Every finding on record at Pavilion of South Shore

Based on observations, interviews, and records reviewed the facility failed to have effective window safety latches that allow the window to only open 4 inches at maximum and to prevent a resident (R1) with Dementia and at risk for elopement from opening her 3rd floor room window. This failure resulted in R1, a resident with Dementia and at risk for elopement, exiting through her 3rd floor window. Subsequently, staff observed R1 face down on the ground from her room window. R1 was unresponsive, blood from her face and abdomen on the ground when emergency services arrived. Police records document a death investigation.This failure was identified as Immediate Jeopardy which began on [DATE]. V2 (Administrator) and V17 (Chief Operating Officer) were notified of the Immediate Jeopardy on [DATE] at 10:00 AM.On [DATE] an acceptable removal plan was received after revision from the original plan submitted on [DATE] at 10:46 AM; on [DATE] 12:58PM; and on [DATE] at 11:37AM.On [DATE] and [DATE] the surveyor confirmed by observation, interview, and record review that the removal plan was initiated, and the immediacy was removed on [DATE]. However, the non-compliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training.Findings include:R1's admission dated was [DATE]. R1's diagnosis include but are not limited to acute combined systolic (congestive) and diastolic (congestive) heart failure, shortness of breath, hypoxemia, other abnormalities of gait and mobility, cognitive communication deficit, cerebral infarction-unspecified, muscle wasting and atrophy, and unspecified dementia-unspecified severity. R1's Minimum Data Set, dated [DATE] section C's BIMS (Brief Interview Minimum Status) score is 2, indicating R1's cognition is severely impaired.R1's care plan dated [DATE] documents, in part Elopement Risk. The resident presents with the risk of elopement and wanderer related to unspecified dementia. The resident presents with impaired cognitive function or impaired thought process related to a diagnosis of dementia. The resident presents with a focus for smoking. R1's hospital medical records dated [DATE] were reviewed and documents R1 sustained a Right scalp avulsion down to bone with brain matter externalized, abrasion to right lateral knee, abrasion to left foot, right back crepitus with possible instability with status post traumatic arrest and time of death is 5:38 AM.On [DATE] at 11:27 AM, R2 stated she (R2) was sleeping and when she woke up staff were just asking questions, and she never saw R1 open the windows prior to the incident. [R2 was R1's roommate.]On [DATE] at 11:49 AM, V7 (Regional Maintenance Director) stated the windows had window safety latches and are popped out to allow the windows to open four (4) inches wide; both safety latches were in place before R1 fell from the window; the day R1 fell from the window, one window safety latch was found on the floor by the bed and the window guide casing was found on the floor broken in pieces under the bed; V7 is unsure where the other window safety latch went but did not find it; window audits are done once a month and as needed; surveyor and V7 observed R1's window had a window safety latch and a screw below the safety latch on one side of the window frame and no safety latch and a screw on the other side of the window; window screen was torn out but remained attached at the top of the window frame and the bottom of the window frame was partially bent. On [DATE] at 12:21 PM, V3 (Certified Nurse Assistant-CNA) stated on [DATE] at around 3:00 AM R1 came into the hallway, sat on the floor, said she couldn't breathe, so I (V3) notified the nurse; after the nurse finished attending to her, we (V3) and (V5) helped her back into bed and R1 was placed on oxygen via a nasal canula; at 4:00 AM I (V3) saw her resting in bed; at 5:00 AM, I (V3) found her sitting up with her feet still on the mattress; R1 was not speaking but her oxygen via nasal cannula was in place; and I (V3) went to get incontinent care supplies and entered the room going straight into the bathroom to warm a towel in the bathroom sink; when I (V3) returned, the resident was no longer in bed; I did not initially notice the window was open; I asked V4 (CNA) and V5 (Registered Nurse) who were in the hallway, if they had seen her (R1), and they said no; I walked back into R1's room and when I looked again, I saw the window screen was torn and the cannula across it; I called out, and staff came; I looked out the window and saw R1 on the ground; we all ran downstairs; I was in shock, and the nurse checked her pulse; I do not know whether the window had been open, if the window stoppers were in place; or if the window was broken.On [DATE] at 1:06 PM, video footage dated [DATE] at 5:09 AM, R2 is observed exiting R1's and R2's room; On 5:11:28 AM, via video recording, there are 2 cars in the facility's parking lot. R1 is seen coming in view of camera footage falling and landing on the ground beside a compact vehicle. 