V8 looked on the outside of R159's door and stated there is not an oxygen in use/no smoking sign posted and there should be one. V8 stated R159 recently returned from the hospital, and someone forgot to post the sign when he was readmitted . V8 stated he will go and get a sign right now to post outside R159's room.On 08/21/25 at 9:46 AM, V2 (Director of Nursing) stated if a resident is receiving oxygen there should be a no smoking/oxygen in use sign posted on the outside of the resident's room. V2 stated the purpose of the sign is to alert family and residents that they should not be any smoking inside or near the room. V2 stated it is a hazard and signage is posted for safety. V2 stated R159 was readmitted from the hospital and there should have been a no smoking/oxygen in use sign posted when he was readmitted outside his door. R159's diagnosis included but not limited to Chronic Respiratory Failure, Unspecified Dementia, Severe Intellectual Disabilities, Seizures, Epilepsy, Obstructive Sleep Apnea, Visual Loss, Dysphagia, Adult Neglect or Abandonment. R159's Order Summary Report dated 08/19/25 documents in part oxygen continuous oxygen via nasal cannula/mask at 2 liters per minute every shift. R159's oxygen care plan undated documents in part R159 has altered respiratory status/difficulty breathing related to chronic respiratory failure, obstructive sleep apnea. Facility provided policy titled, Oxygen Administration dated 03/2020 which documents in part, place an Oxygen in Use sign in a designated place on or over the resident's bed. Facility provide policy titled, Oxygen Care and Storage dated 12/2017 which documents in part, No Smoking signs must be clearly visible in areas where oxygen is stored or in use.

Based on review of records and interview the facility failed to maintain accurate resident record, ensure resident records are readily accessible related to psychotropic medication use for 1 out of 4 residents (R1) reviewed for improper nursing care. These failures can affect 1 resident (R1) who uses psychotropic medication related to correct medical diagnosis and consent documentations. Findings include: R1 is [AGE] years old, initially admitted on [DATE] discharged on [DATE], readmitted on [DATE] and discharged to hospital 3/25/2025. R1 medical diagnosis includes dementia with behavioral disturbance, brief psychotic disorder, and mood affective disorder. Per R1's physician order documents that R1 has an order for the following psychotropic medications: Haloperidol Tablet 5 MG, as needed for aggression for 14 days, Haldol Injection Solution 5 MG/ML (Haloperidol Lactate) inject 5 mg/ml intramuscularly every 6 hours as needed for aggression for 14 days, Olanzapine Oral Tablet 2.5 MG give 1 tablet by mouth in the evening for schizophrenia, psychoses, bipolar disorder and Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) for depression all of these psychotropic medications require consent prior administration. Discrepancies were identified as to the Depakote order dated 02/11/2025, 03/06/2025 and 03/17/2025. Physician orders dated 02/11/2025 and 03/06/2025 for Depakote medication supporting diagnosis for psychotropic medication use for mood affective disorder. Physician order dated 03/17/2025 for Depakote medication supporting diagnosis for psychotropic medication use for depression. On 05/28/2025 at 10:54 AM, V12 (Psychotropic Nurse / Licensed Practical Nurse) stated that nursing staff chose the wrong diagnosis, Depakote was used for mood disorder and not for depression. V12 reviewed all R1's medical diagnosis on the face sheet that does not include depression. V12 stated that he is aware of the difference between two diagnosis and different side effects of prolong use of psychotropic medication. V12 presented consent form for Haldol antipsychotic mediation uploaded on R1's electronic record dated 05/27/2025. V12 stated that medical record just uploaded in R1's electronic record yesterday (05/27/2025), and it should have been uploaded on the date it was signed (03/22/2025). Although R1 has an order for two different Haldol orders, for Haldol 5 MG tablet and Haldol 5 MG per ML injection. R1 has only have one (1) consent form for Haldol 5 MG. V12 stated Now I see what you mean. Consent should be given to both tablet and injection. But I placed PO/per Orem or orally and IM/intramuscular). V12 stated that moving forward he will procure two (2) separate consent forms since there are two (2) different psychotropic medications involved. R1 has an order for Olanzapine Oral Tablet 2.5 dated 03/17/2025 without consent form to start use of psychotropic medication. V12 stated that he went to medical records because it was not uploaded on R1's electronic record. V12 stated that it should have been uploaded once available but medical records failed to upload. Per MAR (Medication Administration Record) for March 2025, R1 was documented of being administered with Depakote for depression.

Based on observations, interviews, and review of records the facility failed to provide and/or obtain routine medication for availability in the medical supply for 1 out of 3 residents (R2) reviewed for pharmaceutical services. These failures have the potential to affect 1 resident (R2) that may impede timely administration and adversely affecting a resident's condition due to delay of acquisition of a medication. Findings include: R2 is [AGE] years old, initially admitted in the facility 12/10/2016. R2 diagnosis includes legal blindness, Parkinson's disease with dyskinesia, major depression, and dry eye syndrome. R2 has an order by physician to receive Latanoprost Ophthalmic Solution eye drops scheduled to be given at 07:00 PM, one (1) drop both eyes for legal blindness. On 05/27/2025 at 12:56 PM, R2 was seen alert and able to express thoughts within topic. R2 stated that he must ask for his eye drops before he can receive it. R2 said, Eye drops, I must ask for them. No, I don't receive my eye drop if I did not ask. I received them before I go to bed. And in the afternoon too. R2 said that he is legally blind because he sees things double instead of single form. At the nurse station with V4 (Licensed Practical Nurse) and V5 (Licensed Practical Nurse), medication cart that stores R2's medication was reviewed with V5. V5 checked all drawers and compartments but unable to find R2's Latanoprost Ophthalmic Solution eye drop. V5 informed V2 (Director of Nursing) who went to check the medication cart with V4, unable to find R2's eye drop. V2 went with V3 (Assistant Director of Nursing) to another floor where pharmacy medication dispenser was located. V3 checked supplies of medication for R2 specific to Latanoprost Ophthalmic Solution eye drop. V3 stated that R2's eye drop was not available, then called pharmacy to ask for details related to Latanoprost Ophthalmic Solution medicine. V3 stated that according to pharmacy, it was delivered to the facility on [DATE]. V2 stated that pharmacy should have been informed about R2's eye drops because electronic system automatically informs the pharmacy. V2 stated that in case pharmacy does not deliver medication for residents. It is the responsibility of nurses to request pharmacy to deliver specific medication in order not to run out of stock. V3 provided documentation from pharmacy dated 05/04/2025 that Latanoprost Ophthalmic Solution eye drops for R2 was delivered on the same date (05/04/2025). Per document, Latanoprost Ophthalmic Solution eye drops have a quantity of 25 uses. Medication Administration Record (MAR) for May 2025 documents that Latanoprost Ophthalmic Solution eye drops has a schedule to be given at 07:00 PM, one (1) drop both eyes for legal blindness. It was recorded as administered daily including date of delivery 05/05/2025 to current date 05/26/2025 or 22 days of use. There was a prior grievance or complaint (Resident / Family Grievance / Complaint Form) dated 05/23/2025 that documents V17 (Family of R2 / POA) was complaining that R2 was not getting his eye drops. The same form was notified by nursing department and was signed by V1 (Administrator). Under Storage of Medications and Medical Supplies policy, dated 12/2017 nursing staff shall be responsible for maintaining medical supply including medication. Under Administering Medication policy dated 11/2020, Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or related functions.

Based on interview and record review the facility failed to implement fall prevention interventions for one (R1) of three residents reviewed for falls. This failure resulted in R1 falling on 02/08/2025 and R1 is hospitalized at the time of this survey. Findings include: R1's face sheet dated 09/15/2024, documents that R1 is a [AGE] year-old resident with diagnoses not limited to: unspecified intellectual disabilities, down syndrome, unspecified, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, nontraumatic subarachnoid hemorrhage, unspecified, traumatic subdural hemorrhage without loss of consciousness. R1's MDS/Minimum Data Set, dated dated dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental Status score of 04/15, indicating that R1 has severely impaired cognition. On 02/08/25, 10:37 AM, V3 (Registered Nurse) states that R1 fell this morning at approximately 9:50 AM. V3 continues to state my CNA (certified nursing assistant) was in the room with her. R1 was walking barefoot. The CNA (V4) told her to go back and get your shoes.When she turned, she lost balance and she fell . V3 reports that V4 called V3 and V3 states that she went to the room and found R1 sitting on the floor, on her bottom. V3 states that V4 reported to her that R1 did not lose consciousness. V3 states that R1 didn't report anything, of what happened. She denied pain and had no visible injuries. V3 adds that V4 did inform V3 that R1 did hit her head on the door. V3 states that she is familiar with R1's care and is usually R1's regular nurse in the morning shifts. V3 reports that R1 has down syndrome, she is ambulatory, but lately she has been more confused, and we must redirect her more. Lately she has become a feeder. We present her with the tray, set her up, and encourage her to eat. She will say yes, but then not eat. So now she is a feeder. V3 reports that staff try to monitor R1 and do try to get her in the day room. We have someone in the day room and have yellow tape which means they are fall risk, by her name. V3 reports that R1 does not use any assistive devices. V3 states that R1's gait is steady, sometimes she gets distracted very easily. If she is walking and if you call her, she can turn fast. Lately she has been going into other residents' rooms. She usually doesn't go, but lately she has been presenting with these behaviors. On 2/08/25, 11:05 AM, V4 (Certified Nursing Assistant) states that she reads the residents' electronic medical record to know the residents' needs. V4 continues I ask the nurses that know the residents and ask them how I can help them. In the POC, there is person information that tells you the basic needs that they need assistance with. V4 reports that R1 needs help with showering, going to the toilet because she cannot clean herself. V4 states that R1 needs help with eating, sometimes she can eat by herself and sometimes she is in her own world and needs assistance. V4 stated that when R1 fell , V4 was in the middle of picking up breakfast trays. V4 states that when I went to her room, I just saw her without shoes. I told her put your shoes on, and she turned and fell . I went to go help her. V4 reports that R1 fell in her room, next to the bathroom door. She was just standing. V4 states that when R1 turned, she lost her balance and fell . She tried to grab the wall and did touch it, but her hand slid down the wall. R1 still fell . V4 reports that R1 landed on her bottom and bumped her head on the door of the bathroom. V4 continues sometimes R1 is a fall risk because V4 states R1 can walk and can lose her balance. On 02/10/25, at 1:09 PM, via telephone V9 (Primary Physician) states that some generalized complications from falls are head injuries, bleeding, and broken bones. V9 states we need to prevent falls; it is hard to prevent at times. V9 states that R1 needs to be monitored more closely. This surveyor asked V9 if a resident's individualized fall prevention care plan interventions are not implemented, does it place a resident at a higher risk to have an avoidable fall. V9 states yes, that is correct, if they are not implemented then it can place the resident at risk for an avoidable fall. R1's MDS section GG dated 12/11/2024, documents R1 requires supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity). Assistance may be provided throughout the activity or intermittently for putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility. R1's MDS section GG dated 12/11/2024, documents R1 requires supervision or touching assistance for walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. R1's MDS section GG dated 01/07/2025, documents R1 requires supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently for putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility. R1's MDS section GG dated 01/07/2025, documents R1 requires supervision or touching assistance for walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. R1's current care plan documents in part R1 is at risk of falls d/t (due to) H/O (history of) falls, intellectual disabilities, down syndrome, medication regimen, traumatic subdural hemorrhage w/o loss of consciousness, nontraumatic subarachnoid hemorrhage, syncope and collapse, goal is R1 will be free of injury. interventions document in part: -Encourage the resident to participate in supervised activities date Initiated: 06/11/2019 revision on: 02/15/2024. -Assist and encourage resident to day room for lunch date Initiated: 01/08/2025. -Ensure that appropriate footwear is in place when ambulating date Initiated: 06/11/2019. R1's nurse's note dated 02/08/202, 9:26 AM, documents in part CNA on duty call this writer (V3) to resident's room. Noted resident sitting in the floor by the door of the bathroom. Per CNA report resident was walking barefoot when she encouraged to have her shoes. Resident turned, lost her balance, and fell backwards hitting her head. Per CNA report resident did not lose consciousness. R1's nurse note dated 02/02/2025, 10:11 AM, documents in part, writer (V3) fed resident breakfast today. Writer encouraged the resident to eat on her own, but the resident kept the spoon with food without putting spoon to her mouth. Writer talked to the resident encouraging her to eat the food that she has in her plate. Resident agreed to writer, but she did not put the spoon in her mouth. R1 was assisted for morning care in the shower room and to get dressed. R1's nurse's note dated 02/08/2025, 4:22 PM, documents in part writer follow up regarding information provided to nurse on duty in regards to her Dx (diagnosis) of Right side subdural Hematoma. Per information given unable to provide if findings are acute, after reviewing previous hospital report, resident already with a diagnosis of right subdural hematoma and right frontal SAH (subarachnoid hemorrhage). Facility document dated 11/2013, titled falling star program policy documents in part to ensure that all residents determined to be at risk for falls or who have fallen are properly monitored the facility may initiate the falling star protocol. Individualized care plan will be initiated, and immediate intervention will be put into place. Facility document dated 5/25/2015, titled Accidents and Incidents: Supervision, Investigating and Reporting documents in part the facility provides an environment that is free from accident hazards over which the facility has control. The facility provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazard and risk, evaluating and analyzing hazard and risk, implementing interventions to reduce hazard and risk, monitoring for effectiveness, and modifying interventions when necessary. Avoidable Accident means that an accident occurred because the facility failed to identify an environmental hazard or individual risk or the need for supervision and/or evaluate/analyze the hazard and risk and/or implement interventions consistent with the resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident and/or monitor the effectiveness of the interventions and modify the interventions as necessary in accordance with the current standards of practice. Facility document dated 04/2017, titled Care Plans, Comprehensive Person-Centered documents in part a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and, resident representative or family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observations, review of records, and interviews the facility failed to safeguard resident rights to properly account and correctly charge resident funds for 7 out of 9 residents (R2, R4, R5, R7, R8, R9, and R10. These failures does not conform with their policy that mandate the facility to hold, safeguard, manage and account resident funds. Four (4) residents (R2, R4, R7, and R8) personal funds accounts were affected and charged dental insurance premiums that should have been included in care cost. 5 residents (R2, R5, R8, R9, and R10) were charged haircuts on their resident funds without proper documentation of consent, residents unable to give consent due to impaired cognition, and/or service date discrepancies. Findings include: On 01/14/2025, at 1:07 PM, V3 (Assistant Administrator) stated that dental insurance premiums were charge by increasing resident's allowance (care cost) credit to accommodate dental insurance premiums. Per V3, dental insurance premiums is part of care cost and not to be charged differently. V3 stated that starting January 2024 there was an increase from 30 dollars to 60 dollars on personal need allowance. Residents that are not under SSI (Supplemental Security Income) should get 60 dollars monthly. Review on R2, R3, R4, R5, R6, R7, R8, R9, and R10's resident fund accounts from January 2024 to January 2025 are as follows: R2 has the following accounting of his resident funds: Charges include dental insurance premiums of $199.36 dollars on 05/14/24, 08/05/2024, and 10/03/2024. $996.80 dollars was charged on 01/07/2025. A credit by way of reduction of care cost of $199.36 dollars was given on 12/5/24 and 01/10/25. R2's total charges or deduction on his account for dental insurance premiums resulted to $1,594.88 dollars. R2's total credit by reduction of care cost resulted to $398.72 dollars. With difference of $1,196.16 dollars charged or deducted to R2's account. R2 also has charges for Beauty Shop / Barber of $10.00 dollars on 01/10/25. R4 has the following accounting of her funds: Charges include dental insurance premiums of $199.36 dollars on 08/05/2024 and 10/03/2024. $996.80 dollars on 01/07/2025. A credit by way of reduction of care cost of $199.36 dollars on 12/05/2024 and 01/10/2025. R4's total charges or deduction on her account for dental insurance premiums resulted to $1,395.52 dollars. R4's total credit by reduction of care cost resulted to $398.72 dollars. R4 had a difference of $996.80 dollars charged or deducted to R4's fund. R5 has the following accounting of her funds: No personal needs allowance credited to resident's fund balance for 02/2024. R5 also has charges for Beauty Shop / Barber of $10.00 dollars on 02/06/2024 and 09/06/2024. R7 has the following accounting of her funds: Charges includes dental insurance premiums of $199.36 dollars on 08/05/2024 and 10/03/2024. On 1/07/2025, R7 has a charge of $996.80. A credit by way of reduction of care cost of $199.36 dollars on 12/05/2024 and 01/10/2025. R7's total charges or deduction for dental insurance premiums $1,395.52 dollars. R7's total credit by reduction of care cost resulted to $398.72 dollars, with a difference of $996.80 dollars charged or deducted to R7's fund. R8 has the following accounting of her funds: Charges includes dental insurance premiums of $199.36 dollars on 10/03/2024 and $598.08 dollars on 01/07/2025. A credit by the way of reduction of care cost of $199.36 dollars on 12/05/2024 and 01/10/2025. R8's total deduction for dental insurance premiums was $797.44 dollars. R8's total credit by reduction of care cost resulted to $398.72 dollars, with a difference of $398.72 dollars charged or deducted to R8's fund. R8 has charges for Beauty Shop / Barber of $15.00 dollars on 09/06/2024 and 01/10/2025. R9 has the following accounting of her funds: R9 has charges for Beauty Shop / Barber of $10.00 dollars on 02/06/2024. R10 have the following accounting of her funds: R10 has also charges for Beauty Shop / Barber of $10.00 dollars on 02/06/2024, 09/06/2024 and 01/10/2025. In summary, there are four (4) residents that have charges on their dental insurance premiums. The funds were deducted from the personal funds account more than what was credited. R2's dental insurance premiums total charges was $1,594.88 dollars, with a total credit in a form of care cost reduction of $398.72 dollars. R2's account has remaining charges of $1,196.16 dollars that needs to be credited back to his account. R4's dental insurance premiums total charges was $1,395.52 dollars, with a total credit in a form of care cost reduction of $398.72 dollars. R4's account has remaining charges of $996.80 dollars that needs to be credited back to her account. R7's dental insurance premiums total charges was $1,395.52 dollars, with a total credit in a form of care cost reduction of $398.72 dollars. R7's account has remaining charges of $996.80 dollars that needs to be credited back to her account. R8's dental insurance premiums total charges was $797.44 dollars, with a total credit in a form of care cost reduction of $398.72 dollars. R7's account has remaining charges of $398.72 dollars that needs to be credited back to her account. Beauty shop or barber charges: R2's resident fund account was charged $10.00 dollars on 1/10/25. R5's resident fund account was charged $10.00 dollars on 02/06/2024 and 09/06/2024. R8's resident fund account was charged $15.00 dollars on 09/06/2024 and 01/10/2025. R9's resident fund account was charged $10.00 dollars on 02/06/2024. R10's resident fund account was charged $10.00 dollars on 02/06/2024, 09/06/2024 and 01/10/2025. On 01/15/2025, at 1:50 PM, V3 (Assistant Administrator) was informed on multiple residents having discrepancies on the amount of dental insurance premium deducted compared to the care cost credited to their resident funds account. There are multiple charges of beauty shop or barber charges to multiple residents. V3 took note on those residents (R2, R4, R7 and R8) and stated that she will review each of their resident fund's account. V3 stated that with regards to barber or beauty shop charges she will check on documentation that residents have written agreement on payment of those services and will get back for answers. On 01/16/2025, at 9:23 AM, with V12 (Business Manager) after review of R2's resident fund account from January 2024 to January 2025, V12 stated, what happened was room and board or care cost accounting needs to be changed. V12 said, I will reach out to our corporate biller to adjust the money. Dental insurance premiums should come from room and board or cost of care, it should be credited back. V12 stated that she does not know how far back the corporate biller can change the audit form (resident fund account itemization). V12 was informed that R4, R7 and R8's dental premium insurance charges are also more than what were credited on their respective resident fund accounts. V12 said, Moving forward, we need to audit the whole account of all the residents. Not only those that you identified. V12 was asked, why were there different charges for dental premiums that includes an amount of $996.80 dollars instead of $199.36 dollars. V12 stated that in the past there was nobody to address the problem. Dental premiums should be taken out monthly, not an accumulation of five (5) months. At 10:25 AM, V3 (Assistant Administrator) was made aware about the concerns that were identified related to resident funds of R2, R4, R7, and R8 during conversation with V12. V3 stated that she will look into the matter. Surveyor followed up with V3 related to charges on resident funds for beauty shop or barber. On 01/16/2025, at 12:55 PM, V3 (Assistant Administrator) provided documents related to resident's haircut services that was deducted to their personal funds. In comparison, all date of services in the documents provided by V3 does not match the date of services on resident funds statement. V3 wrote the date charges were made or debited to indicate a referral date. The following discrepancies were identified: R2's resident funds statement documents that $10.00 dollars was debited to R2's account on 01/10/2025, with date of service of 01/09/2025. But the signed document by V4 (Activity Director) as a witness and without R2's signature date of service was on 12/16/2024. R5's resident funds statement documents that $10.00dollars was debited on 02/06/2024 with the same date of service of 02/06/2024. The signed document by V4 as a witness and without R5's signature date of service was on 02/01/2024. Another deduction of $10.00 dollars was made on 09/06/2024 with service date of 09/03/2024. The signed document by V4 as a witness and without R5's signature does not indicate any date. R8's resident funds statement documents that $15.00 dollars was debited to R8's account on 01/10/2025, with date of service of 01/09/2025. But the signed document by V4 (Activity Director) as a witness and without R8's signature date of service was on 12/16/2024. Another deduction of $15.00 dollars was made on 09/06/2024, with service date of 09/03/2024. document was signed by V4 as a witness and without R8's signature does not indicate any date. R9's resident funds statement documents that $10.00 dollars was debited to R9's account on 07/08/2024, with date of service of 07/06/2024. But the signed document by V4 (Activity Director) as a witness and was without R9's signature date of service was on 06/13/2024. R10's resident funds statement documents that $10.00 dollars was debited to R10's account on 02/06/2024, with the same date of service of 02/06/2024. But the signed document by R8 with a date of service was on 01/18/2024. Another deduction of $10.00 dollars was made on 09/06/2024, with service date of 09/03/2024. The signed document by R10, and the date of service was on 08/08/2024. Another deduction of $10.00 dollars was made on 01/10/2025 with service date of 01/09/2025. But the signed document by R10 with service date of 12/16/2024. V3 was informed about discrepancies on service date of resident funds statements compared to actual service done per signed documents. V3 stated that residents date of service on their personal fund does not match date of service on their signed form. V3 said It should match, I know what you mean. R2 date has like a month difference. V3 said that moving forward, the facility needs to improve their auditing on personal funds, that is why V11 (Business Manager) is there. V15 (Admission Assistant) will help V11. V3 was asked why there are charges that were signed by V4 as a witness without the signature of resident. V3 replied, They just put an X on it (pointing to R2's name on document). On 01/16/2025, at 2:59 PM, V4 (Activity Director) stated that it is her signature that appears on the document that charges residents for their haircut. V4 stated that R5 sometimes understands and sometimes does not understand. When asked if R5 can give consent on paying for his haircut from his personal fund, V4 stated that R5 agrees to have his haircut but sometimes he cannot give consent. V4 was also asked about R8's haircut and whether or not R8 agrees to pay for his haircut through his personal fund. V4 stated, R8 can give consent to get a haircut, but I am not sure if he can give consent that it will be deducted to his account. V4 stated that R8's friend knows that he will get a haircut. But she did not say to R8's friend that it will be deducted to R8's account (resident funds). Both R5 and R8 has a BIMS (Brief Interview of Mental Status) of six (6) that indicates both R5 and R8 have severe cognitive impairment. Document provided by facility that reflects charges of haircuts of multiple residents have signatures of V4 that reads witness by (signature of V4). Multiple residents that were signed by V4 does not indicate resident signatures but has charges for haircuts. On 01/14/2025, at 11:45 AM, R5 was seen in his room and during the meeting, R5 was not able to answer questions about the topic. R5 has diagnosis of vascular dementia. At 12:09 PM, R8 was seen unable to answer to questions. R8 has a diagnosis of dementia with psychotic disturbance. On 01/16/2025, at 3:15 PM, with V2 (Director of Nursing) and V3 (Assistant Administrator). V3 was made aware of R5 and R8's inability to give consent on charges of resident fund accounts due to their limitation of cognition having a BIMS score of 6. V4 was signing as a witness to charge R5 and R8 on their resident funds. V3 stated that it will be hard for R5 and R8 to see other residents having haircuts and they are not given the same. V3 was made aware that it is not the haircut or the charges on the haircut in question. But the fact that it was charged to R5 and R8's resident fund because there are many modes of payment besides charging resident funds. Residents that are not able to give consent due to limitation of cognition have representatives or family members that can provide consent. V2 (Director of Nursing) stated that she understood because it is a common practice like getting consent to start psychotropic medication or getting consent for vaccination. Resident Trust Fund Policy dated 08/11/2011, reads: The purpose is for the facility to hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility.