5:11:35 AM, V3 walked in R1's room; V3 walked into the hallway, spoke to R4 (CNA) and then back into the room with V4 following V3 in R1's room. At 5:11:45 AM, V4 exited R1's room running down the hallway. At 5:12:50 AM, V5 (Registered Nurse) was observed exiting R1's room and walking down the hallway and entering the nurse's station. At 5:12:53 AM, another vehicle is seen pulling up in the parking lot. At 5:13:31 AM, two females staff members are observed exiting the vehicle and observing R1 on the ground. Later were identified as V27 (Dietary Cook) and V28 (Laundry Aide). At 5:20:45 AM, the ambulance is observed parking next to R1; repositioning and placing cervical collar on R1; placing R1 on the stretcher and placing her (R1) in the ambulance vehicle driving away shortly after. On [DATE] 2:20 pm, V7 (Director of Plant Operations) removed the screws he inserted in the window frames below the safety latch on one side of the window frame because the other side of the window's frame safety latch could not be replaced due to part of the safety latch being broken in the safety latch slot. V8 (Maintenance Director) with V7 (Regional Maintenance Director) present demonstrated using minimal force using two hands to open R1's window with one window stopper in place which resulted in R1's window safety latch breaking into pieces. V7 and V8 along with the surveyor observed V8 re-install the one safety latch and 2 screws back into R1's window that is said to be used as an extra layer of protection preventing the window from opening more than 4 inches. At 2:31PM V7 said a window audit is performed once a month. We make sure the windows do not open more than 4 inches. R1's window had 2 stoppers before she fell from the window on [DATE]. V7 said he only found 1 window stopper on the floor that remained free from damage and could not find the other stopper.On [DATE] at 4:16 PM, V18 (CNA) said he has worked with R1 and knows she has dementia; unsure if R1 has ever tried to open a window; thinks R1 is an elopement risk.On [DATE] at 4:36 PM, V4 (CNA) stated R1 was ambulatory earlier in the shift and went to bed; staff were seated in the hallway doing rounds every two hours; around 3:00 AM, R1 came into the hallway saying she couldn't breathe; R1 was seated in a chair, placed on the oxygen concentrator, and then taken back to bed; at around 5:00 AM, while I (V4) was assisting another resident in another room on the 3rd floor unit, V5 (Registered Nurse) asked the CNA to dry R1 because she was soiled; V3 (CNA) prepared incontinent supplies from the linen cart stationed by R1's room and entered R1's room; the CNA returned and asked if I had seen R1 and I told V3 to check the bathroom, but R1 wasn't in the bathroom; I (V4) removed my gloves and followed V3 in R1's room; as I V4 entered the room behind V3, she began to yell she jumped out of the window; V4 observed the window was up, and the oxygen tubing was hanging across it and he (V4) immediately ran from R1's room to alert staff on all floors; V4 went outside to the side of the building near the resident's room and saw her on the ground, face down, with blood coming from her stomach area; R1 typically stayed in her room, walked the hallways, ate in the dining room, and returned to her room independently; V4 has never seen her (R1) open the windows; the window had not been open earlier; usually, if residents are hot, they ask staff to crack the window, and we close it when requested; there were two window stoppers in place the last time I worked in that area about 2 weeks ago.On [DATE] at 9:39 AM, V5 (Registered Nurse) stated on [DATE] at 5:05 AM, she (V5) returned to the R1's room; noticed the window appeared open much wider than usual about 12 inches or more; typically, it opens about 4 inches, but the screen was torn, the bracket broken, R1's oxygen concentrator was near the window and R1's nasal canula tubing was hanging out of the window; she began the understand why V3 (CNA) was yelling she jumped out of the window; unsure how the resident was able to open the window that wide; did not hear any noise or the window opening earlier; she (V5) looked