Based on interviews and records review, the facility failed to provide flu vaccine and education to two (R1, R11) residents of four reviewed. Findings include: R11 is a [AGE] year-old individual admitted to the facility on [DATE]. R11's medical diagnosis includes but not limited to influenza due to identified novel influenza a virus with other respiratory manifestations, type 2 diabetes mellitus with diabetic chronic kidney disease, acute respiratory failure with hypoxia, cognitive communication deficit. R11's MDS (Minimum Data Set) section C dated [DATE], documents R11's Brief Interview for Mental Status (BIMS) as ,d+[DATE] indicating R11 has intact cognitive function. MDS section GG (Functional Abilities) documents R11 requires setup or cleaning assistance with eating and oral hygiene, partial to moderate assistance with toileting and is dependent for shower/bathing, upper and lower body dressing. Hospital records dated [DATE] document R11 presented to the hospital with two-day history of coughing and dyspnea, now admitted to Obs (observation) for further management after Rapid Plasma [NAME] (RPR) test, positive for influenza A. R1 is a [AGE] year-old individual admitted to the facility on [DATE] with medical diagnosis that include but not limited to type 2 diabetes mellitus without complications, atherosclerotic heart disease of native coronary artery without angina pectoris. R1's MDS (Minimum Data Set) section C dated De 30th, 2024, documents R1's Brief Interview for Mental Status (BIMS) as ,d+[DATE] indicating R11 has intact cognitive function. MDS section GG (Functional Abilities) documents R1 requires supervision/touching assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with toileting and shower/bathing. On [DATE], at 11:26 AM, V6 (Infection Control-Registered Nurse-RN) stated flu season monitoring starts from September to May of each year per CDC (Centers for disease control) protocol. V6 further stated in September of each year, she reaches out to residents and families to get flu vaccine consents so she can start vaccinating residents against the flu. V6 stated within ,d+[DATE] hours of a resident being admitted to the facility, she goes to the resident to discuss vaccination status and find out if the resident has received their immunizations. V6 stated some residents decline or agree to the vaccine. V6 stated she is supposed to provide education on the importance of flu vaccines and follow up with the residents to make sure they understand importance and make informed decisions regarding flu vaccinations.V6 stated when R1 was in the facility, her roommate, R11 had symptoms of a flu and was not feeling well, therefore, R11 was sent to the on hospital on [DATE]/2024 and was diagnosed with the flu. R11 returned to the facility on [DATE]. V6 stated R1 was moved to another room and R11 stayed in her room in isolation until R11's symptoms cleared. V6 stated R1 did not have a flu vaccine and V6 did not document that she offered R1 a vaccine or provided education to R1 regarding importance of flu vaccine. V6 stated If it is not documented, it is not done. V6 stated she did not document refusal in residents progress notes and did not go back to offer the flu vaccines later/date. V6 stated she offered R11 a flu vaccine but did not document it in R11's medical records. R11's refusal form is in V6's binder in her office and nurses do not have access to the binder since it is in V6's office in a drawer. V6 stated she should have offered flu vaccination information to R1 and R11 and followed up to make sure R1 and R11 understood importance of getting a flu vaccine and the education and refusal should have been part of R1 and R11's medical records where all medical staff can access to the information. V6 stated its important to offer flu vaccines to the elderly residents so that they don't get very sick if they contract the flu because of their age and other medical morbidities. Review of R1 and R11's immunization records do no not document R11's consent, refusal or education of flu immunizations. Review of ,d+[DATE] Resident Influenza Vaccine Consent documents: Seasonal Flu activity can begin as early as October and as late as May. Review of Facility Policy titled Influenza Policy titled ,d+[DATE] documents: -Vaccine should be ideally administered by the end of October but should continue to be offered as long as influenza viruses are circulating locally, and unexpired vaccine is available.

Based on interview and record review, the facility failed to: a. implement care plan interventions for one resident (R2) and b. failed to ensure staff follow their job description and Driver Safety Rules for two residents (R3, R6) for three of three residents reviewed for falls in the sample of six. These failures resulted in R2 sustaining facial lacerations and R3 sustaining neck fractures. Findings include: a.11/13/2024, at 11:02 AM, V5 (Certified Nursing Assistant) via telephone, said I helped V7 (Certified Nursing Assistant) transfer R2 from shower chair to bed using a gait belt. V7 said I left the room. 11/13/2024, at 11:34 AM, V7 (Certified Nursing Assistant) said I gave R2 his shower the day he fell out of bed. V5 (Certified Nursing Assistant) helped me transfer R2 from the shower chair back to bed using a gait belt. We stood him up, turned him and someone grabbed his legs and we put him in bed.V5 left the room. V7 said I went to the window side of the bed, and rolled R2 towards me. Then, I reached over to pull the diaper out from under R2. R2 rolled towards me onto the floor. I think he hit his head on the nightstand. V7 said the bed was at working height for me, about waist high. V7 said R2 can't move from side to side. 11/13/2024, at 1:24 PM, V2 (Director of Nursing) said, staff had given R2 a shower and transferred him from shower chair to bed via mechanical lift with two persons assist. V2 said R2 can turn, so when he turned in bed, he rolled onto the floor hitting his head on the nightstand and probably the wall with the side of his face. He got some small lacerations there. V2 said now he's going to be a two person assist so that this doesn't happen again. 11/13/2024, at 2:22 PM V1 (Administrator) said, V5 and V7 showered R2 the day he fell out of bed. V5 left the room, V7 was trying to put R2's brief on, he was on the floor so fast. V1 said I told her (V7) she had to go home so that I could complete an investigation, it's part of our protocol. I spoke to V5, she said she helped V7 transfer R2 to his bed then left. V2 said I spoke with the nurse, she said he was on the floor on the mat near the window; lacerations to side of eye and above his eyebrow. V2 said I interviewed staff on unit, they were not witnesses to the incident. V7 was alone in the room by herself. The bed was raised to provide care. I went over the incident with V7. We did the reportable. We brought her back, did some re-education about bed mobility. R2's MDS (Minimum Data Set of 8/26/2024) Section GG documents (Functional Abilities and Goals) documents roll left and right as 2 or substantial/maximal assistance. R2's ADL (Activities of Daily Living) self-care performance care plan (initiated 3/19/2019) documents: Bed Mobility: The resident requires substantial/maximal assistance x2 staff for repositioning and turning in bed and as necessary. 10/25/2024, 10:30 AM, Incident Note Late Entry documents in part: CNA (Certified Nursing Assistant) called this writer for help to resident room. Upon arriving observed resident lying on the floor matt facing the window wall. Resident unable to describe occurrence. Writer assessed resident head to toe, ROM (Range of Motion) completed to all extremities, no observed injuries or discomfort. Observed abrasion on bilateral eyebrows and a small open skin bellow his right eye, and a laceration on his right index finger. Paramedics took resident to (local hospital) to be evaluated. 10/25/2024, at 10:57 AM, R2's hospital record documents in part: [AGE] year-old male presents from nursing home per (local fire department) for fall. Patient has multiple lacerations on his face and injury to his right hand inconsistent with reported history. 10/26/2024. at 7:06 AM, documents in part: patient reported as fall, but his injuries are severe and do not fit with mechanism and description by EMS (Emergency Medical Services). Patient's eyelid lacerations are technically complex and cannot be repaired by (V3). They require ophthalmology namely oculoplastic (eye doctor that specializes in treatment of conditions affecting structures that surround the eye including eyelids, eye socket, and tear drainage system) not available at this hospital. 10/25/2024, at 11:34 AM, Head CT documents in part: right periorbital (around the eye) soft tissue swelling and laceration. b. 11/12/2024, at 11:57 AM, V4 (R3's granddaughter) said R3 has a history of falls, three of them involve the facility van. V4 said per her grandmother, the facility's van driver does not properly secure R3 in the van, resulting in R3 falling two times. V4 said R3's last fall occurred on 10/28/2024, but is unclear if resident fell in van or inside hospital where resident had an appointment. V4 continued stating that someone from (local hospital) told her R3 had a fall but did not say where or when fall occurred. R3 was transferred to (local hospital) due to a neck fracture related to fall. R3 was admitted to ICU (Intensive Care Unit) at (local hospital) where he later developed pneumonia. V4 added the van driver was terminated because of other incidents. 11/13/2024, at 11:02 AM, V5 (Certified Nursing Assistant) via telephone, said I was asked to escort R3 to the hospital for a scheduled procedure. R3 was transferred in his wheelchair to the facility van by V6 (Former Bus Driver). I did not watch V6 place R3 into the van or secure R3. I did not check if R3 was secured, I assumed he was. I sat in passenger's seat in the front of the van. After V6 was done, we proceeded to the hospital. V5 continued, we got to a stop sign, V6 stopped. I heard something fall. I turned around and I saw R3 on the floor. He did not have his seatbelt on. R3 fell out of his wheelchair. V6 got R3 back into R3's wheelchair. I asked R3 if he was okay. R3 complained that his head was hurting. We proceeded to the hospital. When we got to the hospital, I registered R3 for his appointment, then told someone at the front desk about his fall in the van. I told the doctor what happened. They ordered x-rays and a CT scan. They told me R3 had a neck fracture, they were going to transfer R3 to another hospital. I was suspended for 3 days to find out what really happened. 11/13/2024, at 12:12 PM, V6 (Former Bus Driver) via telephone, said I rolled R3 into the van and secured the wheelchair with hooks that are attached to the van's floor. I did not fasten R3's seatbelt. He was sitting on a cushion and sitting towards the edge of the wheelchair. I should have repositioned him. He fell out of his wheelchair onto his butt. We (V6 and V5) got him off the floor, placed R3 back into the wheelchair. R3 was complaining of shoulder pain; that wasn't new. R3 was also complaining of back pain. After we got him back into the wheelchair, we proceeded to the hospital for R3's appointment. I told V5 to let hospital staff know about R3's fall. 11/13/2024, at 1:24 PM, V2 (Director of Nursing) said, the nurse from the hospital called to inform us that R3 was being evaluated in the emergency room because R3 had a fall in the van on the way to the hospital; V5 said R3 was complaining of neck and knee pain. V2 said R3 had fractures to C6-C7 (neck bone fractures). R3 was transferred to another hospital for treatment. V2 added we did an investigation. V5 told us V6 came to stop and R3 fell out of his wheelchair. V6 told us he could not remember if he fastened R3's seatbelt. V2 said, we know that R3's seatbelt was not secured. 11/13/2024, at 2:22 PM, V1 (Administrator) said, R3 was in facility van on the way to the hospital when R3 fell from his wheelchair in the van. V1 said R3 complained of shoulder pain that was not new. V1 said x-rays were done in the emergency room ; R3 had a neck fracture and was transferred to another hospital for treatment. V1 said she was not aware of any previous incidents of falls in the van. 10/28/2024, at 11:00 AM, R3's Nurses Note documents in part: Writer received a called from (local hospital) ER nurse in regards of a fall incident that happened when patient was being transfer(ed) to his appointment this morning. ER nurse mentioned patient was complaining of pain on his neck & right shoulder. 10/28/2024, 2:18 PM, R3's Nurses Note documents in part: Writer received a call from (local hospital) in regards of patient status after a fall, intensive care unit nurse mentioned patient will be transfer(ed) to (local hospital) in reference to a neck fracture for further treatment. ICU (Intensive Care Unit) nurse verbalized resident has a fracture between C6 to C7. Driver Safety Rules (signed by V6 on 7/31/2023) documents in part: Pull seatbelt to make sure resident is secure. Position: Bus Driver (signed by V6 on 7/28/2023) documents in part: Follows established safety policies and procedures. 11/14/22024, at 2:27 PM, V11 (Registered Nurse) said V6 told me R6 slid from wheelchair in van onto van floor; incident occurred on the way back to facility. 11/14/2024, at 3:38 PM, R6 said, I was in my wheelchair in the back of the van, my seatbelt was not fastened. R6 continued, the driver slammed on the breaks, I fell on my a**. 10/9/2024, 1:23 PM, R6's Nurses Note documents in part: Driver from facility van come to this writer to report that resident slide down from his wheelchair during the driving returning from an appointment. Resident is assessed in his room. Resident states that he slid down from the wheelchair stating: I am okay, I am bullet prof (proof), everything hurts not because I fell , because all my body hurts, except my penis. 10/9/2024, 4:45 PM, Nurse Practitioner Progress Note Late Entry documents in part: Seen for a fall. Per nurse, resident slid out of his wheelchair while driving to his appointment. The facility did not produce evidence (for past noncompliance) until later.

Based on interviews and record reviews, facility failed to follow their policy to investigate an allegation of abuse for one of three residents (R2) reviewed for abuse in the sample of six. Findings include: 11/12/2024, at 11:31 AM via telephone, V3 (Emergency Department Physician) said R2 has a known fall risk history. Injury allegedly occurred during resident care at the facility; resident rolled out of bed onto floor. V3 said per facility, R2 was already in a low bed. V3 said R2's injuries were consistent with being punched in the face, not fall from low bed. V3 added R2's eyelid laceration was too complex (involved tear duct, resident crying bloody tears) to be treated at original hospital, R2 was transferred to another local hospital for laceration repair. 11/13/2024, at 11:02 AM, V5 (Certified Nursing Assistant) via telephone, said I helped V7 (Certified Nursing Assistant) transfer R2 from shower chair to bed using a gait belt. I asked V7 if she needed help with R2, V7 said no, I left the room. 11/13/2024, at 11:34 AM, V7 (Certified Nursing Assistant) said I gave R2 his shower the day he fell out of bed. V5 (Certified Nursing Assistant) helped me transfer R2 from the shower chair back to bed using a gait belt. We stood him up, turned him and someone grabbed his legs and we put him in bed, V5 left the room. V7 said I went to the window side of the bed, and rolled R2 towards me. Then, I reached over to pull the diaper out from under R2; R2 rolled towards me onto the floor, I think he hit his head on the nightstand. V7 said the bed was at working height for me, about waist high. V7 said R2 can't move from side to side. 11/13/2024, at 2:22 PM V1 (Administrator) said, V5 and V7 showered R2 the day he fell out of bed. V5 left the room, V7 was trying to put R2's brief on, he was on the floor so fast. V1 said I told her (V7) she had to go home so that I could complete an investigation, it's part of our protocol. V1 did not say what protocol was followed when asked. V1 said I spoke to V5, she said she helped V7 transfer R2 to his bed then left. V1 continued, I spoke with the nurse, she said he was on the floor on the mat near the window, lacerations to side of eye and above eyebrow. V1 said I interviewed staff on unit, they were not witnesses to the incident. V7 was alone in the room by herself. The bed was raised to provide care. I went over the incident with V7. We did the reportable (for fall with injury). We did not do a reportable for abuse, we knew it was a fall. V1 added, we brought her (V7) back, did some re-education about bed mobility. V1's (Administrator) Witness Statement documents in part: 10/28/2024 Administrator spoke to (R2's) son and went over the interventions and how the incident happened. Also spoke about hospital('s) allegation of abuse. Facility's Abuse Prevention Program (10/2022) documents in part: Policy This Pavilion facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This will be done by implementing systems to promptly and aggressively investigate all reports and allegation of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. VII. Internal Investigation: Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of property will result in an investigation.

Based on interviews, and record reviews, the facility failed to ensure one [R2] of 3 residents were free from physical abuse. R1 clinical record indicates in part; R1 was admitted on [DATE] with the medical diagnosis of bipolar disorder with manic severe, psychotic features, restlessness, agitation, disorientation, Parkinson's Disease with dyskinesia, cognitive communication deficit, weakness, and essential hypertension. Minimum data set brief interview dated 9/4/24 scored [7] indicates R1 is moderately cognitively impaired. R1's care plan indicates in part: Abuse and Neglect 8/25/24- R1 became physically aggressive toward female peer. R1 was sent to the hospital for combative behavior, and was diagnosed with urinary tract infection, and treated with antibiotics. R1 needs verbal reminders to engage in activities due to memory deficit. R1 Progress note- 8/25/2024 11:05 Nurses Note Note Text: R1 was sitting by her room in the hallway, when writer was informed by staff that resident smack another resident [R2] that was passing by to get to her room. Writer rushed over to separate residents. Residents were separated, assessed from head to toe, no visible injuries noted. Resident [R1] has 1:1 supervision at this time. Administrator informed, Psych doctor called, and orders given to be petition out for psych evaluation, NP informed, social service informed, and family informed. R2's clinical record indicates in part: R2 was admitted on [DATE] with the medical diagnosis of Hypertensive heart disease, lack of coordination, type II diabetes, and cardiac murmur. Minimum data set brief interview dated 8/12/24 scored [6] indicates R2 is moderately cognitively impaired. R2's care plan dated 8/25/24-R2 experience physical aggression behavior toward her from a female resident. R2's progress note- 8/25/2024 13:08 Nurses Note Note Text: R2 was walking back to her room when writer was informed by staff that resident was smacked by another resident[R1] that was sitting in the hallway. Writer rushed over to separate residents. Resident stated being smacked on her cheek by resident. No complaint of pain at this time. Residents were separated, assessed from head to toe, no visible injuries noted. No complaint of pain. Administrator informed, NP informed, social service informed and family called with no answer, messaged left to please call facility back. R3's clinical record indicates in part: R3 was admitted with muscle weakness, diabetic, anemia, essential hypertension, long term use of insulin, cerebral infarction, and knee joint replacement. Minimum data set brief interview dated 8/23/24 scored [10] indicates R3 is cognitively intact. Interviews: On 9/28/24 at 10:13 AM, R1 stated, I am doing well. I don't remember hitting anyone. I like living here at this facility. I have not been abused and I feel safe here. I take my medication every day. On 9/28/24 at 10:30 AM R2 stated, R1 and I had incident a few weeks ago. I was walking from the dining room, and R1 told me to stop talking about her. I know R1 has a bad memory and is very confused, so I was trying to tell her that I was not talking about her when all the sudden R1 slapped my face. R1 is old and weak, so it did not hurt my face, or leave any marks or bruise. The incident did not make me feel bad or embarrassed. I know R1 was very confused. I never seen R1 act like that before. I did not hit her back, housekeeper and nurse ran over to R1 to calm her down. The nurse came in my room and checked me out. I was fine. The administrator [V1] offered me to move to another floor but I told her that I liked my room and floor I been living on, and I was not afraid of R1. Since R1 came back she has been so nice and pleasant, now I know if she starts saying things that is not true, I will not talk to her, I will tell the nurse. R1 cannot help it, she is so confused. I have not been abused at this facility, I feel safe here, the staff is very nice. On 9/28/24 at 10:40 AM R3 stated, I been living here for a while, and I know R1 and R2. I was in the hallway the day of the incident. R1 thought R2 was talking about her, but that was not true. When R2 tried to explain herself R1 out of nowhere slapped R2 on the cheek. Instantly the housekeeper and nurse came running. R2 did not hit R1 back, everyone knows R1 is very confused and does not know what she is doing. R1 has not hit anyone before, I was surprised that R1 hit R2. R1 went to the hospital and came back a new person. R1 is much nicer, but we know to watch out for her if she get upset. On 9/28/24 at 9:45 AM, V6 [Housekeeper] stated, I saw in the hallway R1 was accusing R2 of something and then all of the sudden, R1 slapped R2 face, and I ran over and called for the nurse to help me. R2 did not strike R1 back she walked away into her room. R1 always sits in the hallway, and I have never saw her act aggressive or hitting anyone. On 10/1/24 at 10:22 AM V9 [Registered Nurse] stated, I was R1 and R2's nurse the day of the incident. V6 [Housekeeper] came and got me and told me that R1 was physically abusive toward R2. I immediately went over to them, R2 walked away and went into her room and R1 was in the hallway talking loudly and agitated. I had staff sit with R1 while I assessed R2. She [R2] did not have any injuries, redness, or pain. R2 said R1 thought she [R2] was talking bad about her and started to argue with her [R2]. R2 said she tried to tell R1 that she was not talking about her, but suddenly R1 slapped her face. R2 said she did not hit R1 back because R1 was confused and agitated. I notified the administrator, physicians, and family member of both residents. R1 was sent out for psych evaluation, we all were so surprised because she never struck another resident here in the facility. R1 returned from the hospital stable and calm, after adjusting her medication. Prior to this incident R1 did not need close monitoring, she stayed to herself and always appeared calm. R1 does not wonder the unit or had any other signs of aggressiveness. However, now the staff monitor R1's behavior, watching for signs of agitation to prevent any other incidents. Both residents and family agreed to allow both residents to live in their same room. I received abuse training earlier this month. The abuse coordinator is the administrator, some types of abuse are physical, verbal, sexual, and mental. On 9/2/24 at 11:00 AM V4 [Licensed Practical Nurse] stated, I am familiar with R1 and R2. R1 is very confused. I was not here when the incident occurred between R1 and R2. Prior to the incident R1 did not require close supervision, she was calm and like to sit in the hallway or in her room. Since the incident, the nursing staff monitor R1 closely for any signs of aggression or agitation, so we can calm R1 down and keep her from becoming aggressive. Since her medication adjustment, R1 has been calm. On 9/28/24 at 1:22 PM, V10 [Certified Nurse Assistant] stated, I am familiar with R1 and R2. R1 did not need close monitoring, she did not have behaviors like being aggressive towards staff or other residents. I knew about the incident. We were in-serviced to monitor R1 closely and watch for any signs of agitation, or increase in confusion, and report it immediately to the nurse and or social worker for intervention and give R1 the extra support needed to prevent any other incidents. I received abuse training a few weeks ago. The abuse coordinator is the administrator. On 9/28/24 at 11:13 AM V3 [Registered Nurse/Nurse Supervisor] stated, I was not working on the day of the incident between R1 and R2. However, I heard that R1 struck R2. R1 was sent to hospital for a psychological evaluation and medication adjustment. R1 is confused. R1 does not have history hitting other residents. I have not received any other complaints about R1. R2 is alert and oriented X2-3. That was the first time R1 was aggressive towards anyone here at the facility. It has been about a month, and they get along fine, no more aggressive behaviors from R1. On 9/28/24 at 2:44 PM, V2 [Director of Nursing] stated, I assisted V1 with the investigation between R1 and R2. I spoke with other residents on the unit. They all said R1 has not hit them or been aggressive towards them in any way. R1 did not have a documented history of physical aggression. R1 did not require close monitoring, she had not been aggressive since she been here at the facility. I in-serviced the nursing staff on R1's updated care plan and to monitor her closely for sign of agitation, restlessness, and signs of urinary tract infections that my trigger R1 to become more confused and agitated. All nursing staff was in-service this month. During our staff meetings the administrator goes over abuse. R1 was sent to the hospital and treated for urinary tract infection and medications were adjusted. R1 has been calm upon her return. On 9/28/24 at 3:15 PM, V1 [Administrator] stated, R1 is a very confused resident. R1 did not have a history of physical aggression. Staff was interviewed and V6 was in the hallway when she noted R2 walking pass R1, when R1 in a loud voice said to R2 where are you going? R2 said in my room when R1 slapped R2. V6 immediately separated the two residents and called for V5[Registered Nurse] to come and help. Each resident was assessed for injuries, no injuries were noted. The physicians, and families were made aware. R1 has dementia and the behavior was triggered for no reason. At the end of my investigation, R1 was having a mental status change that provoked her to get aggressive with R2. Non-intentional abuse. R1's family and R2's family both wanted both residents to remain on the same floor. R2 and her family was okay with R1 remaining on the same floor, they both refused to move to another floor. The staff was in-serviced on watching for signs of agitation, increase in confusion, refusing care, not eating well, or refusing medication to notify the nursing staff, social worker, the physician, and myself for further interventions, such as medial testing of urine, blood work, or adjusting medication and close monitoring to prevent other incidents. During all staff meetings, the staff have an abuse in-service, annually, and all new hires. Reviewed the IDPH reportable initial and final report of 08/25/24. The facility reported incident on 8/25/24 was R1's first incident of aggression. Per interviews R1 prior to the incident did not require close monitoring/supervision. R2 did not sustain any injury and R2 denied any pain at the time of the incident. Policy documents in part: Abuse Prevention Program dated 10/2022. The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods, and services by staff or mistreatment. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior.