out and saw the resident on the ground, face down, part way on her head with blood coming from her head and abdomen area; immediately called 911; It took me (V5) about three minutes to reach R1 outside; R1 had a carotid pulse; I (V5) started to go back for my blood pressure cuff, but the ambulance arrived; is unsure why R1 went to the window; R1's behavior was calm; did not notice if the window was open when she assessed the resident at 3:00 AM or 5:00 AM; police stated the resident pushed through the window; after EMS placed her on the stretcher, V5 retrieved the face sheet, and they transported R1 to the hospital; Another nurse and I (V5) both confirmed she still had a carotid pulse before she left; and do not know what EMS found afterward.On [DATE] between 10:00 AM and 11:00 AM V1 (Administrator) stated she did not have any other video footage from [DATE]-[DATE] prior to R1 falling because their camera system loops every 24 hours. V1 said the video footage provided to IDPH had been retained because the police requested to view video footage that morning. On [DATE] at 10:37 AM, V9 (Social Services Director) stated that on admission, R1 was calm but confused; R1's BIMS (Brief Interview Mental Status) score was 2; R1 knew her name but not her location; although she (R1) had no history of attempting to leave the unit, V9 classified her (R1) as an elopement risk due to her low BIMS and significant confusion; when I (V9) arrived at 9:30 AM, she (V9) saw V2 (Director Of Nursing) and corporate staff speaking with police; staff never told me the details of what happened during R1's incident; the windows have stoppers that normally limit opening to about 2-3 inches; if the black stopper is not present, a screw is used instead; when I open the windows, the stoppers move into place and prevent them from opening beyond a few inches; R1's usual behavior included walking down the hallway, looking into the dining room, heading toward her room, briefly looking into another resident's room, then returning to the dining room to look out the window before going back to her own room.On [DATE] at 11:06 AM, V10 (CNA) stated on [DATE] at about 5:00 AM, V4 (CNA) came through the first-floor door saying R1 had jumped out of the window; V10 ran outside with him (V4) and into the parking lot; (V10) did not see the resident breathing or moving; V10 informed V14 (Licensed Practical Nurse) and called the ambulance; the call was made around 5:15 AM; V10 called the ambulance again, and EMS arrived about five minutes later; we did not start CPR because we are instructed to wait until the nurse assesses the resident; V5 (Registered Nurse) arrived about two minutes later and attempted to apply a blood pressure cuff, but EMS arrived at that time and I returned inside; I have seen the resident on the first floor before, attempting to leave the building; the nurse redirected R1 when she (R1) tried to exit through a door that triggered an alarm; unsure of who the nurse was; not sure if R1 was moved to the third floor because she (R1) tried to exit through the door; and have witnessed R1 going to the window but not trying to exit through the window.On [DATE] at 11:28 AM, V8 (Maintenance Director) provided his supply of replacement window stoppers and an invoice for their last purchase of window stoppers. V8 had a supply of 13 window guides (used to allow the window to egress outward) and 12 window stoppers (safety latches).On [DATE] at 11:34 AM, V7 stated he has not ordered the window stopper but has ordered the window guides from (online store) on [DATE].On [DATE] at 11:40 AM, V8 (Regional Maintenance Director) stated the window should have 2 window stoppers and if one breaks, we put a screw in place of the stopper if the plastic becomes stuck in the slot to install another window stopper; it makes it more secure with adding a screw; since the incident screws have been placed in all the windows; and the window stoppers allow for the windows to open 4 inches. On [DATE] between 2:49 PM and 3:13 PM, 8 windows observed on the 3rd floor unit that were missing one or both safety latches from the window frame. The facility had installed one or two screws below the window safety latches.On [DATE] at 11:48 AM, V11 (CNA) stated, on [DATE] at 5:00 AM, she (V11) responded to a rapid response and went outside to the parking lot; when she (V11) arrived, the ambulance was already assisting R1 who was lying face down on the ground with blood in the area around her.On [DATE] at 11:59 AM, V12 (CNA) stated on [DATE] rounds begin at 5:00 AM; at 5:05 AM, she heard a code and