Based on observations, interview, and record review, the facility failed to ensure employees' personal food items were not stored in the Kitchen's walk-in cooler; failed to ensure the ceiling is not leaking and the drainage pipe is not clogged at the dishwashing area inside the kitchen in an effort to prevent food borne illnesses. These failures have the potential to affect all residents taking oral nutrition at the facility. Findings include: The (09/08/2024) census report documented that there were 204 residents at the facility. The (09/09/2024) Diet Type Report documented that there were 3 residents not taking oral nutrition at the facility. On 09/08/2024 at 9:21am, there were 4 small food baskets inside the walk-in cooler with V9's (Cook), V11's (Dishwasher), V12's (Dietary Aide), and V14's (Cook) names. V9 stated these (small food baskets) are for the Kitchen staff. They (facility) let us (Kitchen staff) keep our food in the walk-in cooler because we (Kitchen staff) don't have a place to keep our food. On 09/09/2024 at 9:43am, there was a puddle of water by the dishwashing area. V28 (Dietary Aide) stated we (kitchen staff) are running the dish machine and when the water from the dish machine gets to the drain the water goes back up. I (V28) think the drain is clogged. On 09/09/2024 at 9:46am, this observation was pointed out to V8 (Dietary Supervisor). V8 stated there should be no water on the floor because it is unsafe and unsanitary. On 09/09/2024 at 9:47am, walking towards the dish machine noted 2 buckets on the floor, directly were the water leak from the ceiling was coming from. V8 stated there is a leak on the ceiling and it is coming from upstairs (residents' floor). On 09/09/2024 at 9:55am inside the walk in cooler, this surveyor pointed out to V8 the kitchen staff's personal food baskets. V8 stated I (V8) think it should be okay if they are labeled. This surveyor inquired if V8 is aware where staff got the food items. V8 stated I (V8) don't know where staff got their food. On 09/10/2024 at 10:10am, the ceiling inside the kitchen by the dish machine was still leaking. The (09/10/2024) email correspondence with V8 (Dietary Manager) documented, in part What is the importance of not having leaks on the ceiling and not having a clogged drain in the kitchen or dishwashing room area? V8 responded 'The importance of not having leaks on the ceiling and not having a clogged drain in the kitchen or room area is free from contamination for all the equipment that we used and safe place to work. The (undated) SANITATION & FOOD SAFETY: STORAGE OF REFRIGERATED FOODS: PERSONAL FOOD ITEMS documented, in part Policy: Refrigerated food is stored in a manner that ensures food safety PROCEDURE: The facility does not allow employees to store personal food items in the dietary department refrigerators or freezers.

Based on observation, interview and record review, the facility failed to assess a resident's ability to safely self-administer medications which affected one resident (R63) when reviewed for self-administration of medications in the total sample of 76 residents and has the potential to affect all 52 residents on the 4th floor in the facility. Findings include: On 9/8/24 at 10:13 am, V22 (Registered Nurse, RN) stated that the residents on the 4th floor are primarily residents with dementia. On 9/8/24 at 11:21 am, this surveyor entered R63's room via an open door and observed R63 laying in bed. This surveyor observed a clear medicine cup containing 5 medication pills on top of the nightstand (3 drawers) near R63's bed. The clear medication cup (30 milliliters) contained the following: one round light pink pill, one round dark pink pill, 2 round brown pills, and one red capsule. This surveyor went to the doorway to the hall and requested that V24 (Certified Nursing Assistant, CNA) who was walking by to enter R63's room. This surveyor asked V24 what this is, pointing to the medication cup, and V24 stated, It's 5 pills. Yes, I do see it. This surveyor requested for V24 to send in the nurse. On 9/8/24 at 11:32 am, V22 (RN) entered R63's room, and this surveyor pointed to the clear medicine cup with 5 pills near R63. V22 stated, Yes, I (V22) see that. This surveyor and V22 reviewed the pills together by identifying the colors and amounts of 2 brown pills, 1 dark pink pill, 1 light pink pill, and 1 red capsule. When asked if V22 was able to identify these medications, V22 said, Yes and stated that the red capsule is Docusate Sodium, the 2 brown pills are Sennosides, the light pink pill is Aspirin and the dark pink pill is Metoprolol. When asked if V22 prepared these medications for R63, V22 stated, Yes, I (V22) did pass these meds this morning. They (CNAs) were changing (R63) and then I was taking care of (R196). And I forgot about (R63). V22 stated that on 9/8/24 around 9:30 am, V22 prepared R63's medications to administer to R63. V22 stated that V22 set down R63's four prepared medications in the medicine cup in R63's room and forgot to come back. When asked if R63 is able to self-administer R63's medications, V22 stated that R63 will take R63's pills by mouth with the nurse present. When asked about V22 leaving R63's prepared medications on the nightstand in R63's room with the door open, what could occur, and V22 stated, (R63) might forget to take them too. When asked if R63 is assessed to self-administer R63's medications, V22 stated that R63 is not allowed to be taking medications by R63's self and that these medications (5 pills in medicine cup) cannot be in R63's room unsupervised without a nurse. R63's Admission Record documents, in part, R63's diagnoses of dementia, adult failure to thrive, schizoaffective disorder, need for assistance with personal care, obesity, hyperlipidemia, hypertension and bipolar disorder. R63's Minimum Data Set (MDS), dated [DATE], documents, in part, that R63's Brief Interview for Mental Status (BIMS) score is a 6 which indicates that R63 has severe cognitive impairment. On 9/10/24 at 11:49 am, when asked about the process of nurses administering medication, V2 (Director of Nursing, DON) stated that the nurse will bring the medication cart close to the resident's room and prepare the medications. V2 stated that the nurse will then verify the five rights (right patient, right medication, right route, right time, and right route) during the medication preparation, and the nurse will bring the medications to the resident, explain each medication to the resident, and will give the medications to the residents. V2 stated that the nurse must ensure that the resident has swallowed the medications and need to be present to make sure (resident) really took the meds properly. When asked if medications like pills in a medicine cup are left unattended by the licensed staff (nurse) in a resident's room, V2 stated that the nurse would not know if the resident took the medication on their (residents') own as ordered, and If the resident did not take the meds, anyone could take that med. It's accessible to everyone. V2 stated, This is a safety issue. V2 stated that a medication self-administration assessment needs to be completed to confirm that a resident is cognitively competent to administer the medication unsupervised (without licensed staff present). This surveyor requested the medication self-administration assessment for R63, and V2 stated that V2 would have to check. On 9/11/24 at 9:27 am, V27 (Assistant Administrator) emailed this surveyor to respond to the follow up on V2's check for R63's medication self-administration assessment, and V27 documents, This is not applicable; (R63) is not able to administer (R63's) own medication. R63's Medication Administration Record (MAR) for September 2024 documents, in part, that R63 is ordered to receive the following medications: Aspirin 81 mg (milligram) tablet oral daily (scheduled at 9:00 am); Docusate Sodium capsule 100 mg oral twice a day (scheduled at 9:00 am); Metoprolol Tartrate tablet 25 mg oral every 12 hours (scheduled at 9:00 am); and Sennosides 8.6 mg tablet oral twice a day (scheduled at 9:00 am). Facility document titled Daily Census and dated 9/8/24 documents, in part, that 52 residents are residing on the 4th floor of the facility. Facility policy dated November 2020 and titled Administering Medications documents, in part, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so . 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safety and resident has successfully completed a competency for self-administration. Facility job description (undated) titled Registered Nurse (RN) documents, in part, The primary purpose of a Registered Nurse's position is to provide each of the residents with routine daily nursing care and services in accordance with each resident's assessments and care plan. Registered Nurse (RN) Essential Duties and Responsibilities: Works using the guidelines established from the Nurse Practice Act and Policies and Procedures and nursing judgement. Assesses, plans, and evaluates nursing care delivered to patients/residents requiring long-term or rehabilitation care. Delivers nursing care to patients/residents requiring long-term or rehabilitation care. Implements the patient/resident plan of care and evaluates the patient/resident response. Directs and supervises care given by other nursing personnel . Maintains knowledge of necessary documentation requirements . Conducts self in a professional manner in compliance with unit and facility policies.

Based on observations, interviews, and record review, the facility failed to a.) implement fall precaution interventions for two (R1, R3) residents, b.) provide adequate supervision and monitoring to prevent falls for two (R1, R2) residents, and c.) provide supervision and monitoring for four (R4, R5, R6, R7) residents during the designated smoking time to ensure residents practice safe smoking in the designated area. Theses failures resulted in R1 falling while in the facility on 07/06/2024 and sustaining a facial laceration. R1 experienced a subsequent fall while in the facility on 07/29/2024 and sustained a head contusion. R2 fell on [DATE] while in the facility and sustained an iliac crest fracture of the pelvis. Findings include: On 08/10/2024 at 8:37AM, surveyor observes a yellow sticker outside of R1's room door next to her name. R1 observed inside of her room sitting up in high fowler's position with head of bed at 90 degrees eating her breakfast meal. R1 is not interviewable. Surveyor observes R1's bed in a high position, R1's bed observed to not be in the lowest position. R1's bed observed in a high position that reaches surveyor's mid lower thigh measuring approximately 2 feet, 2 inches in height. On 08/10/2024 at 9:15AM, V6 (Certified Nursing Assistant/CNA) states the yellow sticker placed outside the resident's rooms next to their names indicates that the resident is at risk for falls. On 08/10/2024 at 9:39AM, surveyor observes a yellow sticker outside of R3's room door next to her name. R3 observed sitting up in her bed in a semi-Fowler's position with head of bed at 45 degrees. R3's primary language is Spanish and R3 is not interviewable. Surveyor observes R3's bed in a high position, R3's bed observed to not be in the lowest position. R3's bed observed in a high position that reaches surveyor's mid upper thigh measuring approximately 2 feet, 5 inches in height. On 08/10/2024 at 9:47AM, V8 (Certified Nursing Assistant/CNA) located inside of R3's room and surveyor makes V8 aware of R3's bed being in a high position. V8 observes R3's bed position and states R3's bed is not in the lowest position. V8 observed operating R3's bed and lowering R3's bed to the lowest position. R3's bed is now in a position that reaches the top of surveyor's calves measuring approximately 1 feet, 5 inches in height. V8 states with R3's bed being in a high position, R3 could have rolled out of bed, hit the floor, and fractured a bone in R3's body. R3 states she is the CNA responsible for caring for R3 but maybe the nurse came in to give R3 her medication and forgot to the lower R3's bed. On 08/10/2024 at 1:52PM, V14 (LPN) states she was the 2nd shift oncoming nurse assigned to the second floor of the facility the day R1 fell on [DATE]. V14 states she did not witness R1's fall and was informed by V13 (LPN) during change of shift report that R1 had fallen in the dining room approximately 10 minutes before 3PM. V14 states when she arrived, V13 was already in the process of taking care of everything pertaining to R1's fall. Nursing progress note dated 07/29/2024 at 3:27PM written by V13 (LPN) documents Observed R1 in a right [NAME] lying position in the dining room next to wheel chair. R1 poor historian. Observed R1 for injury. Hematoma observed to Right side of forehead. Pillow placed under R1 head. 911 call placed. R1 able to move extremities spontaneously within normal limits for resident. Vitals taken 110/64, o2 94, and bloodsugar 120. The 911 paramedics arrived to facility and transferred R1 to hospital. Call placed to Daughter. No answer. Message left. An attempt to contact V13 (LPN) was made on 08/10/2024 at 2:50PM, left voicemail, awaiting call back. On 08/10/2024 at 2:51PM, V15 (Licensed Practical Nurse/LPN) states she was alerted by the Certified Nursing Assistant/CNA assigned to the dining room monitoring shift that R2 had fallen. V15 states she cannot recall which CNA informed her but she remembers it being a male CNA. V15 states the CNA informed her that R2 had fallen while in the dining room due to R2 pushing back in his chair and R2 fell backwards. V15 states R2's wheelchair was locked while R2 was sitting in it. V15 states R2 continued to push his wheelchair backwards against the locked wheelchair until he tilted backwards and fell . V15 states upon her assessment, it felt like R2 had a lump on the back of his head. V15 states she called the doctor and sent R2 out to the hospital to be evaluated. V15 states there were two CNAs inside the dining room during the time R2 fell . V15 states one CNA pressed the call light to call for assistance and the other CNA came to inform her of R2's fall. Nursing progress note dated 07/04/2024 at 1:30PM, written by V15 (LPN) documents R2 noted sitting in lock wheelchair while trying to push self backward, he tilted wheelchair over and hit back of head on floor. Full Body assessment perform, Noted with a small bump on head. Denies pain or discomfort, No SOB, Vital signs stable. PERRLA noted, Lung sounds clear to auscultation. Abdomen soft and non-tender, Active Bowel sounds in all 4 quadrants. Active ROM on upper and lower extremities pt. tolerated well. Skin intact. Safety measures in place. Call light within reach to make needs known. Neruo Check Perform. N/P made aware of fall with order's to transfer resident to hospital for medical evaluation. POA (Daughter) made aware of fall. Will continue to monitor plan of care and document accordingly. On 08/10/20204 at 3:22PM, V16 (LPN) states she was the nurse assigned to care for R1 the day R1 fell at the facility on 07/06/2024. V16 states she was performing medication administration to the residents when a CNA reported to V16 that R1 had fallen. V16 states the CNA reported to her that R1 got up out of the wheelchair and fell . V16 states she does not recall the name of the CNA who reported this to her. V16 states upon assessing R1, R1 had an open area to the forehead and R1 was bleeding. V16 states R1 had a gash in her forehead and she cleaned R1's wound. V16 states she then called the doctor and 911 and sent R1 out to be evaluated at the local hospital. Surveyor inquires to V16 the reason residents continue to fall in the dining room while being monitored by the CNA staff. V16 states she sees the CNAs in the dining room monitoring the residents. V16 states she does not have an answer to how residents continue to fall in the dining room despite being monitored by CNAs in the facility. Nursing progress note dated 07/06/2024 at 6:46PM written by V16 (LPN) documents Writer notified per CNA staff that R1 was observed on the floor, inside of dining room. Upon further assessment, R1 was noted on the floor in supine position with acute hemorrhage to the L forehead. First aide rendered, in-house NP made aware, orders given to transfer resident via 911 to the nearest hospital. 911 initiated, and awaiting transport. ROM performed without pain/discomfort, writer remains at resident's side, awaiting transport of resident. VS: 98.0-82-130/66-97% R/A. On 08/10/2024 at 3:46PM, V17 (R1's Friend) states she comes to visit the facility at least 3-4 times a week and observed R1's bruises on her face. V17 states another resident at the facility informed her that R1 fell inside of the dining room on two separate occasions. V17 states the other resident informed her that it was at least 3 CNAs in the dining room when R1 recently fell . V17 states she witnesses the staff members in the facility on their phones while monitoring the residents in the dining room. V17 states the facility staff are not able to properly monitor the residents due to them being on their phones even with their earpieces in their ears. On 08/11/2024 at 9:45AM, V21 (Restorative Rehab Aide/CNA) located on the third floor of the facility inside of the dining room monitoring residents. V21 states she has been working at the facility since 1998. V21 states she works at the facility as a restorative rehab aide Monday through Friday and on the weekends (Saturday through Sunday) she works as a CNA at the facility. V21 states the CNA staff takes turns monitoring the dining room every thirty minutes to monitor the residents for falls, unsteady gait, and any resident altercations that may arise. On 08/11/2024 at 9:57AM, surveyor located inside of the third floor dining room and observes V21 inside of the dining room with a black bluetooth earpiece inside of her left ear. CNA assignment sheet documents that V21 was assigned to monitor the third floor dining room from 9:30AM-10:00AM. On 08/11/2024 at 11:31AM, V20 (CNA) states he was the CNA assigned to monitor the second floor dining room the day R2 fell on [DATE]. V20 states he noticed that R2 was agitated while R2 was sitting in the dining room. V20 states R2's wheelchair brakes were in the locked position. V20 states he saw R2 pushing against the table with his wheelchair brakes still locked and R2 fell backwards. V20 states he must have looked away for a second because he did not see R2 actually fall. V20 states when he turned back around, R2 was lying on the floor in the second floor dining room yelling out in Spanish. V20 states R2 yelled that he had fell and R2 called out for help. V20 states he was located in dining room when R2 fell but he was also walking around the dining room checking on other residents. V20 states he stayed with R2 while another CNA called the nurse for help. CNA assignment sheet for the second floor of the facility dated 07/04/2024 documents that V20 (CNA) was responsible for monitoring the dining room during the date and time R2 fell in the dining room. R2's Face sheet dated 08/10/2024, documents that R2 is an [AGE] year-old male with diagnoses not limited to: Cardiac arrhythmia, unspecified dementia, need for assistance with person al care, unsteadiness on feet, fracture of right ilium, repeated falls, atrial fibrillation, and osteoarthritis. R2's MDS (Minimum Data Set) dated 07/11/2024, documents that R2 has a BIMS (Brief Interview for Mental Status) of 04/15 indicating that R2 is severely cognitively impaired. R2's Activities of Daily Living (ADL) Assistance documents that R2 is dependent with sit-to-stand, and transfer. R2's MDS documents that R2 utilizes a manual wheelchair and the activity of walking 10 feet was not attempted due to R2's medical condition or safety concerns. R2's hospital records dated 07/04/2024 documents that R2 was admitted to the hospital as a result of experiencing a fall while in the facility. R2 was diagnosed with a closed fracture of the right iliac crest. R2's Fall Risk assessment dated [DATE] documents that R2 has a fall risk score of 16, indicating that R2 is at high risk for falls. Per facility reported incident dated 07/04/2024, R2 sustained a fall which resulted in a closed fracture to R2s' iliac crest while at the facility on 07/04/2024. On 08/11/2024 at 11:45AM, V20 (CNA) states he mainly works on the second floor of the facility. V20 states he remembers when R1 recently fell at the facility on 07/29/2024. V20 states it was towards the end of his shift when R1 fell in the dining room. V20 states R1 fell approximately a couple of minutes prior to the end of his shift. V20 states he was getting ready to leave since it was the end of his shift. V20 states the oncoming 2nd shift CNA staff had arrived to the second floor to relieve him so there was a lot of staff in the dining room during the time R1 fell . V20 states he cannot recall exactly who was located in the second floor dining room. V20 states he remembers at least three CNAs being present in the second floor dining room when R1 fell . V20 states the facility CNA staff changes shifts at 3PM. Surveyor asks V20 who was responsible for monitoring the second floor dining room when R1 fell . V20 states he is not really sure and suggests that surveyor refer the question to management since other CNAs had arrived and clocked in for their shift a couple of minutes earlier that day. V20 states when R1 fell on [DATE], R1 was sitting in a wheelchair closer to the back of the dining room near the TV. V20 states when he saw R1, R1 was lying on the floor.V20 states since he was in the dining room with his other co-workers, they also saw R1 lying on the floor. V20 states the nurse on duty came to assess R1 and V20 left the facility for the day. CNA assignment sheet for the second floor of the facility dated 07/29/2024 documents that V20 (CNA) was responsible for monitoring the dining room during the date and time R1 fell in the dining room. R1's Face sheet dated 08/10/2024, documents that R1 is an [AGE] year-old female with diagnoses not limited to: Cerebral infarction, contracture of right hand, unspecified fall, osteoarthritis of hips, hyperlipidemia, and atherosclerotic heart disease. R1's MDS (Minimum Data Set) dated 06/06/2024, documents that R1 has a BIMS (Brief Interview for Mental Status) of 07/15 indicating that R1 is severely cognitively impaired. R1's Activities of Daily Living (ADL) Assistance documents that R1 requires substantial/maximal assistance with sit-to-stand and transfer. R1's MDS documents that R1 utilizes a manual wheelchair and the activity of walking 10 feet was refused by R1. R1's care plan dated 07/24/2023 documents that R1 is care planned for risk for falls with intervention that includes: bed in low position. R1's hospital records dated 07/29/2024 documents that R1 was evaluated at the local hospital as a result of experiencing a fall in the facility. R1 was diagnosed with a head contusion. R1's hospital records dated 07/06/2024 documents that R1 was evaluated at the local hospital as a result of experiencing a fall in the facility. R1 was diagnosed with a facial laceration. R1's Fall Risk assessment dated [DATE] document that R1 has a fall risk score of 16, indicating that R1 is at high risk for falls. R3's Fall Risk assessment dated [DATE] documents that R3 has a fall risk score of 7, indicating that R3 is at moderate risk for falls. R3's comprehensive care plan dated 08/02/2024 documents that R3 is care planned for risk for falls and is included in the Falling Star Program. On 08/11/2024 at 12:47 PM, V19 (LPN/Fall Coordinator) states she has been the fall coordinator at the facility for about 2 years. V19 states the fall risk program includes the residents who have the yellow stickers on their room doors. V19 states this is done to make sure residents have measures in place to try and prevent falls. V19 states she is made aware of resident's falls by the nursing staff, the DON (Director of Nursing) , and other staff members calling or texting her to inform her. V19 states she was informed that R1's fall on 07/06/2024 was due to R1 attempting to get up from her chair and R1 fell . V19 states she cannot recall if R1 had stitches to her forehead, but V19 remembers that R1 had steri strips on her forehead. V19 states R1 is able to say little words at a time and is able to make her needs known, V19 states she can understand R1. V19 states R1 informed V19 that R1's fall on 07/29/2024 was due to R1 trying to reposition herself in the wheelchair. V19 states R1 fell and was found in a right side lying position in the dining room due to R1 trying to reposition herself. On 08/11/2024 at 2:25PM, V1 (Administrator) states she went to visit R1 after R1 fell on [DATE]. V1 states R1 informed her that R1 was trying to get up out of her wheelchair when she fell . V1 states she reviewed the camera footage and saw that a CNA was located in the dining room with R1 when R1 fell on [DATE] but the CNA could not reach R1 in time. V1 states R1 was evaluated by the wound care team when R1 returned from the hospital and R1 did not have any stitches. V1 states R1 only had bruises on her face. V1 states when R1 fell the second time on 07/29/24, R1 was trying to reposition herself and fell over on her side. V1 states she has received complaints about the staff members being on their phones while monitoring residents in the facility. V1 states she received a complaint approximately one week ago about staff being on their phones. V1 states she has witnessed staff members on their phones at times while working in the facility. V1 states she has even reviewed the camera footage and seen some staff members on their phones while working in the facility. V1 states she addresses it right away and brings this to the staff's attention and tells them to get off of their phones. V1 states she discusses with the staff about how being on their phones can cause distractions and that staff needs to be more involved and keep residents in their line of vision while in the dining rooms. V1 states that employees should not be utilizing their phones and earpieces should not be in staff member's ears because it is not appropriate. V1 states she explains to the staff that they cannot fully care for the residents when they are distracted by their phones and that it is also a dignity issue for the residents. V1 states when R1 fell on [DATE], she reviewed the camera footage and saw that a CNA had just wheeled R2 into the dining room and placed him at the table. V1 states R2's brakes were locked on his chair and R2 pushed himself backwards and fell . V1 states R2 grabbed the table and used all his strength and pushed himself backwards. Surveyor inquires to administrator of the reason why residents continue to fall in the dining room while being monitored by staff. V1 states most of the residents are diagnosed with dementia and their behaviors are often so unpredictable. V1 states upon hire, every employee is given the employee handbook in the facility. V1 states the staff receives the handbook electronically and each staff members signs electronically indicating that they have read and understand the employee handbook. Facility Employee Handbook dated 06/01/2024 Page 39 documents in part, personal calls and messages should not be answered during work time. R1's skin assessment dated [DATE] documents that R1 had bruising to her right eye that was identified on 07/07/2024. Facility policy dated 05/2015, titled Falls-Clinical Protocol documents in part, Treatment/Management: 1. Based on preceding assessment, he staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Facility policy dated 05/2015, titled Fall Management documents in part, Policy statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 4. For residents who have been identified at risk for falls upon admission, a care plan shall be developed which includes the resident and/or his/her family input for interventions that have or have not worked in the past. Additional interventions will be developed to promote a safe environment. The resident's individual needs for staff assistance will be assessed. Then the resident will be placed on the fall prevention program. On 08/10/2024 at 9:59AM, surveyor located on the 1st floor of the facility and observes V10 (Activity Aide) inside of the 1st floor dining room with several residents located in the dining room. Surveyor also observes an opened glass door that leads to the first floor patio adjacent to the 1st floor dining room. Surveyor observes five residents on the patio smoking and not being supervised by staff members. V10 states she is currently responsible for monitoring the residents who are smoking outside on the patio and she is responsible for monitoring the residents inside the dining room for activities and hydration. On 08/10/2024 at 10:01AM, surveyor and V10 now located outside on the 1st floor smoking patio. R4 enters the 1st floor smoking patio with two cigarettes (one behind his left ear and one in his hand) and a light green cigarette lighter in his possession. R4 observed lighting his own cigarette, places the lighter in his pocket, and begins to smoke his cigarette. Surveyor makes V10 aware of this observation and inquires to V10 about the protocol for smoking and safe smoking practices. V10 states she also observed R4 and R4 is not allowed to possess his own smoking materials and all smoking materials should be kept by the facility. V10 is now observed asking R4 to give her possession of the light green lighter that R4 placed inside of his pocket. V10 states R4 resides on the third floor of the facility so she is not sure how R4 got possession of his own smoking materials. V10 suggest that sometimes R4's family comes to visit him in the facility and brings R4 items and maybe R4's family brought cigarettes for R4 and did not tell anyone in the facility. V10 states there is potential that a resident can start a fire, get burned, and hurt themselves if a resident who is not allowed to possess their own smoking materials gets access to smoking materials. On 08/10/2024 at 10:13AM, V10 observed exiting the 1st floor dining room and leaving the smoking bin unlocked and unattended. Surveyor observes the blue, transparent, plastic bin labeled 5.92 quarts with cigarettes and lighters inside of the blue bin. Blue bin has a plastic cover on it and is observed left on a table inside of the 1st floor dining room with several residents observed sitting down in the first floor dining room. V10 enters the dining room and surveyor makes V10 aware of the smoking bin being left unlocked and unattended. V10 then states a resident could have potentially grabbed the bin and obtained access to the smoking materials. On 08/10/2024 at 10:15AM, V11 observed on the first floor smoking patio sitting in a chair. V11 states she is responsible for monitoring the residents who are smoking. V11 states she was not initially outside on the first floor smoking patio monitoring the residents during their smoke break because she was located on another floor of the facility performing showers for the residents. V11 states that there should be someone outside with the residents at all times to monitor them while they are smoking. On 08/10/2024 at 10:22AM, surveyor located on the first floor nurses station and observes the blue smoking bin behind the nurses station on the counter unlocked and unattended. V9 (Registered Nurse/RN) now located at the 1st floor nurses station and observes the blue smoking bin. V9 takes the blue lid off of the smoking bin and acknowledges that the smoking bin is unlocked and was not attended by anyone. V9 states a resident could have taken the cigarettes, began smoking them, and they could have started a fire. V9 states the smoking bin should not be left unlocked and unattended. On 08/10/2024 at 12:10PM, V12 (Social Services Director) states each social worker assigned to a floor is responsible for completing their own smoking assessment for the residents. V12 states the smoking assessments should be performed quarterly and annually, or if with a change in condition. The smoking assessment should include the designated areas to smoke, if the resident is a safe smoker, if the resident is allowed to have their own smoking materials and light their own cigarette, and if they need an apron to prevent smoking hazards. V12 states the staff members in the activities department are responsible for dispersing the resident's smoking materials and lighting their cigarettes. V12 states if a staff member notices that a resident is in possession of smoking materials, then they have to confiscate it immediately. V12 states then the social services staff educate the resident and explain the risks involved with handling their own smoking materials. V12 states R4 is not allowed to have possession of his own smoking materials or lighter. V12 states if R4 is in possession of his own smoking materials and lighter, then R4 could potentially smoke at undesignated times and in undesignated places in the facility. V12 states this could potentially cause a fire in the facility and residents could be injured. V12 states this could also cause an explosion if R4 smokes around residents with oxygen tanks. On 08/10/2024 at 12:20PM, surveyor and V12 reviews R4's smoking risk assessment dated [DATE] and V12 states R4 is supposed to have a smoking risk score. V12 states she does not see a smoking risk score on R4's assessment. V12 states R4's smoking risk assessment does not provide the required information to be included in a smoking risk assessment. V12 states since the information is missing, then R4's smoking risk assessment dated [DATE] is not complete and is not accurate. V12 states the purpose of the smoking risk assessment is to provide full detailed information about resident's smoking abilities, their risk score, where they can smoke, and if they can have their own smoking materials. R4's care plan dated 07/31/2024 documents in part, R4 is a smoker. He has been educated on the negative consequences of continued smoking due to his medical condition. R4 will not smoke without supervision through the review date. R4 will not suffer injury from unsafe smoking practices through the review date. Educate R4 about smoking risks and hazards and about smoking cessation aids that are available. Instruct R4 about the facility policy on smoking: locations, times, and safety concerns. R4 requires SUPERVISION while smoking. Notify the charge nurse immediately if it is suspected R4 has violated facility's smoking policy. R4's smoking risk assessment dated [DATE] only documents that R4 smokes tobacco. On 08/11/2024 at 10:10AM, V10 (Activity Aide) observed standing on the first floor patio while residents smoke. On 08/11/2024 at 10:08AM, V10 walks inside of the facility and away from the smoking patio. R5 then observed with a cigarette in her hand and R5 walks up to R6 while R6 is smoking his own cigarette and R5 is observed lighting her cigarette from R6's prelit cigarette. On 08/11/2024 at 10:10AM, V18 (CNA) walks onto the first floor patio and states that she will now be monitoring the first floor patio. On 08/11/2024 at 10:17AM, while V18 is outside on the first floor smpking patio, R6 then observed with a cigarette in his hand and R6 walks up to R7 while R7 is smoking his own cigarette and R6 is observed lighting his cigarette from R7's prelit cigarette. V18 states residents are not supposed to light their cigarettes with another resident's cigarette because it can cause a fire. On 08/11/2024 at 10:25AM, V10 states R7 smokes but R7 is blind and unable to see and V10 has explained to R5 and R6 that they are not allowed to light their own cigarettes from another resident's cigarette. On 08/11/2024 at 9:51AM, surveyor located on the third floor of the facility and observes that five resident rooms have signs on their doors labeled Oxygen in use. Facility policy, dated 11/09/2023, titled Smoking Policy documents in part, Policy: All residents smoking materials will be kept by the facility. Purpose: To provide a healthy and smoke safe environment for all residents, employees and visitors.7. All residents will be under supervision while smoking. A. Smoking monitors will hold lighters for ignition of cigarettes. 8. Smoking material will be kept under facility staff control. Residents are not allowed to have any smoking materials in their possession. This includes lighters, cigarettes, cigars, loose tobacco, rolling papers, chewing tobacco, pipes, and loose pipe tobacco.

Based on observation, interview and record review the facility failed to provide timely incontinence care to prevent MASD (Moisture Associated Skin Damage), failed to document skin integrity impairment, failed to obtain timely treatment orders, and failed to offload wounds for one of three residents (R2) reviewed for pressure ulcers. These failures resulted in R2 incurring (facility acquired) stage 4 sacrum pressure ulcer (with bone exposed), osteomyelitis secondary to infection, fractured S5 vertebra - in the setting of osteomyelitis, pain rated 5/10, and severe sepsis. The facility also failed to follow physician orders, failed to ensure that dressings were changed daily, failed to prevent MASD, and failed to offload wounds for R1. These failures resulted in R1 incurring a stage 4 sacrum wound with undermining (extensive damage beneath the skin surface). Findings include: On (11/27/23) IDPH (Illinois Department of Public Health) received allegations that R2 is being left in urine/feces contributing to wound development. R2 is not repositioned timely (> 2 hours). R2's dressing is not being changed on a consistent basis; on weekends the dressing is left soiled. R2 is complaining of back being broken. R2's diagnoses include dementia, mild protein-calorie malnutrition, type II diabetes mellitus, transient ischemic attack, and adult failure to thrive. R2's (11/2/23) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). R2's (11/2/23) functional assessment affirms 1 to 2 staff are required for toileting, turning and repositioning. R2's (5/30/23) care plan states resident is at risk for pressure ulcer development related to impaired mobility, incontinence, and history of pressure ulcer. Intervention: Resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. R2's (11/14/23) POS (Physician Order Sheets) include sacrum: clean with wound cleanser, apply medihoney, cover with foam dressing. Change daily and as needed. R2's progress notes include (11/13/23) dressing was changed, area above buttocks (exact location, wound description, wound stage, wound drainage, and/or wound measurements are excluded). (11/26/23) PRN (as needed) medication given 5/10 pain in buttocks. (11/29/23) Medical doctor ordered Levaquin (Antibiotic) 500 milligrams daily for 10 days due to elevated white blood cell count. (12/1/23) Resident's wound observed with a foul smell during dressing. Doctor ordered to send resident to hospital for wound evaluation. Resident admitted for sepsis at hospital. On 12/18/23, surveyor requested R2's initial wound assessment and the wound assessment prior to (12/1/23) hospital transfer. Surveyor received R2's (11/16/23) wound assessment which affirms (facility acquired) MASD. Classification: incontinence. Date identified: 11/16/23 however the (11/13/23) progress note affirms a wound was present 3 days prior. R2's (11/29/23) sacrum wound assessment affirms pressure ulceration (stage 4). Wound deteriorated, increased in size, undermining present. Peri wound with dark discoloration, mild odor present. R2's (November 2023) TAR (Treatment Administration Record) affirms sacrum treatments were documented 11/14/23 (2 days prior to initial wound assessment). R2's (12/1/23) history & physical states patient presents to the emergency department for sacral wound evaluation from the nursing home. [NAME] blood cell count 12.1 (High). Patient appears to have infected sacral wound, concern for underlying osteomyelitis. Sacral wound with exposed muscle. Pelvis CT (Computed Tomography) with signs of acute osteomyelitis. Fracture at S5 vertebra cannot exclude pathologic fracture - in the setting of osteomyelitis. Sacral decubitus ulcer coursing to the coccyx and inferior most sacrum. Of note a portion of the skin ulceration tunnels within the subcutaneous fat approximately 3 centimeters superiorly posterior to the upper coccyx and lower sacrum. There are some thin fluids within the ulceration and adjacent edema/cellulitis. Diagnosis: Severe sepsis. Sacral ulcer acute. Sacral osteomyelitis acute. On 12/18/23 at 11:17am, surveyor inquired about R2's (11/13/23) dressing change which was documented in the progress notes. V22 (Licensed Practical Nurse) stated, The CNA (Certified Nursing Assistant) told me the dressing was coming off and asked me to change it. She (R2) had a wet to dry (dressing) already on, I just put a new bandage back on. Surveyor inquired if R2 had treatment orders (on 11/13/23). V22 responded, We don't need orders for a wet to dry dressing. Surveyor inquired about the appearance of R2's (11/13/23) wound. V22 replied, I don't remember. On 12/18/23 at 12:24pm, surveyor inquired if physician orders are required for wound treatments. V15 (Wound Care Nurse) stated, A physician order is always required for wound treatment, for all wound treatment we do require physician order. Surveyor inquired when R2's skin integrity impairment was identified. V15 reviewed the electronic records and responded, On November 13 it was an area of moisture skin damage and then on the 16 it deteriorated and became stage 2 pressure sore. Before she was sent out (12/1/23) it was debrided by wound care doctor and stage 4. Surveyor inquired what causes MASD. V15 replied, Contact with urine is moisture. She (R2) had a very fragile skin, and she is incontinent. Surveyor inquired what causes dark discoloration of the peri wound. V15 stated, Pressure. Surveyor inquired what causes a stage 4 wound. V15 responded, Pressure and moisture all together plus not just that also different factors; it's a process of repositioning and history of pressure ulcer that also contributing to stage 4. Surveyor inquired what causes undermining. V15 replied, Pressure, in her (R2) case undermining was created when doctor debrided the wound. Pressure, plus moisture, plus the wound itself all together that's how her (R2) wound developed. Surveyor inquired what an odorous wound is indicative of. V15 stated, Infection. Surveyor inquired what causes osteomyelitis. V15 responded, Infection of the bone. Surveyor inquired about the appearance of R2's wound prior to 12/1/23 hospital transfer. V15 stated, It was deep, it was all the way up to the bone after debridement. __ On 11/13/23, IDPH (Illinois Department of Public Health) received allegations that R1 is not provided appropriate wound care and bed sores are deteriorating. R1's diagnoses include dementia, type II diabetes mellitus, end stage renal disease, dependence on dialysis, and pressure ulcer. R1's (11/1/23) BIMS determined a score of 5 (severe impairment). R1's (11/1/23) functional assessment affirms resident requires maximal assistance with turning/repositioning and 1-2 person assist with toileting. Upper extremity impairment (one side) and lower extremity impairment (both sides) was also noted. R1's care plan includes (10/17/23) resident is at risk for pressure ulcer development related to immobility, incontinence, type II diabetes mellitus, and failure to thrive. (11/20/23) readmitted with unstageable (coccyx/left buttock) pressure ulcers. R1's POS includes (11/20/23) skin check every shift. Turn and reposition in bed every 2 hours and as needed. Utilize foam wedges or pillow to offload pressure areas. Apply zinc oxide cream to buttocks, sacrum and perineal area every shift after incontinence care. (11/29/23) Sacrum: clean with wound cleanser, apply medihoney, pack open areas with calcium alginate, cover with foam dressing. Change daily and as needed. R1's (11/20/23) wound assessments include the following (present on admission) coccyx (unstageable) pressure ulceration. Tissue types: 40% epithelial, 15% bright pink, 45% slough loosely adherent. 4.5 x 2.5 x 0.2cm (centimeters). Left buttock (unstageable) pressure ulceration. Tissue type: slough loosely adherent 100%. 2.5 x 2.0 x 0.2cm. R1's (11/30/23) wound assessment states pressure ulcer at coccyx and left buttock are connected with undermining and therefore recalcified by wound care nurse practitioner as one wound with location at sacrum. R1's (12/7/23) sacrum wound assessment states (stage 4). Tissue types: bright beefy red 80%, slough loosely adherent 20%. 6.0 x 5.0 x 2.0cm (increased in size). On 12/12/23 at 2:07pm, R1 was lying in bed and on his back therefore the sacral wound was not off loaded. Surveyor inquired about R1's wounds. V5 (Licensed Practical Nurse) responded, I know the wound care nurse (V15) just changed his dressings and his pouch (re: colostomy) about 10, 15 minutes ago. V16 (Family) at bedside also affirmed R1's dressing was just changed. V5 removed R1's incontinence brief (as requested) and his right hip was covered with a red rash. V5 stated, He's got a rash and it's probably from the diaper, it's too tight or if it's not changed often. A (4 x 4) border dressing (dated 12/12) observed on R1's sacrum appeared clean, dry and intact. V5 removed R1's border dressing (as requested) the small open area (between the buttocks) had no treatments and/or dressing atop of the wound. The large open area on R1's right buttock appeared to be packed with a dressing however the dressing (outside the wound) had dried sangeunous drainage and was adhered to R1's skin. Surveyor inquired if the dressing packed in R1's wound appeared as if it was just changed. V5 stated, No, the dressing says 12/12 but it doesn't seem like it. It shouldn't be dry; it should be fresh. If it's open or tunneling (referring to the wounds) it should be honey or something like that and it looks dry. Surveyor inquired if a dry dressing promotes wound healing. V5 stated, No, it has no purpose. On 12/12/23 at 2:20pm, surveyor inquired about R1's treatment orders. V15 (Wound Care Nurse) stated, He has daily medihoney, calcium alginate and a dry dressing. Every morning calcium alginate and medihoney goes directly to the wound bed. Medihoney and/or zinc oxide were not present on R1's skin and or inside the border dressing. Surveyor requested to see R1's treatments. V15 responded, We don't keep them separately; we have a house supply that we use. V15 opened the treatment cart and presented wound cleanser (with R1's name), border dressings and calcium alginate. Surveyor inquired where R1's medihoney was located. V15 replied, Medihoney? I used the last, it was just a little bit left. So now Im gonna open a new one however medihoney was not available on the treatment cart at this time. R1's (December 2023) TAR (Treatment Administration Record) affirms on Saturday (12/9/23) (daily) sacrum treatments were not documented. On 12/14/23 at 2:34pm, surveyor relayed concerns regarding facility staff not following treatment orders and/or changing dressings daily as ordered. V21 (Medical Director) stated, Nursing have to take care of the patients, they have to do a better job. Surveyor inquired about potential harm to resident wounds if treatments are not followed and/or not administered daily (as ordered). V21 responded, It can get infected and make it worse. The prevention of pressure ulcer policy (revised 1/2019) states; assess the resident on admission (within 8 hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly for the first 4 weeks, then quarterly and upon any changes in condition. CNA's will inspect the skin on a daily basis when performing or assisting with personal care or ADL's. Select appropriate pressure reducing support surfaces based on resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Evaluate, report and document potential changes in the skin. If the resident refused the care, document the reason why and notify the supervisor.

Based on observation, interview and record review the facility failed to ensure (R3's) functional assessment was accurate, failed to ensure staff use proper and/or appropriate transfer techniques, failed to implement and/or revise fall care plan interventions, failed to provide supervision, and failed to obtain a timely x-ray for one of three residents (R3) reviewed for falls/IOUO (Injuries of Unknown Origin). These failures resulted in R3 sustaining acute fractures of the left lateral 7th through 9th ribs (identified 12/2/23) and pain rated 3/10. The facility also failed to implement the falls management policy, failed to document (R4's) fall, failed to notify (R4's) family/physician immediately and failed to conduct daily skin assessments. These failures resulted in R4 sustaining a large bruise to the right arm (identified 12/11/23 - by the State surveyor). Findings include: R3's diagnoses include dementia, abnormal posture, difficulty walking, transient ischemic attack, and generalized muscle weakness. The fall log affirms R3 fell on [DATE] and 11/12/23. R3's (11/12/23) incident report states informed by CNA (Certified Nursing Assistant) that resident was on the floor. Resident observed lying on the floor next to his bed with feces and urine. Resident has right side weakness due to previous stroke. No witnesses found. [R3's November 2023 pain assessments affirm pain level was rated 0 post fall]. R3's progress notes state (11/30/23) staff reported resident was unable to get up this morning due to painful area on his abdomen and chest on left side. Nurse Practitioner made aware, order chest x-ray. [Nothing was documented 11/23/23 through 11/29/23]. (12/2/23) Writer received call from hospital, resident has left lateral acute fracture on ribs 7, 8, and 9. (12/3/23) Resident noted with facial grimacing when care was being provided. PRN (as needed) medication was provided. (12/5/23) Resident noted with facial grimacing when care was being provided. PRN medication was provided. R3's (December 2023) pain assessments affirm pain level was rated 2-3. R3's (12/2/23) history & physical states patient presents to the emergency department for evaluation of a possible fall. Per EMS (Emergency Medical Service) as well as by patient, patient fell about a week ago last Saturday (11/25/23) when he was walking, lost his balance, fell towards the side and hit a table, landing over the table with his (left) side rib cage. Patient has more pain over the left side when he moves. Mild tenderness over the right lower rib cage. Worst tenderness over the left mid clavicular line lower ribcage as well as mid-axillary line. Tenderness over torso. He had too much pain with doing x-rays, given Fentanyl (Schedule II Narcotic) afterwards. On 12/13/23 at 9:51am, surveyor inquired about R3's rib fractures (identified 12/2/23). V1 (Administrator) stated, I believe he might have had an unwitnessed fall and maybe fell on the table. On 12/13/23 at 12:03pm, surveyor inquired about R3's (11/30/23) change in condition. V17 (Licensed Practical Nurse) stated, Staff reported to me that he was uncomfortable and then I went to see him (R3). I asked him (R3) you in pain? He said I don't know but he look uncomfortable and maybe were in pain. At that moment the Nurse Practitioner was there, and I can see he (R3) was no good and did not want to get up. He (Nurse Practitioner) order x-ray for the abdomen, chest and hip. I (V17) placed the order that day but I think it was the next day that they come and do the x-ray. Surveyor inquired if the x-rays were ordered STAT (on 11/30/23). V17 responded, Yes. Surveyor inquired about STAT turnaround time. V17 replied, Normally we call and say to the technician this is stat and they (technician) say we will be there as soon as possible they don't give the hour or anything like that. I remember I was calling to the x-ray and they don't answer two times. Surveyor inquired how R3 incurred an injury. V17 stated, He didn't tell me any because he doesn't look like he want to answer me. Surveyor inquired about R3's functional status. V17 responded, That day he was in a (Brand Name wheelchair) when I went to see him. They (Staff) told me he (R3) is not too stable they use a 2 or 3 people to get in the (Brand Name wheelchair). On 12/14/23 at 2:27pm, surveyor inquired about potential harm to a resident that has an unwitnessed fall. V21 (Medical Director) stated, To my knowledge we (facility staff) always report any fall and for any unwitnessed fall. We always send the patient to the emergency room for evaluation. They (residents) can have a broken bone, or they can have a bleeding in the head (a hematoma) so we always send them out. R3's (12/2/23) x-ray (obtained 2 days after pain was noted) affirms acute fractures of the left lateral 7th through 9th ribs. R3's (9/20/23) BIMS (Brief Interview Mental Status) determined a score of 7 (severe impairment). R3's (9/20/23) functional assessment states (1 person) physical assist is required for bed mobility and transfers however observation and interviews were incongruent with this assessment. R3's (12/15/22) care plan states resident is at risk of falls related to dementia, weakness, and history of falling. Interventions: one side rail placed for bed mobility and transfers. Educate on safe transfer technique, assist to bathroom as needed. Resident is able to toilet himself with one person assist. Monitor/report any changes (re: declines in function). On 12/11/23 at 12:05pm, R3 was observed (in the dining room) seated in a wheelchair, leaning towards the left side, and appeared uncomfortable. On 12/11/23 at 12:10pm, surveyor inquired when R3 was placed in the wheelchair. V8 (CNA) stated, We got him up like at 7:30(am), it took four of us (staff) to transfer him to the chair. Surveyor requested to inspect R3's incontinence brief. V7 (CNA) and V8 placed a gait belt on R3 (R3 has fractured ribs) and instructed him to stand however he (R3) was unable to do so. R3 was lifted from the chair and stated, Don't let me slip as his feet were sliding sideways on the floor. V7 and V8 proceeded to transfer R3 (instead of placing him back in the chair) and almost dropped him on the floor however his butt landed on the mattress (near the floor). R3 has a low bed made of PVC pipes which is unable to be raised and/or lowered to accommodate resident and/or staff during transfer. [R3's bed did not have side rails for bed mobility and/or transfers as stated on the care plan]. Surveyor inquired if R3 can walk. V8 stated, When I first started around 6 or 7 months ago but not now. You see we have difficulty at him holding up. Surveyor inquired if R3 is able to stand. V8 stated, No. Surveyor inquired if R3 is able to turn and/or reposition himself. V8 stated, No, he's totally care. V8 removed R3's brief which was moderately saturated with urine and contained a large bowel movement. V8 stated, He's wet and dirty. R3's (12/7/23) care plan states resident has fracture of multiple ribs of left side however supervision and/or additional fall prevention interventions (re: mechanical lift) are excluded. The accidents and incidents policy (revised 5/2015) states adequate supervision is defined by the type and frequency of supervision, based on the individual residents assessed needs and identified hazards in the resident environment. A systematic approach has been put in place to promote resident safety and reduce accident/incidents. This approach includes identification of hazards, implementation of interventions, and supervision. __ R4's diagnoses include dementia, lack of coordination, abnormalities of gait/mobility, and need for assistance with personal care. R4's (10/30.23) functional assessment affirms moderate assistance is required for dressing and maximal assistance is required for toileting. R4's (10/25/23) care plan states resident is at risk for falls related to history of falls, restlessness, and agitation. Interventions: be sure resident's call light is within reach. Ensure that resident is wearing appropriate footwear when ambulating. On 12/11/23 at 11:55am, R4 was lying in bed however the call light was on the floor and out of reach. Surveyor inquired about the location of R4's call light. V6 (CNA) stated, It's by the bed on the floor. Surveyor inquired if R4 could reach the call light. V6 responded, Not from this angle he couldn't. Surveyor observed a large bruise on R4's right arm and requested the assigned Nurse. V6 left the room (without assisting R4) and did not return. R4 sat up, put a pull-up on and walked (with slow, shuffled, unsteady gait) to the doorway (without socks and/or shoes). On 12/11/23 at 12:02pm, V4 (LPN/Licensed Practical Nurse) entered the room and assisted R4 to the bathroom. Surveyor inquired about the bruise on R4's arm. V4 responded, With the shoulder? He (R4) has a bruise over there, let me see and assessed the resident. Surveyor inquired how R4 sustained the bruise. V4 replied, I just came back from vacation and affirmed she was unsure. V4 accessed R4's EMR (Electronic Medical Records) and stated, There is no incident there, I don't see any incident put in risk management if we saw something like this (referring to R4's bruise). Nobody reported that he (R4) has a bruise. On 12/11/23, at 12:16pm, V4 (LPN) inquired how R4 sustained the bruise (R4 responded in Spanish). V4 affirmed A few days before, he (R4) remember a fall, that's what he tell me. On 12/14/23 at 12:40pm, surveyor inquired about R4's bruise. V1 (Administrator) stated, he (R4) told me that he fell and hit the wall with his arm when the CNA was taking care of the roommate. A a male Nurse had also gone into the room. We traced back to see who was working. The CNA (V20) stated, he (R4) was walking around the room bumped into the wall and slid down to the ground, she said he didn't fall. I asked the Nurse (V3) about the incident. He (V3) said, the CNA called me, I (V3) asked did he (R4) fall. She (V20) said, No. I (V1) said if he (R4) was on the floor and fell you (staff) have to do risk management. I had to educate them (V3, V20), if they (residents) crawl to the floor, you lower them to the floor, or they slide to the floor, you have to report it timely. Whoever witness the fall needs to report it to the nurse supervisor regardless of whether they witness it. The nurse needs to assess the resident, communicate with the doctor, and take orders if they (residents) need pain management or further evaluation. They (staff) have to document the incident report on the risk management on the computer. V20's (12/11/23) statement affirms R4 fell on [DATE] (5 days prior to IOUO investigation). The fall management policy (revised 5/2015) states any time a resident sustains a fall, a report of that occurrence is to be completed by the licensed nurse. The family and doctor will be notified of the occurrence. Documentation will support the monitoring, findings and actions taken. A separate accident/incident/unusual occurrence report is to be completed.