responded, but the ambulance had already arrived; EMS checked the resident's pulse; V12 returned inside because a nurse requested a blood pressure cuff; I had never worked with R1; normally, windows on the floors remain closed, but if a patient requests ventilation, V12 opens them only 2-3 inches; and the windows don't open past 2-3 inches. On [DATE] at 2:15 PM, V15 (R1's Family Member) stated on [DATE] at 6:07 AM, he (V15) received a call from the facility telling him his mom was taken to the hospital because she had fallen from the window; he (V15) was told R1 had been doing well earlier before the incident, had received oxygen, and had soiled herself before the CNA entered the room; unknown staff member told him they will call him back with updates because the facility wanted to find out what hospital R1 was taken to; V15 called the facility back at 6:36 AM and there were no updates; at 7:44 AM the director of nursing called him (V15) and informed him his mother had passed away; R1 had dementia and unsure of her wandering; V9 (Social Service Director) informed him (V15) R1 was on the first floor for a couple of days after admission but moved to the third floor after R1 attempted to leave the facility because she was trying to go back home to her apartment; he (V15) and his sister had planned to obtain Power Of Attorney within the coming weeks and move R1 to Georgia; and V15 was receiving updates from V9 that R1 was participating in physical therapy. (Through review of records and interviews the surveyor was unable to confirm R1 ever resided on the first floor.)On [DATE] at 1:36 PM, V14 (Licensed Practical Nurse) stated the certified nurse assistant asked me (V14) what a Code Purple was; V3 (CNA) entered the unit and informed me (V14) R1 had jumped out the 3rd floor window; immediately went to the parking lot; assessed R1's right radial pulse because I (V14) did not want to move R1's head and a radial pulse was present; R1 had a head injury with bright red, un-clotted blood coming from her head or face and from underneath her body; all of the staff that responded was in shock, and I did not want to move her, so I continued monitoring her pulse; regarding the windows, some only open a few inches, while others-such as those at the end of the hallway-can open fully; I have never received an in service on window safety; I have been R1's nurse and R1's behavior was quiet, confused, and identified as an elopement risk; I believe she was admitted to the first floor; unsure if R1 wandered.On [DATE] at 1:56 PM, V16 (Housekeeping Manager) stated he (V16) was in the office when the cook called him to come outside; he entered the parking lot from a rear door of the facility and observed R1 lying face down on the ground where R1's room window was above on the 3rd floor; staff arrived immediately; could not see any obvious injuries or blood; explained that the facility's windows have stoppers allowing them to open about four inches; some windows have one stopper, others have two; has had in services on window safety on [DATE] and on the day, [DATE] after the incident; including reporting damaged screens or jarred windows; the purpose of window safety is to keep pests out and prevent residents from trying to exit through windows; R1 frequently wanted to smoke; and she had not personally seen her with smoking contraband.On [DATE] at 9:01 AM, V9 (Social Services Director) stated the facility is called at the moment an incident occurs regardless of the incident or what time of day; no one has reported anything about the windows having some failure in the safety mechanism or environmental safety; everyone knew she (R1) was on elopement risk; the facility had an in-service on the safety of the windows; the facility had in-services on the windows prior to the incident; I spoke to the son after the incident about his mother's clothing and the son did not mention anything about the incident during our conversation, he called about his mother's belongings.On [DATE] at 9:25 AM, V19 (Administrator in Training) stated V19 arrived at the facility on [DATE] at approximately 7:45 AM; police, V2 (Director of Nursing), and V17 (Chief Operating Officer) were already present; I was informed that a resident had jumped from a window after apparently forcing it open; police were on-site and interviewed several staff members; I knew R1 had a low BIMS (Brief Interview Mental Status) score and lived on the dementia floor; and had been at the facility about a month and had not yet evaluated window safety.On [DATE] at 10:40 AM, V2 (Director of Nursing) stated, on [DATE] at 