Based upon observation, interview and record review the facility failed to provide nursing care to (R6), failed to follow the abuse prevention program and failed to ensure that one of six residents (R3) in the sample remained free from abuse. R3 sustained (6/18/23) dislocated shoulder and affirmed that staff caused the injury. Findings include: On (6/20/23) IDPH (Illinois Department of Public Health) received allegations that on 6/18/23, R3's shoulder was dislocated by an unknown staff. R3's diagnoses include dementia without behavioral disturbance. R3's (5/8/23) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). R3's (5/8/23) functional assessment affirms (1 person) physical assist is required for bed mobility/locomotion. (2 persons) physical assist is required for transfers. On 6/20/23 at 1:26pm, surveyor inquired about R3's dislocated shoulder. V4 (Family) stated, I went to see him (R3) last Sunday (6/18/23) and as soon as I (V4) got off the elevator, I heard him (R3) yelling. When I (V4) went to the room there were 2 staff members in there, my dad (R3) said they hurt me and pointed at one of them (staff). I (V4) asked the guy (staff) did you do something to him (R3)? He (staff) said, I didn't touch him. My dad (R3) tells me, I can't even move my arm it hurts so bad. He (R3) was yelling, he was hurting when the guy (staff) moved his (R3) arm. I told the Nurse and all she did was give him (R3) Tylenol. He (R3) fell asleep, and I (V4) left. My brother (V11) went there (facility) a few hours later and said it doesn't even look like his (R3) shoulder was even, so he (V11) asked for him (R3) to be sent to the hospital. I called the facility, and they (staff) told me his (R3) shoulder was dislocated. R3's progress notes include (6/18/23) 5:00pm, resident visited by son (V11) with POA (Power of Attorney) on the phone, stated, the resident's (R3) right shoulder seemed injured and requested that the resident be sent to ER (emergency room ) for further evaluation. AROM (Active Range of Motion) assessed, resident incapable to move RUE (Right Upper Extremity). (6/19/23) Resident shoulder was dislocated and was placed back in hospital. On 6/20/23 at 2:08pm, R3 affirmed he speaks Spanish, therefore V5 (Certified Nursing Assistant) translated the conversation for R3. R3 responded appropriately during interview. Surveyor inquired about R3's dislocated shoulder. V5 stated, He (R3) says, somebody (staff) dislocated it, the black man. He (R3) says, he (staff) just held him from the arm and twisted it to one side. On 6/20/23 at 2:29pm, surveyor inquired about R3's dislocated shoulder. V2 (DON/Director of Nursing) stated, He (R3) did have a fall a week and a half, almost two weeks ago. When he (R3) did have the fall we sent him to the hospital, but he was not complaining about increased pain on the shoulder, they (hospital) only check if he hit his head or whatever. They (staff) sent him (to the hospital) Sunday night (6/18/23) because of increase pain in the shoulder. Surveyor advised, R3 stated staff dislocated his shoulder. V2 responded, This is my first time I (V2) heard this. Yesterday (6/19/23) that was not the case when I (V2) assess him (R3). He (R3) tries to get up on his own and tried to do things on his own then alleged that R3's dislocated shoulder was likely related to 6/6/23 fall (which occurred 12 days prior to injury) because he was taking pain medication. On 6/21/23 at 2:45pm, surveyor inquired about R3's (6/18/23) injury. V1 (Administrator) stated, We contributed it to his previous fall. When you (surveyor) interviewed him (R3) he was saying that someone twisted his arm. Surveyor inquired if staff were suspended. V2 responded, (V10 CNA/Certified Nursing Assistant) who was the CNA on Sunday was suspended yesterday (2 days after the injury). (R3) keeps going in his room and they (staff) try to keep him (R3) out of the room because he falls. I talked to (V10) to see if he (V10) touched R3 or he held him back with any type of force when transferring him. He (V10) said many times he (V10) would just put his arms out to like help him (R3) do a pivot transfer [R3 requires 2 persons assist with transfers] and he didn't complain of pain. He (V10) put the brakes on his (R3) chair, so he (R3) was holding on to the bed, and held onto it. I (V10) left him (R3) because he (R3) just keeps screaming and I (V10) don't want to have any concerns with him (R3). Surveyor inquired why R3's injury (of unknown origin) was not considered abuse. V1 replied, First we didn't know it was a dislocation, when I talked with (V2) she thought he (R3) fell recently and maybe it occurred at that time because he was requesting pain medication. R3's (6/6/23) incident report states resident was noted in the bathroom sitting on his buttock. Head to toe assessment perform with no visual injuries. Level of pain is blank. R3's (June 2023) Medication Administration Record affirms Tylenol was only documented on 6/9/23 for pain rated 3. R3's pain level was rated 0 (6/14/23 through 6/17/23) however on (6/18/23) R3's pain was rated 7 therefore likely not related to (6/6/23) fall. On 6/26/23 at 3:07pm, surveyor inquired about potential harm to other residents if an injury of unknown origin (allegedly caused by staff) is not addressed immediately. V1 replied, I seriously doubt that staff are hurting any resident. They (staff) should notify the attending and find out what they (physician) want to do and what course they want to take. The DON and the Nurses they always watch the patient and what's going on. If somebody's hurting residents let em go. We definitely need to do more watching just to see if anything of that nature happens so we can take action. __ R6's diagnoses include dementia and encounter for palliative care. R6's (5/3/23) BIMS affirms resident is rarely/never understood. R6's (5/10/23) care plan states resident has potential for abuse or neglect related to poor communication. Intervention: treat with dignity and respect. On 6/20/23 at approximately 2:15pm, R6 stated I don't feel well while surveyor was interviewing R3 (roommate). Surveyor immediately approached the Nurse's station and reported to V6 (Registered Nurse) that R6 was not feeling well. V6 subsequently entered R6's room and advised that R6's Nurse was currently off the floor. V6 then exited the room without inquiring why R6 was not feeling well, obtaining vital signs and/or offering any intervention. On 6/20/23 at 2:28pm, V2 (Director of Nursing) entered R6's room (as requested). Surveyor stated, R6 was not feeling well and V6 was made aware, however V6 neglected to address R6's concern. V2 advised she would look into it however also neglected to assess R6 at this time. R6's progress notes exclude (6/20/23) documentation. R6's physician order sheets exclude (6/20/23) orders. R6's (6/20/23) medication administration record affirms PRN (as needed) medications (Bisacodyl suppository, Lorazepam, Morphine, and/or Tylenol) were not administered. The (10/2022) abuse prevention program states in part this facility affirms the right of our residents to be free from abuse, neglect, deprivation of goods and services by staff or mistreatment. This will be done by: identifying occurrences and patterns of potential mistreatment. Identifying concerns of residents' allegation of deprivation of goods and services by staff. Immediately protecting residents involved in identified reports of possible abuse, neglect, and mistreatment The facility will take steps to prevent potential abuse while the investigation is underway. Employees of this facility who have been accused of abuse, neglect or mistreatment of resident will be removed from resident contact immediately.

Based upon interview and record review the facility failed to follow the fall management policy, failed to implement appropriate fall prevention interventions and failed to provide supervision to one of three residents (R1) reviewed for falls. These failures resulted in R1's (4/2/23) fall with laceration(s) to right side of eyebrow requiring two (2) stitches above right eyebrow and six (6) stitches below. R1's (4/19/23) fall with laceration to left side of head requiring two (2) staples. R1's (4/23/23) fall with right forehead contusion and bleeding injury which required sutures. R1's (4/30/23) fall with laceration to upper lip and hematoma to forehead. R1's (6/7/23) fall with laceration to right side of eyebrow requiring seven (7) sutures. Findings include: R1's diagnoses include dementia, generalized muscle weakness, difficulty in walking and history of falling. The (April-June 2023) facility fall log affirms R1 fell on [DATE], 4/19/23, 4/23/23, 4/30/23 and 6/7/23. On 6/17/23, R1 was transferred to the hospital (due to change in condition) and was not in the facility during this survey. R1's (5/25/23) BIMS (Brief Interview Mental Status) affirms cognitive skills for daily decision making are severely impaired. R1's (5/25/23) functional assessment affirms (1 person) physical assist is required for transfer, walking and locomotion off unit. Mobility devices: wheelchair. R1's (5/30/23) cognition care plan states resident scored 3/15 (severe cognitive impairment) on the BIMS assessment. R1's (4/2/23) incident report states staff called for help at dining room. Writer observed resident lying on the floor. Resident noted with two (2) lacerations at right side of the eyebrow. Resident unable to describe occurrence. No witnesses found. R1's (4/2/23) initial reportable incident states resident returned from the hospital (4/3/23) with 2 stitches above right eyebrow and 6 stitches below. R1's (4/19/23) incident report states CNA (Certified Nursing Assistant) called writer for help. Writer observed resident sitting on floor mattress. Laceration observed at the left side of the head. Resident confused unable to describe occurrence. No witnesses found. Incident location: resident's room. R1's (4/19/23) initial reportable incident states resident fell while attempting to walk without the wheelchair. Resident returned from the hospital (4/20/23) with 2 staples on the left side of the head. R1's (4/23/23) incident report states CNA notify that resident has a little bump on right side of forehead with little bleeding. When I go to his room, resident is seated on floor mat noted with fresh injury to forehead. CNA said she noted resident came out from the toilet, he gets up with unsteady gait and poor balance. Resident unable to report how he hit his head. No witnesses found. Incident location: resident's room. R1's (4/23/23) CT (Computed Tomography) includes indication: fall/frontal contusion. R1's (4/30/23) incident report states CNA called for help to resident room. Upon arriving observed resident lying on the floor on his back. Observed resident with small laceration at upper lip. No witnesses found. Transferred resident to hospital for medical evaluation. R1's (4/30/23) history & physical states He does have a small hematoma to his forehead. R1's (6/7/23) incident report states resident noted sitting on the floor, noted laceration to side of right eyebrow. No witnesses found. Incident location: resident's room. R1's (6/7/23) initial reportable incident states resident admitted to hospital for 24-hour observation with seven (7) sutures on his right-side forehead. R1's (2/24/23) care plan includes risk for falls. Intervention: (4/3/23) PT (Physical Therapy) evaluation and treatment. Remove footrest. (4/19/23) Environment rearranged. (4/23/23) Helmet. (4/30/23) Psychological evaluation and medication review. (6/7/23) Anti-roll back mechanism for wheelchair and non-skid socks when ambulating or mobilizing in wheelchair however frequent rounds, supervision and/or room change closer to nursing station are excluded (R1's falls were unwitnessed). V7 (LPN/Licensed Practical Nurse) documented R1's 4/2/23, 4/19/23, and 4/30/23 incident reports. On 6/21/23 at 11:29am, surveyor inquired about R1's cognitive status. V7 (LPN) stated, He's (R1) confused, definitely there's confusion but he's able to let you know if he's okay with short words. He (R1) just says yes or no. Surveyor inquired about R1's fall prevention interventions. V7 responded, He (R1) has a low bed, he has a mat to the side of the bed, he has a soft helmet and as soon as he wake up, we put him close to the nurses station to be supervised by staff. We also make rounds continuously. Surveyor inquired how R1 fell four (4) times (in the room) if staff put him close to the Nurse's station as soon as he woke up. V7 refrained from response. Surveyor inquired about R1's (4/2/23) injury .V7 reviewed the documentation and replied, Staff was telling me that this was open and immediately we had to send him to the hospital because there were 2 cuts on the (right) forehead. He come back from the hospital with stitches. Surveyor inquired about R1's (4/19/23) injury. V7 stated, That one has the laceration from the left side on the head. He (R1) had 2 staples to the left side. Surveyor inquired about R1's (4/30/23) injury. V7 responded, The injury was for small laceration on the upper lip. Surveyor inquired if it was appropriate for R1 to reside at the facility. V7 replied, We have been put all the interventions in place and the precaution to put him close to us but really sometimes when you working they fall. On 6/21/23 at 12:03pm, surveyor inquired about appropriate fall prevention interventions for R1 if his falls were unwitnessed. V2 (Director of Nursing) stated, In the room, there was no supervision when he (R1) fell . We try to keep him (R1) monitored or at least do more frequent rounds with him when he's in the room. Surveyor inquired if R1's fall care plan includes moving resident closer to the nurse's station, frequent rounds and/or supervision. V2 affirmed, it does not. Surveyor inquired about R1's (4/23/23) injury. V2 responded, Resident (R1) has a laceration on the right forehead. I believe he (R1) came back with sutures. Surveyor inquired about R1's (6/7/23) injury. V2 replied, I saw that he had a small laceration on the right eyebrow, it opened again. They put sutures on that one. Surveyor inquired how R1 sustained (6/7/23) laceration (requiring 7 sutures) if a helmet was supposed to be implemented on or about 4/23/23. V2 stated, It's literally up to here (pointing at mid forehead) but every time that he (R1) fall (pause) he is tall, the body fall on the mattress, but the head hit the floor. Surveyor inquired if it's appropriate for R1 to reside in the facility. V2 stated, When it comes to his diagnosis yes, he does have dementia and he does have seizures he just gets very confused. We will have to review if social services should be looking for a place for him that could do more with him or maybe have a dementia unit. On 6/26/23 at 3:04pm, surveyor inquired about potential harm to R1 (or other residents) post sustaining multiple unwitnessed falls. V13 (Medical Director) stated, It's not good when they (residents) keep falling but the thing is the patient (R1) is not very cooperative and he (R1) has a low bed. It can be some harm definitely, hopefully they (residents) are being watched all the time so we (staff) can prevent injury. Surveyor inquired about potential injury post falls. V13 replied, To my knowledge its mostly laceration. The fall management policy (revised 5/2015) states staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. As a fall occurs the Nurse on duty will initiate a new intervention to prevent further falls. The plan of care will be updated at this time. The revisions to the fall of care will be monitored for effectiveness and adjustments made as needed.

Based on interview and record review, the facility failed notify a resident's physician after resident's falls (R2); failed to ensure staff are aware of resident fall prevention interventions (R1); failed to implement fall prevention interventions for (R3). These failures affected (R1, R2, R3) reviewed for falls and resulted in: R2 being sent to hospital for evaluation of change in condition 14 days after falling. R2 was diagnosed with subdural hematomas (brain hemorrhages) subsequently expired. R1 fell and sustained left mandibular ramus fracture (lower jaw fracture). R3 fell and sustained a right humerus fracture (upper arm fracture) and intramuscular hematoma (bruise within the muscle). Findings include: 1) R2's medical record (Face Sheet) documents R2 is an [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: [CONDITION(S)] ([CONDITION(S)]), Dementia, Long Term (Current) Use of Aspirin, Cognitive Communications Deficit, Muscle Weakness, and Major Depressive Disorder. R2's MDS (Minimum Data Set, [DATE]) documents R2 is severely cognitively impaired and requires extensive assistance with all ADLs (Activities of Daily Living). Facility's initial incident report ([DATE]) documents R2 was sent to the hospital for evaluation due to resident change in condition. Diagnosis: Subdural Hematoma, Chronic. [DATE] at 1:35 PM, V7 (Licensed Practical Nurse-LPN) stated, she was the Nurse responsible for R2 at the time of both of R2's falls. I don't know if R2 had prior falls, but I received R2 as a fall risk. R2 kept trying to get out of bed. We were doing close monitoring. I assessed after each fall, there was no obvious injury. I notified V6 (Nurse Practitioner-NP) and family of each fall the only thing I can say is we did what we could. [DATE] at 1:12 AM, V5 (R2's Physician) stated: The patient should have gone out at that time (after first fall). I didn't find out until later (that) R2 had fallen. If I had been notified that (R2) had fallen I would have sent R2 to the hospital because the falls were unwitnessed and R2 has dementia (you don't know if resident hit head). I discussed the CT scan with the radiologist at the hospital. The subdural hematomas were chronic, and my interpretation is that they were there for at least two months. [DATE] at 3:45 PM, V6 (NP) stated: Honestly, it was 1:00 AM in the morning. They woke me up. I didn't send (R2) out. There was no bruising/pain. I heard about the subdural hematomas. I feel that they had them prior to admission to the facility. R2 was falling at home. I wish I would have sent (R2) out. I'm sure I let V5 (R2's Physician) know. R2's Death Certificate documents R2's cause of death as Complications of Intracranial Hemorrhages due to Fall. Progress Notes: On [DATE] at 2:00 AM: Resident observed with periods of confusion and steady trying to get out of bed. Resident will be monitored q1hr by writer with aide seating close to resident's room. On [DATE] at 7:45 PM: Resident noted inside of her restroom (located in bedroom) sitting on the toilet with her foley removed. On [DATE] at 6:44 AM: Resident noted with confusion and agitation in earlier part of shift. Resident requested, repeatedly, to go home, stating, When can I go home? I want to go home! Resident also attempts to transfer, independently, to the restroom, stating,I have to pee! Writer educated resident on placement and purpose of Foley catheter. Resident confused and did not understand purpose. Resident continued to ask the same questions, repeatedly. -[DATE] at 11:42 PM: At 11pm on rounds yelling called to room by cna, R2 on the floor lying flat on back stated was trying to get up slipped to the floor. Denies any pain or discomfort when asked stated did not hit head neuro check started. (V6- NP) and (family member) also notified. -[DATE] at 3:01 PM: Resident confused needs constant redirection. -[DATE] at 8:11 PM: close monitored during the shift to get out the bed redirected several times. -[DATE] at 12:48 AM: Call to room by cna on the floor (V6-NP) call informed of fall the home of (family member). -[DATE] at 12:55 AM: Post Fall evaluation: fall was unwitnessed. -[DATE] at 5:02 PM: Upon assessment noted lethargic, however responding to verbal and tactile stimuli. (V6-NP) called made aware of resident's condition. V6 ordered to send resident to local hospital. -[DATE] at 7:27 AM: Resident was transferred to (local hospital) for subdural hematoma. -,d+[DATE] at 5:30 PM: On [DATE] at 5:30 PM I had a phone conversation with the (family member) of (R2). I explained to (family member) in detail about the findings of the tests performed at (local hospital) on [DATE] including the diagnosis of subdural hematoma. According to the CT scan performed, subdural hematomas noted in (R2's) imaging were described as chronic. I also explained that subdural hematomas can occur even after a minor head injury and that the amount of bleeding can be small and develop over several weeks. This type of subdural hematoma is often seen in older adults. These may go unnoticed for many days to weeks until symptoms are more apparent. And that it (is) difficult to establish a clear-cut timeline for their onset. (Family member) verbalized understanding and was satisfied with our discussion. 2) R1's medical record (Face Sheet) documents R1 is an [AGE] year-old admitted to the facility on [DATE]. R1 has diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), History of Falling, [CONDITION(S)] Disorder, and Type 2 Diabetes Mellitus. R1's Minimum Data Set (MDS, [DATE]) documents R1 is severely cognitively impaired with continuous inattention, disorganized thinking, and altered level of consciousness. Facility's final incident report ([DATE]) documents in part, R1 sustained a fall inside their room resulting in a mandibular ramus fracture. Witness statements reveal that the resident has frequent behavior of playing with water all the time. R1's hospital record (Emergency Department Progress Note of [DATE]) documents R1 presented as trauma after ground-level fall at (Nursing Home). Found to have left mandibular fracture on imaging. On [DATE] at 9:58 AM, V8 (Registered Nurse-RN) stated, she was the nurse responsible for R1's when R1 fell on [DATE]. V8 stated R1 has a history of many recurrent falls and is known to play with water. V8 said they were doing rounds/passing medications and saw R1 was on the floor (in R1's), the water was on. V8 stated R1 could not tell V8 what happened but did tell V8 that R1 hit their head. When asked by Surveyor what fall interventions were in place for R1, V8 stated: I don't know. They're in the chart, in the Progress Notes but you would have to dig through a lot (of Progress Notes) to find them (interventions). On [DATE] at 2:48 PM, V4 (Restorative Nurse) stated, R1 is a fall risk with a history of prior falls, and behavior of playing with water (in hand sink in R1's room). V4 stated, residents' care plans are updated after each fall with interventions and staff are in-serviced. This information is kept in a binder on the units as well as the residents Kardex which is accessible to both Nurses and CNAs (Certified Nursing Assistants). V4 stated it is their expectation that staff review this information if they were not present for in-service or have questions. On [DATE] at 2:22 PM, V12 (CNA) stated she was the CNA responsible for R1's care when R1 fell on [DATE]. V12 stated, R1 plays with water at night. I saw R1 playing with water (around 1:00 AM, hand sink in R1's room). I turned off the water and put R1 back to bed. At 2:30 AM, I saw R1 standing by the sink, the water was on and had overflowed (onto the floor). I turned the water off, put R1 back to bed, and went to get a towel (to mop up the water). When I came back, (R1) was lying on the floor. When asked by Surveyor what fall interventions were in place for R1, V12 stated, R1 is not a fall risk so you can't restrain them. V4 told me I should turn the water (intake valve under the sink) off. R1's at risk for falls care plan (undated) lists as an intervention Keep environment free from clutter with unobstructed paths and dry floors. It does not list an intervention to address R1's behavior of playing with water. 3) R3's medical record (Face Sheet) documents R3 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: End Stage Renal Disease, Hypertension, [CONDITION(S)] Disease, and Type 2 Diabetes Mellitus. R3's MDS (Minimum Data Set of [DATE]) documents R3 is moderately cognitively impaired, requires extensive assistance for all ADLs (Activities of Daily Living), and has a history of falls. Facility's final incident report ([DATE]) documents R3 had an unwitnessed fall on [DATE] at approximately 6:50 PM from rolling out of bed resulting in a right humerus fracture. Hospital Record (Progress Notes of [DATE]) document R3 sustained a right humerus fracture and intramuscular hematoma after fall. [DATE] at 10:13 AM, V9 (Licensed Practical Nurse-LPN) stated: The CNA (Certified Nursing Assistant) notified me that R3 fell out of bed. R3 was face down on the floor next to the bed. We assisted R3 back to bed. There was no obvious injury, no complaint of pain, R3 was unable to verbalize how (R3) fell . I assessed R3 and called the NP (Nurse Practitioner) who told me to send R3 out to the hospital for evaluation. R3 is a fall risk. When asked by surveyor what fall precautions were in place, V9 stated: there were no fall precautions in place at the time of the fall. R3 was in a different room, a room change had recently been made. So, I'm under the assumption that all of R3's equipment was not there. R3 needed side rails and floor mats. I lowered the bed to the lowest position and had my CNA make frequent rounds (every 30 minutes). [DATE] at 2:30 PM, V10 (CNA) stated they did not remember the resident. All residents at risk for falls should have floor mats and low bed. V10 stated most times I find out that a resident is a fall risk by their wrist band. R3's at risk for falls care plan documents M-rails (side rails that aid in repositioning and sitting up) were initiated on [DATE].

Based on interview and record review, the facility failed to protect and prevent a cognitively impaired, non-verbal resident, with behaviors, from physical abuse. A Certified Nursing Assistant held a resident down against his will. As a result, R1 was noted with bruising from his left arm to his shoulder after the incident occurred. This failure affects one of three residents, (R1) in a total sample of three residents. Findings include: R1 is a [AGE] year old male resident of the facility. R1 has the following Diagnoses: [REDACTED]. R1's Brief Review of Mental Status (BIMS) notes R1 is not alert or oriented. R1 is severely cognitively impaired. R1's care plan notes the following: he speaks very little, he has behaviors that could increase the risk for potential for abuse or neglect; dementia, impaired cognition, depression, non-verbal, and history of substance abuse. He presents with signs and symptoms of depression due to memory deficits, multiple health problems, and loss of independence. Progress notes, dated 12/11/2020, notes staff reported resident has discoloration at left upper arm and bilateral hands. Staff assessed resident head to toe; discoloration to left upper arm and bilateral hands. Range of motion checked. No discomfort or grimacing noted. No further discoloration or injuries noted. Resident is unable to describe occurrence. Initial report, dated 12/11/2020, notes V3's, Former Certified Nursing Assistant (CNA), statement. On Wednesday 12/09/2020, I gave R1 a shower at 9:00AM. R1 was resistant and I sat him in the shower chair. R1 attempted to get up and I held him down to prevent him from falling. I was shaving him and he was fighting me. I just held him down until I was done. I did not have any intention of hurting him. Final report, dated 12/15/2020, notes V4 (Licensed Practical Nurse, LPN) reported to V1 (Administrator) R1 was noted by V6 (CNA) to have bruising on his left upper arm to his shoulder. On 12/14/2020, V1 interviewed fourth floor staff one by one. Cameras were reviewed. On 12/09/2020, V3 was seen taking R1 to the shower room. R1 was being resistant to enter the shower room. V3 stated that R1 was refusing him from removing his gown and he sat him on the shower chair to remove his gown and bathe him. R1 was attempting to get up and he held him down with one hand to keep him from falling. V3 states he was not trying to hurt him, but was trying to keep him from falling. He did not realize that he was using too much force and was very sorry for any harm he may have caused. The facility determined that V3 did not have the intention to hurt R1 on 12/09/2020, during the shower, but the fact that he did not report the incident to his superiors is unacceptable. Abuse is substantiated. Progress note, dated 12/17/2020, R1 was observed grimacing when touching or moving his left arm, referral to therapy for evaluation. Pain medication given. V3 could not be contacted during this investigation. On 12/31/2020,at 10:48AM, V4 stated, If a resident is combative, we are not supposed to shower them. We are supposed are to ask for help by pulling the call light. Everyone knows this. We can scream and ask for help. There is always plenty of staff in the building and someone could come to help. I worked double shift, the day of the incident. It was in evening. V6 reported to me. She was changing the resident and she noticed the bruising on his left arm. I had to make an incident report and report immediately to V1 because R1 could not let us know what happened. When I assessed him, he was not grimacing in the face. He does not know how to express himself. Staff need to talk to him when he becomes combative. On 12/31/2020 at 11:06AM, V5 (CNA) stated, If a resident becomes combative during a shower I inform the nurse. I let the resident be or try to finish the shower. If the resident cannot say if he/she wants to finish the shower, hold the resident to make sure they do not fall. I need to report to the nurse. The importance of reporting to the nurse is if the resident falls, it will be documented. On 12/31/2020 at 11:52AM, V6 stated, About three weeks ago. I was providing care to R1. I was changing him and putting him to bed. In was in the process of changing him, I saw bruising on left hand. I called V4. She came immediately. If a resident becomes combative, I will leave them if they are comfortable. I will come back and then offer shower again. When they are friendlier and try to offer again. I cannot hold the resident down. I usually pull the alarm. If I cannot leave them alone, I will call for help. On 12/31/2020 at 12:01PM, V7 (Director of Nursing) stated, I expect the CNAs to report to nurses to get more assistance. Give the combative residents more time to be redirected. If they cannot be redirected, they need to get assistance from other staff. I do not expect my staff at any time to hold down residents. The resident could be injured unknowingly. Always give the resident space. Staff are supposed to pull the call light if a resident becomes combative. R1 is a dementia resident. He is confused. He can become combative. He is redirect-able. There is a risk of injury because we wouldn't know or the type of behavior. We would not be able to do any interventions for this residents. After this incident, have two CNAs assist when showering now as an intervention. On 12/31/2020 at 12:07PM, V1 stated, If abuse is substantiated, the employee is terminated. I have never had incidents involving V3. He was aware this happened and he did not report to anyone. He stated R1 was slipping and he did not want him to slip from chair. He stated he held him. I stated he used to much force. If a resident is combative, they need to use the call light and call for help. With the dementia residents, staff need to work with them when they are more at ease. The staff do know who is going to give him/ her a harder time. While reviewing the camera footage, I saw that R1 was resistant to showering. I told him not to come. V3 should have told us what occurred. Any incident as small as it is, need to be reported. I do not expect my staff to use force at any time. I would rather the resident to miss his shower to keep him safe. My responsibility to keep residents safe, staff follow the protocols, report to IDPH (Illinois Department of Public Health) right away while I gather information, and protect the resident. Also, get the staff involved out of the building. Interventions from R1's care plan include: approach in a friendly, calm manner, treat with respect and dignity, communicate with the resident regarding to his capabilities and needs, cue, reorient, and supervise as needed, monitor, document, report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. Facility Abuse Policy, dated 01/2017, notes abuse means any physical or mental injury inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Employees are required to immediately report any occurrences of potential mistreatment they observe, hear about or suspect to a supervisor or the administrator or local police as soon as possible at the time of the occurrence.

Based on observations, record review, and interviews, the facility failed to ensure resident safety, by failing to adequately supervise a resident who was left unattended by facility staff during a resident transfer; failed to ensure that a resident transfer was conducted safely by trained facility staff; and failed to implement fall interventions to ensure resident safety. These facility failures, resulted in a fall related incident for 1 of 3 residents (R1), who sustained a thighbone fracture at the right knee, as a result of an improper transfer. Findings include: On 4/25/19, V1 (Administrator) presented documentation of a facility investigation of an incident involving R1. V1 stated, The psychologist tried to transfer (R1) and apparently couldn't hold her up, and one of my nurses came and helped to put her on the wheelchair. My DON did the investigation, but she's not here today. She'll be back tomorrow. Review of the incident reports included a facility investigation dated 4/12/19, and written by V2 (Director of Nursing) who documented, On 3/29/19 at about 10:30 AM, CNA (Certified Nurse's Aide) assisted resident to sit at side of bed. CNA went to get mechanical lift to transfer resident. Psychologist entered the room and attempted to transfer resident by himself to the wheelchair. The resident started to slip and called out. Nurse on the floor was in hallway, came in to room and assisted doctor to place resident in the wheelchair. Resident did not fall or touch the floor. On review of the diagnostic services results report dated 3/29/19, it was documented that R1 was found to have a Cortical [MEDICAL CONDITION] supracondylar region of the distal femur of the right knee. On 4/8/19, R1 was transferred from the nursing home to the hospital. According to the hospital patient information and transfer form, Patient admitted on [DATE] from nursing home. admitted for increased heart rate and altered mental status. diagnosed with [REDACTED]. On 4/25/19 at 11:35 AM, R1 was observed laying in her bed watching television. The call light was above the bed, but not within her reach. There were no fall mats on either side of the bed; and no signage or instructions to identify R1 as a fall risk resident, as required per facility policy. During an interview on 4/25/19, R1 was asked if she recalled the incident on 3/29/19. R1 stated, I fell down a couple of weeks ago. My nurse (V13-Certified Nurse's Aide) left me alone at the edge of the bed and then my doctor (V11) tried to put me on my wheelchair but he couldn't hold me up, so I must've twisted my knee or something. I screamed and screamed for help and some other guy came in (V12-Licensed Practical Nurse), and they both put me on my wheelchair. I was in pain later and I remember going to the doctor and they said I got a fracture on my leg right here (pointing to her knee area). On 4/25/19 at 11:48 AM, V7 (RN) was interviewed regarding the incident involving R1. During the interview, V7 stated, I can't tell you much about (R1) because this is my second day on the job. Asked whether there were special instructions pertaining to the care of R1, V7 stated, Not that I'm aware of. Asked if the previous nurse gave any sort of endorsement pertaining to R1, V7 stated, No. Asked if there were special instruction for R1 was to remain in bed, V1 responded, I don't know. Asked specifically if R1 was a fall risk, V7 stated, I'm not sure, like I said, I don't know her because it's my second day. On 4/25/19 at 12:05 PM, Surveyor then asked V6 (Certified Nurse's Aide) if she was the aide taking care of R1. V6 stated, Yes, I have her (R1) today. Surveyor asked if she knew anything about R1, V6 stated, Yes, I was told she fell last month I think. Surveyor asked if there was anything posted in the room or anywhere that showed R1 was a fall risk, V6 stated, No, not that I know. Asked how R1 gets moved from her bed, V6 stated, She don't like to get up. During an interview on 4/29/19 at 11:45 am, V2 (DON) stated, I did the fall investigation and based on that, I determined she did not fall. The psychologist shouldn't have transferred her. She's been here for several years and I think she's fallen maybe once a couple of years ago, but she has always been high risk for falls. She requires a mechanical lift because I know she has always had right sided weakness that puts her at risk for falls. V13 (CNA-Certified Nurse's Aide), stated during an interview on 4/29/19 at 12:08 PM, I put her at the edge of the bed and I went to get someone to help me, and next thing you know she was on her wheelchair with (V11) pushing her down the hallway. Asked why R1 was placed at the edge of the bed, V13 stated, I always do that because I have to move her to the chair. Asked if there were any special instructions on how to move or transfer R1, V13 stated, No, we always put her at the edge and then I put her on the chair with someone helping me. Asked if there were any special instructions on how to transfer R1, V13 stated, No, not that I was told. During an interview on 4/29/19 at 12:15 PM, V12 (LPN) stated, I was the nurse involved in the incident with R1. I was close to her room around 9:30 or 10:00, and I heard a loud scream saying help, help, help. So I came to the room right away, and I saw the psych doctor (V11) grabbing her around her waist trying to help her up. I quickly helped him and placed her on the wheelchair, but I never saw her fall or anything. I did get a call later from (V3-ADON) asking me if R1 ever hit the floor and I told her no, but she said the resident said she did hit the floor. On 4/29/19 at 1:09 PM, an interview was conducted with V11 (Clinical Psychologist). During the interview, V11 stated, I've been seeing (R1) for about a year now and I conduct my visits with her usually every Friday or so. When I came to see her this time, I came in to the room and she was by herself sitting at the edge of the bed, and I was concerned she was going to fall, and I was shocked she was left alone by herself. There was no one around and this concerned me, of course. R1 was unsteady and she asked me to help her to her chair, so I did, which I shouldn't have. When I tried to lift her, I immediately knew I couldn't manage her weight and she started shouting for help. The nurse came in immediately and helped, and we both helped her get on her wheelchair. She didn't fall or anything I don't recall, but it's possible I suppose, during the tense moment I struggled to keep her up, she could have twisted her knee or something. Surveyor asked V11 if there were any instructions pertaining to R1 indicating she was a fall risk, V11 stated, No. I wasn't told she was a fall risk, nor were there any type of instructions anywhere present to alert me or anyone. The facility Policy and Procedures dated 2/18 and titled Falling Star Program Policy states, Policy: To ensure that all residents determined to be at risk for falls or who have fallen are properly monitored by initiating the falling star protocol. Procedure: Residents will be identified according to initial fall screening; A yellow strip will be placed on resident's chart; A yellow strip will be placed on room number plaque of the resident's door; A yellow strip will be placed on the resident's wheelchair or walker; A yellow strip will be placed at the end of the residents bed; A yellow strip will be placed on the residents chart; Individualized care plan will be initiated and immediate intervention will be put into place; Staff will be notified of any new resident at risk for falls or who has fallen via shift report and a message posted on point of care; Recommendations and updating of individualized interventions will be implemented and documented on the resident's care plan; Program will be monitored by restorative nurse and DON.

Based on interview and record review the facility failed follow their policy and procedures to prevent a wandering resident from being physically attack involving 2 of 5 (R1, R2) residents reviewed for physical abuse. This failure resulted in R1 wandering into R2's room, where R2 physically attacked R1, R1 sustained multiple human bites and puncture wounds to upper extremities, scratches, and lacerations to the facial area. Findings include: R1 is [AGE] year old resident admitted to the facility on [DATE] for long term nursing care and rehabilitation. R1 has [DIAGNOSES REDACTED]. A Social Service screening tool to determine the presentation of abuse and/or neglect factors assessment dated [DATE] conducted by the facility social worker shows R 1 assessed as High risk for abuse and neglect. He needs to be monitored on a daily basis. Care Plans dated 7/13/18 show (R1) is a wanderer, he tends to wander in the hallways and into other residents rooms. He does sun down in the afternoon, related to disoriented to place. Impaired safety awareness. (R1)'s safety will be maintained through review date. R2 is an [AGE] year old resident with [DIAGNOSES REDACTED]. Care Plans dated 10/12/18 show (R2), History of Aggressive, Manipulative Behavior. (R2) has a history of aggressive, attention-seeking and/or manipulative behavior. The history includes conflicts/altercations with others threatening behavior, Verbal and Physical aggression. Another Care Plan dated 4/20/18 shows interventions Do not leave alone in bathroom; Dr. Called with an order for [REDACTED]. 10/17/18 interview with V2 (DON-Director of Nursing) states, Yes, I'm kind of familiar with what happened. That was considered a resident-to-resident abuse so the administrator (V1) did the investigation and reported it to your department. I will get you the report. I know the resident wandered into another resident's room and (R1) was hit, scratched and bit by (R2) that's all I really know about it. 10/17/18 interview at 12:15 PM with V5 (CNA-Certied Nurses Aide) states, I was working on the short side of the hall where (R2)'s room is. (R2) was my resident. (R1) I guess wandered into the room but I didn't see him. I just heard a noise, more like an outcry. (R2) was in the room standing by the wash basin in the room. Yes she can stand. By the time I got in the room (R1) was already outside of the room. I brought (R1) to the nurses's station to show the nurse (V5). I saw both of (R1)'s arms with scratches and teeth marks on both his arms and face. I called the nursing supervisor right away (V3). 10/17/18 interview at 12:30 PM with V3 (Nursing Supervisor) states, I was on a different floor when I heard (V5-CNA) page me to come upstairs. I did not see what happened, I was there to assess the residents. I checked (R1) and he had both arms with bite marks and it was bleeding. You can actually see the teeth marks. There were three bite marks up and down both arms and they were bleeding. I cleansed the area with normal saline and covered them with 4x4's (gauze) and wrapped up his arms. It was bad. I checked with (R2) and asked V5 (CNA) to translate for me to see if she was okay too. We know (R1) wanders around but he is very harmless, It's (R2) that is the problem. (R2) is very angry, I don't know why. Even when we try to check her blood sugar she doesn't want it and she lashes out at staff. I recall she did the same thing about a month ago and she scratched someone else (R5). Asked to describe R1's injuries, V3 stated, (R1) had about 3 or 4 bite marks on each arm. It was shaped like teeth you know, curved like your mouth, and they were deep. He had a lot of scratches too all over his arms and face and had one bite mark on his face. I called the doctor right away and I was surprised he just ordered triple antibiotic and to monitor (R1). I thought the doctor was going to send him out to get a vaccination or something. Then we called both family members of (R1) and (R2). Asked how this attack happened, V3 stated, I don't know. I didn't see it but they should have been watching him. 10/17/18 interview at 2:00 PM with V6 (RN-Registered Nurse) states, I was at the nurse's station doing charting then the CNA (V5) came to me. I went right away to the area on the far end of the short side of the hall to (R2)'s room. The nurses and I, we grabbed the hands of the male resident (R1). I saw this (altercation) from afar. I saw (R2) grabbing (R1). The CNA separated them. I went and help them separate them. I told one of the CNA's to bring (R1) back to his room and I assessed him. I saw scratches on the hands and bites on both hands and scratches on the face. I did see scratches but only on the hands. I saw bite marks, multiple bite marks. They were scantily bleeding. I paged the supervisor and she came right away. She treated the arm and did first aide. I paged the doctor and he ordered antibiotics. Asked when the last time he saw R1 walking the halls, I saw him around 5:00 I think before dinner. Asked to clarify whether he saw the incident as it occurred, V6 stated, Yes I saw it while I was sitting at the nursing station. Asked how this was possible as the attacked occurred in the room according to (V5), V6 revised his statement, I saw both in the hall but I didn't see the actual attack. Asked again how V6 responded to the incident V6 stated, I went right away and separated them. Asked to clarify if there was a second incident in the hall, V6 stated, No I meant I was separating the two residents away. Asked if R1 was given anything for pain, V6 stated, No, he didn't look like he was in pain. Asked if he were to be bitten multiple times if it would be painful, V6 stated, Yes, it probably would be painful. Asked if he heard R1 screaming, V6 stated, No I didn't hear anything. Tours conducted of the nursing floor on 10/17/18 at 11:30 AM and 10/18/18 at 10:30 AM show that the nursing station with only a clear view of the long hall but no clear view of the short hall (where the R1 walked in to R2's room) especially if sitting at the station. Records review of Nurses Note dated 10/2/18 at 8:08 PM written by V6 states, 7:45 PM Resident wandering around the floor and co-female resident in front of door of her room (hallway) scratch and bite him on his two hands and left side of the face. Separated both resident by staff. Assessment done by writer and other parts of the body no injury noted. 7:55 PM Called MD to relay the incident and MD ordered to clean with NS (normal saline) and apply triple antibiotic ointment once daily until healed all affected areas. [MEDICATION NAME] 875 mg PO BID (by mouth twice daily) x 5 days. 8:05 PM Notified resident POA (Power of Attorney). 10/17/18 interview at 3:15 PM with V7 (CNA) states, I did not witness it (the altercation) but I saw the residents on the floor after it. (R2) usually sits on the outside of her room. I saw (R1), he seemed calm but he looked upset and he looked pretty beat up. It was scary. I saw 2 bite marks on both this arms and his face was bleeding. 10/17/18 interview at 3:20 PM with V8 (CNA) states, (R2) is usually sitting outside her room a lot. She is aggressive. I saw (R1) with marks all over him but I did not see what happened. I just know she (R2) is mean. 10/17/18 interview at 3:05 PM with V9 (CNA) states, I was on break and did not see it at all. I just saw bite marks about 3 or 4 on his arms and his face was scratched up and bleeding. (R1) goes in and out of rooms, the nurses know this. I took (R1) back to his room and changed his diaper and then V6 (RN) came and saw him. Records review of Nurses Note dated 10/2/18 at 8:06 PM written by V3 (nursing supervisor) states, Notified by nurse on duty, that one of female resident attacked (R1), he was scratched in his face and teeth biting on both hands and arm which was bleeding. Staff separated both resident and applied first aid on him, when we asked (R2) stated, (R1) came to my room and was watching me. I hit him to leave me alone. Asked why not use alarm, (R2) said, I forget everything. Doctor notified and explained the situation. Order was to apply antibiotic ointment on the area and keep monitoring him. We discussed to doctor because it was teeth biting do you want us to send to hospital, he said not not necessary. Order carried out. Patients wife notified, wife will come to facility in early morning , administrator notified, keep monitoring. 10/18/18 at 11:34 AM with V10 (Physician) states, I saw (R1) the next day. I put him on antibiotics and he didn't need to go to the hospital. I saw him also nine days ago. He did go home the next day and we provided home health for him and all. Asked to describe the wounds sustained by R1, V10 stated, When I saw him nine days ago the wounds had healed. There were 5 or 6 bites on each arm. I was told by the nursing staff my patient was attacked by another resident. Asked if the puncture wounds would scar, V10 stated, Well, like I said, they are healed now but maybe they will but eventually they will heal over. Asked attack was preventable, V10 stated, I go to a lot of nursing homes and I see this often so I don't know. Asked how long it would take to R1 to have sustained all those injuries, V10 stated, Well the facility only told me about the altercation and the injuries, but I suppose getting all those injuries, (R1) must have been in the other patients room for awhile and they probably should have kept a close eye on him, I suppose. MD visit note documented on 10/3/18 at 6:17 PM states, Attending note: late entry. Patient was attack by another resident last night, patient was hit arms, bite hand and arm, A x O x 1, no agitation no fever. A human bites. Plan wound care/[MEDICATION NAME] 875 mg xd. Antibiotic ointment. Patient to be discharged today with home health. Facility policy dated 1/2017 titled Abuse Neglect, Exploitation, Prevention, Investigation, Reporting states in part, but not limited to, This facility affirms the right of our residents to be free from exploitation, mistreatment, abuse or neglect and misappropriation of resident property. Residents must not be abused by anyone, including, but not limited to , facility staff, other residents, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility, staff of other agencies serving the resident, family members, resident representative, legal guardians, friends, volunteers or other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes neglect. This assumes that all instances of abuse of all residents, irrespective of any mental or physical condition, even those in a coma, cause physical harm, pain or mental anguish. Physical abuse refers to the infliction of injury on a resident that occurs other than by accidental means this includes but is not limited to, hitting, slapping, pinching and kicking.