5:18 AM, she (V2) received a call from the Dietary Manager reporting that a resident had fallen from a third floor window; I arrived at the facility around 6:15 AM; the ambulance had already transported R1 to the hospital, and police-one detective and two uniformed officers-were on the unit; R2 had been moved, and she (V2) began collecting staff statements; R1's son V15 (R1's Family Member), who had initially been contacted by V5 (Registered Nurse), called the facility requesting updates; at approximately 7:00 AM, the medical examiner informed the police sergeant that the resident had expired; V15 was called again, the DON notified him of his mother's death and informed him she had been taken to the (local hospital); She later showed the surveyor a text she had sent to V15 time stamped [DATE] at 8:15 AM; staff reported they did not see or hear the incident; V2 stated V3 (CNA) had been seated across from R1's room but stepped away after being asked by V5 (Registered Nurse) to provide incontinence care; staff could not confirm when R1 was last observed in bed; R1 was identified as an elopement risk, and policy requires placing the resident's photo in the elopement risk book and monitoring every two hours; V2 stated that her first window safety in service occurred a long time ago since the incident and an in-service on window safety was conducted for all staff after the incident; staff assess windows during rounds and document repair needs in an electronic work order repair software; V2 was not aware of any prior issues with the resident's window stoppers; V2 observed oxygen tubing hanging from R1's window when viewing the room from the doorway; the window appeared open approximately the width of the length of a ruler (gestured with her hands and then verbally said about the length of a ruler); in her experience, windows typically open about four inches and do not open fully.No elopement risk assessment was found in R1's electronic health record, only R1's social services comprehensive evaluation dated [DATE] documents, in part R1 can physically leave the building on her own, is independently mobile via ambulation, R1 has a diagnosis of dementia and has a history of elopement attempts and R1 exhibits pacing behavior and attempts to exit unit or facility.Facility's Director of Plant Operations Policy undated documents, in part, Director of Plant Operations works alongside maintenance and operation leadership to ensure their assigned facility is safe, compliant, efficient, and well maintained, meeting all regulatory, accreditation, and organizational standards.Repairs and replaces door and window hardware.Facility's Elopement Risk assessment dated [DATE] documents, in part, it is the policy of this facility that all residents are provided with adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors or conditions that put them at risk of elopement. All residents assessed to be at risk of elopement will have this issue addressed in their plan of care. Facility's Standard Supervision and Monitoring Policy with a revised date of [DATE] documents, in part, this guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs.The Immediate Jeopardy began on [DATE] and was removed on [DATE], when the facility took the following actions to remove the immediacy:Immediate Jeopardy Removal PlanIncidentOn [DATE], at approximately 5:10 a.m., R1 removed the window safety mechanism, resulting in the resident exiting through the window. Staff immediately initiated the emergency response process, including notification of 911. R1 was transported to the hospital, and the facility was informed residents had expired at 7am.Date and Time Immediate Jeopardy Declared: [DATE]th at 10:00amCorrective Actions for the Affected Resident911 was immediately contacted for emergency assistance for R1 on [DATE].The resident's roommate was immediately relocated to ensure safety on [DATE].The resident room window, window restrictor, and all associated hardware were immediately inspected on [DATE].The resident room and surrounding area were assessed for any additional environmental safety hazards on [DATE].The window safety device (2 metal self-tapping screws) was replaced prior to the room being returned to service on [DATE]. These safety devices were on hand at facility.Administrator and Director of Nursing were notified on [DATE].The residents' physician and responsible party were notified on [DATE].Identification of Other Residents at [NAME] facility-wide inspection of all resident room windows, dining room windows, hallway and shower rooms and window safety devices