Based on interview and record review, the facility failed to follow their care plan interventions to monitor and supervise a resident identified to have confusion and wandering behaviors for 1 of 5 residents reviewed for supervision and safety for wandering behaviors. This failure resulted in R1 wandering into R2's room, and R2 physically assaulting R1, and R1 sustaining painful human bites and puncture wounds to upper extremities, hands, and lacerations to the facial area. Findings include: R1 is [AGE] year old resident admitted to the facility on [DATE] for long term nursing care and rehabilitation. R1 has [DIAGNOSES REDACTED]. A Social Service screening tool to determine the presentation of abuse and/or neglect factors assessment dated [DATE] conducted by the facility social worker shows R1assessed as High Risk for abuse and neglect. He needs to be monitored on a daily basis. Care Plans dated 7/13/18 show (R1) is a wanderer he tends to wander in the hallways and into other residents rooms. He does sun down in the afternoon, r/t disoriented to place, Impaired safety awareness. (R1)'s safety will be maintained through review date. R2 is an [AGE] year old resident with [DIAGNOSES REDACTED]. Care Plans dated 10/12/18 show (R2), History of Aggressive, Manipulative Behavior. (R2) has a history of aggressive, attention-seeking and/or manipulative behavior. The history includes conflicts/altercations with others threatening behavior, Verbal and Physical aggression. Another Care Plan dated 4/20/18 shows interventions Do not leave alone in bathroom; Dr. Called with an order for [REDACTED]. Per V1 (Administrator) R2 was given an involuntary/judicial admission to be transferred out to the hospital on [DATE] due to the attack she incurred to R1. Involuntary discharge petition states, Aggressive toward resident and started to teeth bit and scratch arms and face. In addition R2 had previously assaulted a prior resident (R5) on 8/22/18. Nurses Notes dated 8/22/18 at 11:45 am states,CNA attention were called by the noise in room. Upon entering the room (R5) was found on (R2)'s bed. R2 hitting R5 on the face and back. V1 was asked about the incident report for between R2 towards R5, V1 stated, I can only find the front sheet of the report we filed to your office regarding this (abuse) incident, sorry. 10/17/18 interview with V2 (DON-Director of Nursing) states, Yes, I'm kind of familiar with what happened. That was considered a resident to resident abuse so the administrator did the investigation and reported it to your department. I will get you the report. I know the resident wandered into another resident's room and (R1) was hit, scratched and bit by (R2) that's all I really know about it. 10/17/18 interview at 12:15 PM with V5 (CNA-Certied Nurses Aide) states, I was working on the short side of the hall where (R2)'s room is. (R2) was my resident. (R1) I guess wandered into the room but I didn't see him. I just heard a noise, more like an outcry. (R2) was in the room standing by the wash basin in the room. Yes she can stand. By the time I got in the room (R1) was already outside of the room. I brought (R1) to the nurses's station to show the nurse (V5). I saw both of (R1)'s arms with scratches and teeth marks on both his arms and face. I called the nursing supervisor right away (V3). 10/17/18 interview at 2:00 PM with V6 (RN-Registered Nurse) states, I was at the nurse's station doing charting, then the CNA (V5) came to me. I went right away to the area on the far end of the short side of the hall to (R2)'s room. The nurses and I, we grabbed the hands of the male resident (R1). I saw this (altercation) from afar. I saw (R2) grabbing (R1). The CNA separated them. I went and help them separate them. I told one of the CNA's to bring (R1) back to his room and I assessed him. I saw scratches on the hands and bites on both hands and scratches on the face. I did see scratches but only on the hands. I saw bite marks, multiple bite marks. They were scantily bleeding. I paged the supervisor and she came right away. She treated the arm and did first aide. I paged the doctor and he ordered antibiotics. Asked when the last time he saw R1 walking the halls, I saw him around 5:00 I think before dinner. Asked to clarify whether he saw the incident as it occurred, V6 stated, Yes I saw it while I was sitting at the nursing station. Asked how this was possible as the attacked occurred in the room according to (V5), V6 revised his statement, I saw both in the hall but I didn't see the actual attack. Asked again how V6 responded to the incident V6 stated, I went right away and separated them. Asked to clarify if there was a second incident in the hall, V6 stated, No I meant I was separating the two residents away. Asked if R1 was given anything for pain, V6 stated, No, he didn't look like he was in pain. Asked if he (V6) were to be bitten multiple times by a resident if it would be painful, V6 stated, Yes, it probably would be painful. Asked if he heard R1 screaming, V6 stated, No I didn't hear anything. Tours conducted of the nursing floor on 10/17/18 at 11:30 AM and 10/18/18 at 10:30 AM show that the nursing station with only a clear view of the long hall but no clear view of the short hall (where the R1 walked in to R2's room) especially if sitting at the station. Records review of Nurses Note dated 10/2/18 at 8:08 PM written by V6 (Registered Nurse) states, 7:45 PM Resident wandering around the floor and co female resident in front of door of her room (hallway) scratch and bite him on his two hands and left side of the face. Separated both resident by staff. Assessment done by writer and other parts of the body no injury noted. 7:55 PM Called MD to relay the incident and MD ordered to clean with NS (normal saline) and apply triple antibiotic ointment once daily until healed all affected areas. [MEDICATION NAME] 875 mg PO BID (by mouth twice daily) x 5 days. 8:05 PM Notified resident POA (Power of Attorney). 10/17/18 interview with V3 (Nursing Supervisor) states, I was on a different floor when I heard the nurses page me to come upstairs. I did not see what happened, I was there to assess the residents. I checked (R1) and he had both arms with bite marks and it was bleeding. You can actually see the teeth marks. There were three bite marks up and down both arms and they were bleeding. I cleansed the area with normal saline and covered them with 4x4's (gauze) and wrapped up his arms. It was bad. I checked with (R2) and asked V5 (CNA) to translate for me to see if she was okay too. We know (R1) wanders around but he is very harmless, It's (R2) that is the problem. (R2) is very angry, I don't know why. Even when we try to check her blood sugar she doesn't want it and she lashes out at staff. I recall she did the same thing about a month ago and she scratched someone else. Asked to describe R1's injuries, V3 stated, (R1) had about 3 or 4 bite marks on each arm. It was shaped like teeth you know, curved like your mouth, and they were deep. He had a lot of scratches too all over his arms and face and had one bite mark on his face. I called the doctor right away and I was surprised he just ordered triple antibiotic and to monitor (R1). I thought the doctor was going to send him out to get a vaccination or something. Then we called both family members of (R1) and (R2). Asked how this attack happened, V3 stated, I don't know. I didn't see it but we should have been watching him. Records review of Nurses Note dated 10/2/18 at 8:06 PM written by V3 (nursing supervisor) states, Notified by nurse on duty, that one of female resident attacked (R1), he was scratched in his face and teeth biting on both hands and arm which was bleeding. Staff separated both resident and applied first aid on him, when we asked (R2) stated, (R1) came to my room and was watching me. I hit him to leave me alone. Asked why not use alarm, (R2) said, I forget everything. Doctor notified and explained the situation. Order was to apply antibiotic ointment on the area and keep monitoring him. We discussed to doctor because it was teeth biting do you want us to send to hospital, he said not not necessary. Order carried out. Patients wife notified, wife will come to facility in early morning , administrator notified, keep monitoring. 10/17/18 interview at 3:15 PM with V7 (CNA-Certified Nurses Aide) states, I did not witness it (the altercation) but I saw the residents on the floor after it. (R2) usually sits on the outside of her room. I saw (R1), he seemed calm but he looked upset and he looked pretty beat up. It was scary. I saw 2 bite marks on both this arms and his face was bleeding. 10/17/18 interview at 3:20 PM with V8 (CNA) states, (R2) is usually sitting outside her room a lot. She is aggressive. I saw (R1) with marks all over him but I did not see what happened. I just know she is mean. 10/17/18 interview at 3:05 PM with V9 (CNA) states, I was on break and did not see it at all. I just saw bite marks about 3 or 4 on his arms and his face was scratched up and bleeding. (R1) goes in and out of rooms, the nurses know this. I took (R1) back to his room and changed his diaper and then V6 (RN) came and saw him. 10/18/18 at 11:34 AM with V10 (Physician) states, I saw (R1) the next day. I put him on antibiotics and he didn't need to go to the hospital. I saw him also nine days ago. He did go home the next day and we provided home health for him and all. Asked to describe the wounds sustained by R1, V10 stated, When I saw him nine days ago the wounds had healed. There were 5 or 6 bites on each arm. I was told by the nursing staff my patient was attacked by another resident. Asked if the puncture wounds would scar, V10 stated, Well, like I said, they are healed now but maybe they will but eventually they will heal over. Asked attack was preventable, V10 stated, I go to a lot of nursing homes and I see this often so I don't know. Asked how long it would take to R1 to have sustained all those injuries, V10 stated, Well the facility only told me about the altercation and the injuries, but I suppose getting all those injuries, (R1) must have been in the other patients room for awhile and they probably should have kept a close eye on him, I suppose. MD visit note documented on 10/3/18 at 6:17 PM states, Attending note: late entry. Patient was attack by another resident last night, patient was hit arms, bite hand and arm, axox1, no agitation no fever. A human bites. Plan wound care/[MEDICATION NAME] 875 mg xd. Antibiotic ointment. Patient to be discharged today with home health. Facility policy dated 1/2017 titled Abuse Neglect, Exploitation, Prevention, Investigation, Reporting states in part, but not limited to, This facility affirms the right of our residents to be free from exploitation, mistreatment, abuse or neglect and misappropriation of resident property. Residents must not be abused by anyone, including, but not limited to , facility staff, other residents, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility, staff of other agencies serving the resident, family members, resident representative, legal guardians, friends, volunteers or other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes neglect. This assumes that all instances of abuse of all residents, irrespective of any mental or physical condition, even those in a coma, cause physical harm, pain or mental anguish. Physical abuse refers to the infliction of injury on a resident that occurs other than by accidental means this includes but is not limited to, hitting, slapping, pinching and kicking. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, emotional distress, mental illness, or results in the deterioration of a resident's physical or mental condition. Prevention: The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents who have behaviors such as entering other residents' rooms

Based on interview and record review the facility failed to have two staff members present to to assist with the bed mobility of a depended resident high risk for fall during care. This applies to one of three residents (R6) reviewed for falls in a sample of 11. As a result, R6 was being repositioned in bed by one staff and was allowed to roll off the bed. R6 sustained a serious injury of a laceration over the right eye which required sutures. Findings include: 1. R6 face sheet includes [DIAGNOSES REDACTED]. Additional acitve [DIAGNOSES REDACTED]. According R6's (MDS) assessment dated [DATE] R6 is impairment on both sides in the upper and lower extremity. R6's restorative nursing progress noted dated 7/08/16 documented R6 needed 2 person assistance with transfers and bed mobility all the time. Remain a total assist. R6's care plan with last dates of 7/08 and 8/16/2016 identified R6 as being hat risk for fall. There was an intervention dated 7/08/2016 for R8 to have 2 person present at all times for bed mobility and transfers. Accident/Incident investigation report dated 7/15/16 documents a fall on 7/8/16 at 1:00 pm in which R6 was in supine position on the floor with bleeding coming from right face head area.5cm laceration was noted over right eye. Resident obtained four sutures over right eye with orders to remove Inservicing to staff was given and R6's assigned C.N.A (certified nurse aide) was sent home. Facility outcome of investigation included with the Accident/incident report of 7/15/16 concludes as documented in the outcome of the incident and resulting investigation,The resident(R6) is almost fetal position and is on a air mattress. The fact she was not in the middle of the bed and pillows placed properly, her lower extremities pulled her body to the floor. C.N.A was not aware On 8/19/16 at 2:15 pm and 8/23/16 at 3:00 pm, E1(Director of Nursing) and E5(Registered Nurse care plan/restorative) agreed C.N.A had used improper technique by turning R6 away rather then toward her and she should have had her centered in bed so gravity doesn't take her over. On 8/23/16 at 10:15 am Z5(Attending Physician for R6) described R6 as not able to turn self, and based on what you described it would have been avoidable fall.

Based on observation, interview and record review the facility failed to accurately assess, document and identify pressure ulcers; the facility also failed to implement preventative and healing interventions to prevent the development of new pressure ulcers and promote the healing of new pressure ulcers for 3 (R1, R3, and R5) of 5 residents reviewed for pressure ulcers in a sample of 30. This deficient practice resulted in R3 developing eschar to the right heel which then became a Stage III pressure ulcer that increased in size and also developed another Stage II pressure ulcer to the left upper buttock. R5 has a facility acquired Stage IV right heel wound, a facility acquired left buttocks abscess and a Stage IV sacral wound. 1) R3 is a [AGE] year old resident with [DIAGNOSES REDACTED]. A Laboratory Report, 10/26/12, documents a [MEDICATION NAME] of 3.1 (Normal 3.4-4.8) and a protein of 5.5 (normal 5.6-8.3). The Laboratory Report, 12/19/12, documents R3 as having heavy growth of Mecillinam Resistant [DIAGNOSES REDACTED] Aureus, moderate growth of Escherichia Coli and heavy growth of Streptococcus Pyogenes and was placed in contact isolation. The first documentation of R3's pressure ulcer to the right heel was in Nurse's Notes, 10/24/12, which noted eschar tissue to the right heel measuring 3.0 by 3.0 centimeters. R3's Comprehensive Skin Assessment, 10/24/12, documents no risk factors (this section was blank) and the development of a new site to right heel. The original Miscellaneous Weekly Skin Care Documentation Flow Sheet, provided by E5 (Treatment Nurse), documented no measurements or assessment information from 10/24/12 through 11/8/12. On 1/25/13 at 12:25 p.m., E5 stated, "I couldn't find the original form, so I amended this one." E5 then provided an amended copy of the Comprehensive Skin Assessment documenting on 11/2/12 the lesion to the right heel measuring 3.0 by 3.0 centimeters. The Wound Care Specialist Initial Evaluation, completed by Z1, 11/6/12, documents R3 with a "unstageable (due to necrosis) of the right heel." The Etiology documents the wound acquired from pressure measuring 3.0 by 3.0 centimeters. On 12/18/12, the wound care physician signed off the case and the podiatrist was consulted. The only podiatrist evaluation, 12/13/12, documents a stage 3 pressure ulcer to the right heel. The Interdisciplinary Care Plan, 9/7/12, documents R3 has an alteration in skin integrity related to Dementia, Incontinence, Decreased Sensory Perception, Diabetes and Comorbidities. Interventions include skin care to be checked during showers and routine care, heel protectors, dietary consult as needed, and nutritional supplements per dietitian recommendations. The Braden Scale, 9/17/12 and 12/7/12, documents R3 is at mild risk for the development of pressure ulcers. The facility was unable to provide documentation of skin care being checked per the care plan interventions. On 1/23/13, between 11:30am and 12:50pm, observations were made at 15 minutes intervals of R3 in his bedroom without heel protector boots on. On 1/23/13 at 12:50pm, E19 (nursing assistant) stated, "(R3) is suppose to have on heel protectors. I threw away the dirty ones when I showered R3. I am waiting for the new ones to come up. I will call down." E19 was then observed making a call to obtain the heel protectors. On 1/25/13, at 10:35 a.m., E2 (Director of Nursing) stated heel protectors are available on all units in the storage closets or in the Restorative Office. E2 also stated the staff have access to the heel protectors and they may need some training. The Physician order [REDACTED]." There are no orders in the Physician order [REDACTED]. On 1/24/13 supplement orders were obtained from the physician. The Miscellaneous Weekly Skin Care Documentation Flow Sheet documents the wound as follows: 11/2/12- 3.0 by 3.0 centimeters of necrotic tissue to the right heel pressure ulcer. 11/9/12- 3.0 by 3.0 centimeters of necrotic eschar tissue to the right heel pressure ulcer. 11/16/12- 2.7 by 3.0 of 30% necrotic tissue, 10% slough to the right heel pressure ulcer. 11/30/12- R3 was in the hospital. 12/7/12- Upon return from he hospital R3's pressure ulcer to the left heal measured 2.8 by 4.5 centimeters with 20% necrotic tissue, 20% slough. 12/14/12- 3.0 by 5.0 centimeters with 10% necrotic tissue to the right heel pressure ulcer. 12/21/12- 3.1 by 5.0 centimeters, with 10% necrotic tissue to the right heel pressure ulcer. 12/28/12- 3.2 by 5.0 centimeters with 10% necrotic tissue to the right heel pressure ulcer. 1/4/13 3.4 by 5.0 centimeters the right heel pressure ulcer. 1/11/13- 3.6 by 5.0 centimeters to the right heel pressure ulcer. 1/18/13- 3.2 by 4.3 centimeters to the right heel pressure ulcer. The Quarterly Nutrition Progress Note, 10/1/12, documents R3's skin condition as intact The Nutritional Progress Notes, 12/10/12, documents R3 has no skin breakdown The Nutritional Progress Note, 1/22/13, documents a stage 2 area to the left upper buttock with recommendations to add supplements. There is no documentation by the dietitian of the stage 3 pressure ulcer to the right heel, only the left buttock. On 1/24/13, E16 (Dietitian), stated she documents on every pressure ulcer monthly and receives a weekly skin care report. E16 stated the first note on any pressure ulcers was the 1/22/13 note. E16 further stated, "I would have started (R3) on a protein supplement had I seen there was a stage 3 pressure ulcer, even without a low protein and [MEDICATION NAME] level, to promote wound heeling. The recommendations made 1/22/13 provides an additional 30 grams of protein." On 1/24/12 at 11:35 a.m., E2 (Director of Nursing) stated, the dietician is notified weekly of pressure ulcers. On 1/23/12 at 11:20 a.m., E5 stated R3's only pressure ulcer was to the right heel. R3's Comprehensive Skin Assessment, 1/19/13, documents the development of a new pressure ulcer, stage 2, to the left upper buttock area measuring 1.2 by 0.9 centimeters. On 1/25/13 at 11:30 a.m., Z1(wound physician) was interviewed by phone and indicated he was out of town and without access to documentation he was unable to provide responses to questions regarding the care of R3. The facility policy, 8/11, Pressure Ulcer Prevention/Skin Care, documents 3. Protocol for prevention of pressure ulcers guidelines will be followed for all at-risk residents (moderate, high or severe). Moderate Risk, 1. Quarterly review of nutritional status and more frequently if indicated and 3. Nutritional supplement as indicated per recommendation of dietician and physician's orders [REDACTED]. 2. On 1/22/12 at 10:00 a.m. the facility provided a copy of the facility ' s current pressure ulcer report. R1 was not listed on the report. On 1/23/13 at 10:15 a.m., E5 (Wound Care Nurse/Licensed Practical Nurse, LPN) was asked if R1 has any pressure ulcers? E5 stated that R1 does not have any pressure ulcers. R1 was lying in bed. Visualization of R1 ' s buttocks revealed two pressures ulcers to the right buttock. The wounds with opened, and the wound bed was reddened. R1 ' s peri-wound (surrounding tissue) was macerated. Located over the bottom most ulcer was a [MEDICATION NAME] dressing that was rolled up and peeling at the edges. E5 stated " Oh this is new, it wasn't ' t there before. " E5 stated she had worked the previous day (1/21/13) and R1 did not have a pressure ulcer. R1 ' s physician's order [REDACTED]. There was no documentation in R1 ' s medical record related to the two wounds on R1 ' s right buttock. There were no treatment orders located in R1 ' s medical records for the pressure ulcers. E5 stated that the facility ' s policy is for nurses to notify the physician immediately and obtain wound care orders. E5 stated " I will call the doctor and get an order. " E5 then stated she will measure the wounds. With assistance from E7 (Certified Nursing Assistant, C.N.A), E5 measured the wounds and stated the measurements are as follows: Upper most wound 0.2 X 0.1cm; lower most wound 2.2 X 1.3cm. E5 stated " the night nurse is still here, maybe she put it ([MEDICATION NAME] dressing) there. " At 10:25 a.m., E6 (Registered Nurse, RN) was sitting at the desk. E6 stated that she worked with R1 on the night shift (1/22/13). E6 stated that R1 does not have any pressure ulcers. At 11:00 a.m., E5 returned with a typed document stating these are the physician ' s notes. E5 now states, " I forgot, we noticed it yesterday " . E5 refused to give the surveyor the documentation and stated " this is mine, I will get you one " . E5 was asked to provide the nursing (wound care) documentation, the original physician ' s documentation and physician's order [REDACTED]. E5 stated she doesn't ' t have access to the computer, and would not provide the information. On 1/24/13 at 9:15 a.m., there was still no documentation in R1 ' s medical records related to the 2 pressure ulcers. There were no documented physician's order [REDACTED]. E5 stated " I ' m going to write the order. " E5 then stated she didn't ' t have time to complete the wound care documentation. E5 then documented a physician's order [REDACTED]. On 1/29/13 at 11:52 a.m., R1 ' s care plan still had not reflected the wound that was healed on 1/14/13 or the new wound currently being treated. E5 stated she had not had a chance to document on either incident. On 1/30/13 at 9:50 a.m., R1 ' s care plan was still not updated. E5 again stated she has not had time to update the care plan. Z1 was informed at 9:53 a.m. and stated " she has not done it, and she is going to do it. " 3. Minimum Data Set (MDS) for R5 dated 11/6/12 shows an [AGE] year old resident at high risk for pressure sore requiring total staff assist for transfer and extensive assist for bed mobility. Weekly Wound report dated 1/11/13 reveals R5 has a facility acquired Stage IV right heel wound, a facility acquired left buttocks abscess and a Stage IV sacral wound. The physician's orders [REDACTED]. Review of R5's clinical record reveals no Care Plan for alteration in skin integrity. During the initial tour of the facility on 1/22/13 at approximately 10:00 a.m., R5 was observed in her room, lying supine in a low bed under the covers, awake, alert and oriented, complaining of not wanting to be in the facility. R5's bilateral heel were in direct contact with the mattress. R5 stated she does not want to get out of bed today. There was a urinary catheter in place. At 2:30 p.m., R5 was observed in the dining room, sitting in a wheelchair with a sad look on her face. On 1/23/13 at approximately 11:30 a.m., R5 was in her wheelchair in her room. E5 (Treatment Nurse) was present and was asked by surveyor to assess R5's right heel wound. R5's sock was removed and there was no dressing on the right heel. E5 proceeded to conduct wound assessment of the right heel and stated the wound is open and healing. E5 stated she will apply a collagen dressing and contact the physician for a change in treatment order. E5 applied collagen and [MEDICATION NAME] dressing and covered right heel wound with border gauze. E5 was asked to provide the current treatment administration record (TAR) for R5 but was unable to locate it. R5 was transferred to the dining room for lunch. On 1/24/13 at approximately 10:00 a.m., E2 (Director of Nursing-DON) provided survey team with a current treatment order for treatment to the right heel every three days. Neither E1 (Administrator) nor E2 (DON) were able to explain why treatment order was not available nor accessible on the previous day. On 1/23/13 at 1:25 p.m., R5 was observed being transferred from wheelchair to bed with 2 person physical assist. R5 was being assisted by E13 (Certified Nurses Aid-CNA) and E14 (CNA). R5 was moaning and complaining of "my butt hurts terribly". Once in bed, E13 and E14 proceeded to provide incontinent care for R5. There was an undated dressing on R5's sacral area. The dressing was soiled and of poor integrity. E13 and E14 completed the incontinent care, failing to apply protective barrier cream to R5's perineum. R5 was placed on multiple layers of linen, a draw sheet folded in four under the incontinent pad. E13 stated R5 usually has draw sheet and incontinent pad on her bed. R5 was made comfortable in bed, E13 and E14 left the room. R5's heel were not off loaded. Facility Pressure Ulcer policy dated 8/11 states all residents at risk for pressure sore should have moisture barrier cream applied as needed. On 1/25/13 at approximately 10:30 a.m., E2 presented survey team with hand written care plans for pressure sore for R5. E2 had no explanation as to why the care plan was not available in the clinical record on 1/22/13 through 1/24/13.