were completed to verify that each device was present, secure, and functioning properly on [DATE].An additional window safety device (2 metal self-tapping screw) was installed on all resident room windows as an added layer of protection on [DATE]. Additional safety devices were purchased on [DATE] (see invoice).Nursing, Maintenance, Housekeeping, Activities, and all Department Managers were educated to immediately report any damage, loose, or missing window safety devices to maintenance and/or nursing leadership for immediate correction on [DATE] in TELS. TELS is monitored by the maintenance director on a daily basis including weekends and holidays. The Regional Director of Maintenance covers TELS when Maintenance Director is on vacation, etc.All residents (9 residents) at risk for elopement were reassessed utilizing elopement risk assessment on [DATE] by Social Services Director. Each resident's care plan was reviewed and revised as needed to ensure individualized approaches related to elopement risk on [DATE].All residents are assessed for elopement risk utilizing an elopement risk assessment by social service director upon admission, quarterly, annually and upon significant change of condition including an elopement attempt or an elopement incident. Social Service and professional nurses were educated on this process on [DATE].Social Service Director monitors the elopement program including changes in elopement scores.Systemic Changes to Prevent RecurrenceOn [DATE], the Maintenance Director completed a 100% inspection of all resident room windows and window safety restrictors and added an additional mechanism to provide window safety on all resident rooms, hallway and shower room windows. Dining room windows were screwed shut with 2 screws on [DATE].All resident room windows and window restrictors will be inspected monthly by the Maintenance Department, with findings documented in Window Maintenance Binder.All nursing, housekeeping, dietary and therapy, activity and department heads received education regarding: Immediate reporting of damaged or missing window safety devices and facility policies regarding window safety and identification of window safety issues starting on [DATE]. Each department is 100% completed except for 1 activity aide on FMLA scheduled to return [DATE]. Activity Director is responsible for training the activity staff member upon return.All agency staff will be in-serviced prior to beginning their first shift worked at the facility by the Charge nurse.All newly hired staff in nursing, housekeeping, activities, dietary, and therapy department managers will be in serviced upon hire prior to first working day by Maintenance Director.The Maintenance Director will be responsible for ensuring timely repair or replacement of any deficient window safety devices identified during inspections or reported by staff.A new window maintenance policy was developed on [DATE] and includes what the facility will do if a window malfunctions. A revised Window QA tool was developed on [DATE].Supervision Policy was reviewed by QAPI team on [DATE].All residents who are assessed as At Risk for Elopement will have their care plans reviewed weekly by IDT to assure appropriate interventions are in place. IDT (Nursing, SS, Dietary, Activities) were in serviced on [DATE] on this new process.MonitoringThe Maintenance Director or designee will audit all resident room windows and safety devices for 3x's weeks for 2 weeks, weekly for 4 weeks, and monthly thereafter to ensure continued compliance. All findings will be logged into Window Maintenance Binder and reported to Administrator.Administrator will complete random audits of resident room windows and safety devices 3 times per week for 4 weeks and monthly thereafter to ensure continued compliance.Director of Nursing or Regional Director of Operations will complete random audits of residents assessed for elopement risk to ensure appropriate supervision in place. These audits will be completed 3 times weekly for 4 weeks and weekly for 4 weeks and monthly thereafter.Audit findings will be reviewed through the facility's QAPI Committee. The committee will analyze trends, implement additional corrective actions as needed, and continue monitoring until sustained compliance is achieved. Completed: [DATE]