Based on observation, interview, and record review, the facility failed to: a) ensure that 1 sampled resident (R30) who was high risk for elopement in the sample of 30, was monitored to prevent leaving the facility unsupervised. b) ensure that 3rd floor dining room window bolts which prevent full opening of windows in the dining room, are not broken. c) inform staff that 1 sampled resident with dementia ( R30 ) in the sample of 30 was high risk for elopement. This failure resulted to R30 successfully leaving the 3rd floor unit through the 3rd floor Dining Room window on [DATE] at 5:05 AM, and falling to the 1st floor patio concrete floor. This has a potential to affect 24 residents who are listed as high risk for elopement(R31-R54) on the 3rd floor. This failure resulted in Immediate Jeopardy which started on [DATE] at 5:05 AM, when R30 managed to open the 3rd floor window, and lowered himself out of the 3rd floor window, using linens tied to the leg of a table in the 3rd floor dining room. R30 fell in the process, and sustained multiple fractures of the left lower extremity and internal bleeding. As a result of these injuries, R30 expired at the hospital on [DATE]. Findings include : 1) R30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R30's care plan dated [DATE] mentioned that R30 has moderately impaired cognitive skills for daily decision making, is ambulatory with cane, and is alert but with bouts of confusion. His care plan also showed that he has a wandering, roaming, or pacing behavior related to Dementia, manifested by attempts to leave the facility without an escort, and roaming in and out of peer's room. Review of R30's Nurses Notes dated [DATE], indicated that R30 made multiple attempts to leave the unit during ,[DATE] shift. On an undetermined shift on [DATE], R30's nurses notes also indicated that he was anxious, and verbalized that he " wants to go home." On [DATE], R30's nurse's notes also showed, that he again voiced desire to go home on an undetermined shift. R30's nurses notes also indicated that on [DATE], after an altercation with another resident, R30 became hostile, uncooperative and wanted to leave the facility. During [DATE] interview at 1:38 PM, E5 (,[DATE] Certified Nurse Aide/ CNA) said that on [DATE], she was the only CNA working on the 3rd floor during ,[DATE] shift. E5 mentioned that the facility was short-staffed that night, so they moved another 3rd floor CNA to the 2nd floor, and left her to care for 50 plus residents. E10 confirmed that she was floated to the 2nd floor during ,[DATE] shift on [DATE] and that, normally, there are 2 CNAs during night shift on the 3rd floor. Facility's census on [DATE] indicated that there were 56 residents including R30, on the 3rd floor under E5's care on ,[DATE] shift. Facility's list indicated that 24 of these residents ( R31-R54) on the 3rd floor are listed as high risk for elopement. E5 said she was up and down all night, but at around 4:30 to 5:00 AM, she was sitting at the small hallway near the 3rd floor dayroom/dining room. E5 said R30 came back twice and motioned to her on the second time, if he could go to the 3rd floor dining room. E5 said yes, and R30 went to the dining room and kept the door closed, without any staff supervising him. E5 went to the Utility Room and said that ,[DATE] minutes later, she heard a strange noise coming from the 3rd floor dining room. E5 said that when she opened the dining room door, she saw that the first window on the left was opened, and linens tied to the leg of a table, were hanging out of the window. E5 continued that she thought that she saw the top of R30's head. E5 screamed for E6 (3rd floor nurse) to come, and when she looked down the window, E5 saw R30 lying on the 1st floor patio. E5 said she does not know how R30 opened the 3rd floor dining room window. E5 said that she did not see R30 carry linens to the dining room either. During [DATE] observation of the 3rd floor unit, the linen cart is just outside the 3rd floor dining room door, and R30 could have easily taken a linen without E5's knowledge when E5 went inside the Utility Room, especially that the 3rd floor dining room door was kept closed during that time. E5 said that on ,[DATE] shift, the 3rd floor dining room door is usually closed, so that no residents could go inside the room unsupervised or unmonitored. E5 said that normally, on ,[DATE] shift, they don't allow residents inside the dining room by themselves, because they could choke or slip and fall. However, E5 said that R30 does this routine everyday, and no one told her that R30 is confused, had previous elopement attempts, and had verbalized desire to go home. E5 added that had she known these, she would have monitored R30 closely. E5 also added that R30 is even allowed to leave the unit and go to other floors unsupervised. Similarly, during [DATE] interview with E6 at 4:00 PM, E6 also said that she is not aware that previously, R30 verbalized desire to go home in [DATE]. R30's [DATE] nurses notes and social service progress notes, show that R30 expressed desire to go home on this date. E6 added that there is also a list of residents high risk for elopement on the 3rd floor, but that, R30's name isn't included in that list. Furthermore, E5 continued that R30's wristband is not color coded to indicate that he is an elopement risk. During [DATE] conversation with E7 (Social Service Assistant ) and E8 ( Social Worker ) at 1:30 PM, E7 said that the list of residents high risk for elopement ( prior to revision on [DATE] after R30 fell ), included R30's name. E8 also said that R30's wrist band is color coded to indicate, that he is an elopement risk when he first came in to the facility. E8 wasn't sure if on [DATE] R30's wristband was still color coded to reflect risk for elopement. E7 was unable to produce the elopement list prior to [DATE] because he said that with the revision, the new names were already added to the previous list. R30's care plan for elopement, wandering, pacing, and roaming behavior dated [DATE], showed that it was not updated when R30 verbalized desire to go back home on [DATE]. Although these interventions included posting his photo at the nurses station and notifying staff of elopement risk potential, these intervention were not done, as both E5 and E6 were not even aware that R30 is an elopement risk. According to E6 during [DATE] interview, R30's name was not even included in the list of elopement risk residents, nor was his wrist band coded to reflect high risk for elopement. The color coding of wrist band of R30 for elopement risk was not even part of his care plan. According to E8, when he interviewed R30 on [DATE], R30 was not able to provide E8 with an address where R30 desired to be discharged to. During [DATE] observation with E9 (Maintenance Director) at 11: 40 AM, the 3rd floor Dining Room was noted with 4 windows facing Kedzie Street. Each window has a left and right glass panel that could slide to the side but can only be opened to a maximum of 7 inches, if the window bar bolt is in place at the latch . This bar prevents full opening which is up to 32 inches sideways and 18 inches from top to bottom per measurement with facility ruler. Per E9, when he got to the facility on [DATE] at around 7 AM, the window bar was already put back in place, but the screw/bolt that holds it in place was missing. E9 said that this window bar prevents the sliding to the right of the window panel of the 1st window. E9 added that it might have been the years of banging the window during opening, that broke the screw/bolt that holds the window bar in place. E9 explained that R30 might have been the 1st person to have lifted and removed the window bar, which allowed him to slide open the window fully. E9 said that he did not see any screwdriver and that, using a screw driver to remove the screw would have been improbable. E9 added that when he checked the rest of the 3rd floor windows, he discovered that 3 out of the 4 windows in the dining room had window bars with broken bolts/ screws. Several residents rooms ( 3 ) according to E9 were also found with broken window bolts, but all had been replaced already as of [DATE]. Review of R30's Chicago Fire Department record showed that 911 was dispatched on [DATE] at 5:16 AM, and arrived at the facility at 5:20 AM. This Fire Department incident report # 0146 indicated, that R30 was found at the facility's outdoor terrace with a large hematoma to the left side of the head and with shortening and rotation of the left leg. Added to this, this report showed that at 5:30 AM, R30's ECG showed that he has sinus bradycardia, his heart rate at 48/minute and his BP at ,[DATE]. R30's respiration was at 28/minute. At 5:41 AM, his BP was at 76/P and his heart rate remained at 48. During [DATE] phone interview with Z1 at 7:20 AM, Z1 said that R30's BP was never stable when he came to ER. Z1 said that R30's abdomen became distended so a DPL was performed and blood was found in his abdomen. Z1 added that with that finding and the drop in R30's hemoglobin, R30 was sent to OR for an Exploratory Laparotomy. Z1 said that she suspected initially that the cause of internal bleeding was the spleen, because there was a large collection of fluid around R30's spleen. Z1 continued that R30 had about 500 cc of blood removed intraabdominally, and a large retroperitoneal hematoma. Z1 said that she did not find the active source of bleeding when she opened up R30, but despite of the blood and fluids he was given eversince he was admitted , R30's BP did not stabilize. According to Z1, everytime R30's aorta is unclamped, his blood pressure would drop despite of the pressors and blood, and that it was probably from the hemorrhagic shock and acidosis. Z1 said that the bleeding was from his trauma from the injuries he sustained after his fall. Per Surgery and Procedure Documentation dated [DATE] 11:21 AM, R30 was provided with morgue care at this time. Review of facilty's list of resident on the 3rd floor on elopement risk showed that on [DATE], 24 residents in the list ( R31 - R54 ) were all identified by the facility as elopement risks. E2 ( Director of Nursing ) and Z2 were notified of these failures that led to the Immediate Jeopardy on [DATE] at 1:56 PM. While the Immediacy was removed on [DATE], the facility remains out of compliance at severity level 2, because the facility has yet to inservice the new hires on all shifts, has yet to assess if new interventions and policies are effective on the possible affected residents, and the facility's evaluation of the new plan of care has yet to be conducted The facility took the following steps to correct the Immediate Jeopardy: a) All windows were checked and bolted by maintenance staff starting [DATE] at 9:00 AM, and were finished by 2:00 PM. As part of the QA process, maintenance will randomly audit 10 rooms including the Dining Rooms on each floor monthly, to ensure that the windows are bolted. b) Starting [DATE], all residents were assessed by Social Service staff for elopement risk potential, and their names were added to the hourly monitoring log to be done and initialed by the CNAs. Their photos are also placed along with the list in each nurses stations. The Asst. DON will monitor this program weekly, to ensure that the hourly log is done in a timely manner, and to ensure that these residents photos are posted in the nurses station log book. Starting [DATE], all newly admitted residents with [DIAGNOSES REDACTED]. Until a photo is taken, a description will be provided for these residents. The log and the description or photo will be forwarded to the nurses station and the front desk by the admitting nurse. Nurses and CNAs will be inserviced regarding this policy and procedure starting [DATE] by the ADON and this will be completed to include all staff by [DATE]. c) An inservice concerning monitoring and supervision of residents with Dementia was done on [DATE] by Z3. The night shift staff was inserviced by the DON on [DATE] to complete inservicing all the staff on each shift. Initially, on [DATE], the ADON completed an inservice with all staff on interventions when residents voice desire to leave facility or attempted to leave the facility, and the importance of reporting this information to the nurse. d) Although on [DATE] residents were assessed for elopement risk by social service staff, this list was revised to include a star next to their names, on those high risk to elope. These residents are not to leave the unit unattended. The staff will be inserviced by the ADON and DON on [DATE] on this update. e) Beginning [DATE], a discharge readiness assessment will be done by social service staff on those who verbalize desire to leave the facility. If appropriate, a discharge plan will be developed based on the assessment. This is an ongoing process that will be monitored by the administrator or designee. f) Starting [DATE], 2 CNAs will be working on ,[DATE] shift on the 3rd floor. If a CNA calls off, a replacement will be assigned. The CNA Supervisor, DON, or ADON will contact other CNAs to fill in but if no CNA is available, the CNA supervisor will work the floor. If the CNA supervisor is not available, a nurse will be contacted to work the floor, or an agency CNA will be contacted for coverage. The CNA Supervisor and ADON will be inserviced by the DON on this new call off policy on [DATE]. Based on observation, record review and interview, the facility failed to provide adequate supervision and failed to have individualized interventions in place for 2 of 30 residents at high risk for falls, R25 and R57, and failed to have preventive measures in place to prevent injury in the event of a fall. Both residents sustained falls during the survey process. Findings include: 1. R25 is an [AGE] year old resident admitted to the facility on [DATE]. R25 ' s [DIAGNOSES REDACTED]. During the initial tour of the facility ' s skilled unit with E2, Director of Nursing (DON) on [DATE] at 10am, E2 told surveyor that R25 in on isolation precautions for Skin Rash of Unknown Origin. R25 was in a low bed, awake and appeared restless and agitated. R25 did not respond to surveyor's greeting. E2 stated that R25 is at fall risk and thus the low bed. On [DATE] at 9:40am, R25 was again observed in his room sitting on the edge of his bed, restless, agitated, with continuous unintelligible speech. E19, Nurse, was present and told surveyor that R25 is not able to verbalize his needs and is upset because he has to stay in his room due to contact isolation. E19 went on to say that R25 likes to propel himself on the unit and participate in activities. R25 has had at least 17 fall incidents during the previous year, most recent on [DATE] during assisted transfer when R25 sustained " minor cut on ear with scant bleeding " ; [DATE], unwitnessed fall from low bed , no injuries; [DATE], unwitnessed in room near bed, sustained " hematoma and small laceration to right side of head." Incident report dated [DATE] at 10:15am states R25 was observed on floor near bed, with no injuries. R25 assessed as at high risk for fall. Care plan shows the following recommendations that were not in place despite R25 agitated and restless behaviors: alarm safety belt; mat on floor, blue body positioning device on bed, self releasing seat belt while up in chair. R25 was observed in low bed on [DATE] at 9am with mats near bed, not his usual self, but asleep, not responding to verbal stimulus. There was a dressing on the right forearm. E2, Director of Nursing, told surveyor at 11:30am that R25 was noted with a skin tear this morning. R25 was later observed sitting in regular chair near his bed, agitated and somewhat confused, with no safety devices in place. Unusual Occurrence Report dated [DATE] shows R25 was assessed at 8:15 am for skin tear of undetermined origin. 2. R57 is an [AGE] year old resident with Hypertension, Anxiety State, Dementia, Diabetes Mellitus and Dysphasia. R57 speaks and understands Spanish only. During initial tour on [DATE], R57 was observed in bed with bilateral hand splints in place and hands visibly contracted. R57 is at high risk for falls with a history of fall with fracture. The active clinical record contains no information regarding the circumstances of this fall history. Last fall assessment was done [DATE] with score of 23 (score of 14 and higher signifies risk). On [DATE] at approximately 11:45am, R57 was observed in bed, positioned on her right side with a wedged cushion at her back. Surveyor and E2 were doing skin observation on R57 ' s roommate, and at approximately 12 noon there was a loud noise coming from behind the privacy curtain. R57 was observed on the floor next to her bed, bleeding from a wound on the left side of her forehead. R57 was groaning loudly and appeared very agitated and incontinent of feces. E2 responded immediately, assessed R57 who sustained a lacerated wound to the left side of forehead. First aid was rendered and R57 was transported to the emergency room for evaluation. R57 ' s Minimum Data Set (MDS) shows long and short term memory problem, moderately impaired cognition. R57 requires extensive to total assistance for activities of daily living (ADL). The care plan for fall prevention is generic and include placing resident close to nurses station. R57 ' s room is down the hall, away from the nurse ' s station. Care plan was last updated on [DATE] and contained no individual approach to fall prevention. R57 was observed on 3 of 3 days with bed in regular position (no low bed), no floor mat, and no bed alarm and with a positioning cushion on the bed. These approaches are not addressed on the care plan. R57 has bilateral half side rails which are not always up. E27, Care Plan Coordinator, told surveyor that all fall precautions are documented on the care plan. During a lengthy phone interview with Z4, family member, on [DATE] at 5:00pm, Z4 said he noted facility ' s phone number on the caller I.D. and immediately called the facility fearing an emergency. There was no message left on his voicemail system. Z4 was told that R57 fell and had a cut near her eye. Z4 told surveyor he believes the fall could have been prevented as he feels R57 and other residents on the unit are no getting proper care. Z4 went on to say that several years ago R57 was dropped in the facility by staff while being showered, and sustained a fractured hip (this information not available in the active chart) and on another occasion she fell and sustained bruising on her face. Z4 visits R57 almost daily. R57 is not able to move on her own, and if in a sitting position would roll. She is not able to use hands due to contractures. She shakes a lot due to Parkinson ' s disease. He would often find her soiled with urine and feces and would often need to change her himself. Z4 has not observed any fall precautions for R57, except for one-half side rail which he says would not prevent fall. R57 returned to the facility on [DATE] at 7pm with a [DIAGNOSES REDACTED]. On [DATE] at 3pm, R57 was observed up in her wheelchair in the dayroom. R57 was positioned away from the activity, up against the wall, not within full view of staff. R57 ' s head was bent forward with her neck at a 90 degree angle. Z4, family member, was in the facility and, along with surveyor, noted R57 with sign of bleeding from the left nostril. E28, Nurse, wheeled R57 to her room and left R57 unattended in the wheelchair with wheels unlocked. E28 went back to R57 ' s room about five later to assess R57 ' s bloody nose. with R57 ' s head bend forward. E28 said this bent head is R57 ' s usual posture and stated she needs to put R57 to bed for better view of nasal orifice. Using Spanish language surveyor asked R57 if she was experiencing any pain. R57 glanced at surveyor but elicited no response.E28 later told surveyor that there was no active bleeding coming from nostril. R57 was observed afterward in her bed which was at its usual height, bilateral half side rails up. There was no fall mats next to the bed.

Based on observation, record review and interview, the facility failed evaluate to timely and thoroughly assess a new area of excoriated neck tissue for 1 of 30 sampled residents,R4, and failed to treat the [MEDICAL CONDITION] tube sites for 2 of 6 sampled residents, R6 and R59, receiving [MEDICAL CONDITION] tube feeding, to assess, treat, document or evaluate injuries of unkown origin for 2 of 2 residents outside of the sample (R 55 and R 56). Findings include: 1) R4 is a [AGE] year old Depression, Diabetes and Hypertension. During the initial tour of the facility on 4/26/11, R4 was observed in bed, awake. E2, Director of Nursing, told surveyor that R4 speaks Spanish only and has stage II Hip and Sacral Ulcers. R4 is assessed as high risk for skin breakdown. On 4/27/11 during medication pass observation with E19, nurse, R4 was in bed with dressing on right foot and heel which was not there on the previous day. R4 ' s head was turned toward her felt side and there was an area of redness/excoriation noted on the left, frontal aspect of her neck. When prompted by surveyor E19 said that R4 favors her head turned to the left and when R4 drools, that side of her neck becomes wet. E19 turned R4 ' s head slightly, confirmed wetness from drooling and left the room. R4 was making a loud teeth grinding sound which caught a nurses aid attention. The nurses aid, name unknown, asked R4 in Spanish what was wrong. There was response from R4. E19 made no comment and did nothing. E21, Treatment Nurse, told surveyor at 11:30am that she assessed R4 ' s neck and that the rash is confined to the readily visible portion of her neck and she will notify the doctor. E21 said she had no previous knowledge of this skin condition. When asked if R4 was repositioned for full view of her neck, E21 said no. Surveyor prompted E21 to conduct another assessment in surveyor ' s presence. R4 was turned and the neck area from frontal midline to dorsal midline was red, with tan colored drainage and emitting a foul odor. E21 described the drainage as ' purulent discharge ' . R4 ' s physician was notified, R4 sent to the hospital and hospitalized with [DIAGNOSES REDACTED]. On last day of survey, R4 remained hospitalized . 2) R6 is an [AGE] year old resident receiving feeding via a gastrostomy tube. R6 has dementia and is cognitively impaired. During routine wound check with E2, Director of Nursing, on 4/28/11 at 12 noon, E2 exposed R6 ' s [MEDICAL CONDITION] tube site and revealed a soiled dressing. Surveyor prompted E2 to remove the dressing. The [MEDICAL CONDITION] tube site was moist and there was saturated 4x4 gauze dressing packed around the wound stoma. E2 removed the 4x4 and said there is leakage around the site. E2 stated she had no prior knowledge of this and would contact R6 ' s physician. 3) R57 fell on [DATE] at 12 noon, sustained a head injury and sent out to the hospital for evaluation. R57 returned to the facility on [DATE] at 7pm with a [DIAGNOSES REDACTED]. On 4/29/11 at 3pm, R57 was observed up in her wheelchair in the dayroom. R57 was positioned away from the activity, up against the wall, not within full view of staff. R57 ' s head was bent forward with her neck at a 90 degree angle. Z4, family member, was in the facility and, along with surveyor, noted R57 with sign of bleeding from the left nostril. Z4 was visibly alarmed at this and immediately went to the nurses ' station and reported this observation to E28, nurse. Surveyor was standing nearby and E28, with little regard for information given by Z4, started to make casual conversation with surveyor who redirected her, E28, to address Z4 ' s concern. Surveyor followed E28 to the dayroom as she looked at R57 and said " she is bleeding! " E28 wheeled R57 to her room and left R57 unattended in the wheelchair with wheels unlocked. E28 went back to R57 ' s room about five minutes later, attempting to assess bloody nose with R57 ' s head bend forward. E28 said this bent head is R57 ' s usual posture and stated she needs to put R57 to bed for better view of nasal orifice. Using Spanish language surveyor asked R57 if she was experiencing any pain. R57 glanced at surveyor but elicited no response. E28 later told surveyor that there was no active bleeding coming from nostril. R57 was observed at 3:30pm in her bed groaning. The bed was at its usual height, bilateral half side rails up. There was no fall mats next to the bed. Surveyor asked E28 whether R57 has pain. E28 stated, " She should be in pain, especially after having had her nose cleaned out " . E28 did not know if R57 had an order for [REDACTED]. There was no order in place to address pain associated with facial fracture. There is no evidence that post head injury assessments and monitoring were being carried out. 4) R59 receives feeding via a [MEDICAL CONDITION] tube. On 4/26/11 at 1pm, E19, Nurse, was administering medications by [MEDICAL CONDITION] tube route to R59. Surveyor prompted E19 to assess R59 ' d [MEDICAL CONDITION] tube site. E19 raised R59 ' s gown and discovered that there was no dressing in place and discover a heavy buildup of dry, crusty substance around the stoma. E19 said, " Oh boy, it needs to be cleaned and dressed " . E19 also stated there should be a dressing in place at all times. 5) R55 is a [AGE] year old female who was admitted to the facility 4/2/2002 and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Minimum (MDS) data set [DATE] states R 55 is severely cognitively impaired, rarely makes self understood and rarely understands what others say. R55 requires extensive assistance from staff for bathing, dressing and grooming needs. On 4/28/2011 at 12:30 PM, R55 was observed sitting in the hallway outside of the unit 2 nurses station. R55 was sitting in her wheel chair with her legs crossed at the ankles. Dressings were noted to the lower leg above her ankle length stockings on both the left and right lower legs. The dressings had no date or staff intials to indicate when the dressing was applied. On 4/28/2011 at 12:30 PM, E20 (registered nurse) was asked why R55 had a dressing to bilateral lower legs. E20 stated I don't know what is under the dressings, I did not apply them. E23, ( licensed practical nurse ) was also asked why R55 had dressing to her lower legs. E23 also indicated she did not know what was under the dressings as she did not apply them. Both nurses indicated that R12 director of nursing had done the treatment on the AM shift for 4/28/2011. Niether nurse knew what was under the dressings despite the fact that R55 has an order for [REDACTED]. E2 director of nursing was interviewed on 4/28/2011 at 12:35 PM. E2 stated she had not applied the dressings to R 55 's lower legs. E2 stated that no one had reported any injury to R 55 to her. Record review on 4/28/2011 for R 55 showed no physician notification of injury, no physicians order for the treatment, no documentation in the progress noted for any injury or open areas to lower legs. Review of treatment sheets for R 55 had no order for dressings to the lower legs. There is no care plan in place for injuries to lower legs. On 4/28/2011 at 2:00 PM, E2 ( Director of Nursing) removed the dressing from R 55' s' lower legs per surveyors request. When E2 removed the dressing the leg had a deep indentation where the dressing had been. Appeared the dressing was to tight. The right outer leg had a 3 x 3 centimeter circular area with active bleeding from the dry 4 x 4 that was stuck to the area. Normal saline was applied to the 4 x 4 before removal. Pressure applied to the to area. There was also a 0.5 x 0.5 centimeter scabbed area to the outer right lower leg. When the dressing was removed form the left leg there was a 0.5 x 1.5 centimeter pink open area with top layers of skin removed as well as three scabbed areas one 0.5 x 0.5 centimeter, one 1 inch x 0.2 centimeter and another 0.2 x 0.2 centimeter. E2 was asked how these injuries occurred stated " I don't know how they occurred." E 18 certified nurses aid was interviewed on 4/28/2011 at 3:05 PM. E 18 stated R 55 had the dressings on her lower legs when she got her out of bed that AM. E 18 stated she did not recall the dressings being there the day before. The physician was notified on 4/28/2011 at 2:30PM of presents of the injury after prompting by the surveyor. Orders for treatment were received at that time. The facility also presented a care plan dated 4/28/2011 for R 55 approaches include provide wound care, observe for signs of infection, document wound care and keep area clean and dry. R 56 is a [AGE] year old male admitted to the facility on [DATE] and readmitted on ,[DATE] 2010 with a [DIAGNOSES REDACTED]. Minimum (MDS) data set [DATE] states that R 56 rarely makes self understood, rarely understand others and is severely cognitively impaired. R 56 requires extensive assistance of staff to transfer,bathe, dress and groom himself. 6) On 4/28/2011 at 12:30PM, R 56 was observed sitting in the hallway in front of the unit 2 nurses station. R 56 had his head down sleeping. A dressing was noted to his left arm. The dressing was from his wrist to his mid arm. A skin tear that had dry blood to area was noted above the dressing near the lateral aspect of the elbow. This area was not covered by the dressing. On 4/28/2011 at 12:30 PM, E 23 (LPN) stated she was not R 56' s' nurse today E 20 (RN) was his nurse. E 23 stated she had not applied the dressing. E 20 also indicated that she had not applied the dressing to R 56' s' left forearm. E 20 stated she did not know what was under the dressing. E2 (DON) also stated she had not applied the dressing to R 56' s' left forearm. Record review of R 56' s' record shows no documentation of any injury in the nursing progress notes, no physicians order for treatment, no doctors notification of injury. Current treatment record reviewed shows no treatment ordered for R 56' s' left forearm. On 4/28/2011 at 2:00 PM E2, (DON) removed the dressing from R 56' s' left forearm. The dressing was not covering an injury. The injury was above the dressing a 2 x 3 centimeter skin tear was noted above the dressing. The gauze dressing had a scant amount of dried blood on it. E 2 instructed E 3 (ADON) to notify the doctor of the injury and get orders for a treatment as well a doing a investigation on how the injury occurred after surveyor prompting. On 4/28/2011 at 3:00 PM E 17 certified nurses aid was interviewed regaurding R 56' s' injury. E 17 stated he did not get R 56 up that AM that night shift got him up. E 17 stated he did not notice anything on R 56' s' arm that morning when he first observed him at 7:00 AM. The facility also presented a care plan dated 4/28/2011, on 4/29/2011, at 9:00 AM for R56 for left arm skin tear. R56 is to wear protective sleeves to both arms to prevent further injury.