Based on observation, interview, and record review the facility failed to have effective window safety latches to prevent a resident (R1) with Dementia and at risk for elopement from opening her 3rd floor room window. This failure resulted in R1 exiting through her 3rd floor window. Subsequently, staff observed R1 face down on the ground from her room window. R1 was unresponsive, blood from her face and abdomen on the ground when emergency services arrived. Police records document a death investigation.Findings include:R1's admission date was 6/30/2026. R1's diagnosis include but are not limited to acute combined systolic (congestive) and diastolic (congestive) heart failure, shortness of breath, hypoxemia, other abnormalities of gait and mobility, cognitive communication deficit, cerebral infarction-unspecified, muscle wasting and atrophy, and unspecified dementia-unspecified severity. R1's Minimum Data Set, dated [DATE] section C's BIMS (Brief Interview Minimum Status) score is 2, indicating R1's cognition is severely impaired.R1's care plan dated 6/30/2026 documents, in part Elopement Risk. The resident presents with the risk of elopement and wanderer related to unspecified dementia. The resident presents with impaired cognitive function or impaired thought process related to a diagnosis of dementia. The resident presents with a focus for smoking. Hospital medical records dated 7/29/2026 reviewed and documents R1 sustained a Right scalp avulsion down to bone with brain matter externalized, abrasion to right lateral knee, abrasion to left foot, right back crepitus with possible instability with status post traumatic arrest and time of death is 5:38 AM.On 7/30/2026 at 11:49 AM, V7 (Regional Maintenance Director) stated the windows had window safety latches that are popped out to allow the windows to open four (4) inches wide; both safety latches were in place before R1 fell from the window; after R1 fell from the window, one window safety latch was found on the floor by the bed and the window guide casing was found on the floor broken in pieces under the bed; is unsure where the other window safety latch went but did not find it; window audits are done once a month and as needed; surveyor and V7 observed R1's window had a window safety latch and a screw below the safety latch on one side of the window frame and no safety latch and a screw on the other side of the window; window screen was torn out but remained attached at the top of the window frame and the bottom of the window frame was partially bent. On 7/30/2026 at 12:21 PM, V3 (Certified Nurse Assistant-CNA) stated I (V3) returned to R1's room and R1 was no longer in bed; I did not initially notice the window was open; I asked V4 (CNA) and V5 (Registered Nurse-RN) who were in the hallway, if they had seen her (R1), and they said no; I walked back into R1's room and when I looked again, I saw the window screen was torn and the cannula across it; I called out, and staff came; I looked out the window and saw R1 on the groundOn 7/30/2026 at 1:06 PM, surveyor was provided video footage dated 7/29/2026 at 5:12:50 AM, V5 (Registered Nurse) observed R1's window was open; oxygen tubing was hanging out of the window; looked out of the window and observed R1 was lying on the ground facing down. On 5:11:28 AM, via video recording, there are 2 cars in the facility's parking lot. R1 is seen coming in view of camera footage falling and landing on the ground beside a compact vehicle. On 7/30/2026 2:20 pm, V7 (Director of Plant Operations) removed the screws he inserted in the window frames below the safety latch on one side of the window frame because the other side of the window's frame safety latch could not be replaced due to part of the safety latch being broken in the safety latch slot. V8 (Maintenance Director) with V7 (Regional Maintenance Director) present demonstrated using minimal force to open R1's window which resulted in R1's window safety latch breaking into pieces. V7 and V8 along with the surveyor observed V8 re-install the one safety latch and 2 screws back into R1's window that is said to be used as an extra layer of protection preventing the window from opening more than 4 inches. At 2:31PM V7 said a window audit is performed once a month. We make sure the windows do not open more than 4 inches. R1's window had 2 stoppers before she fell from the window on 7/29/26. V7 said he only found 1 window stopper on the floor that remained free from damage and could not find the other stopper.On 7/30/2026 at 4:16 PM, V18 (CNA) verified an observation of the 2 windows located at the end of the hallway on the third floor unit with one stopper on both windows and one screw in place of the second stopper; he (V18) has worked with R1 and knows she has dementia; unsure if R1 has ever tried to open a window; thinks R1 is an elopement risk.On 7/30/2026 at 4:36 PM, V4 (CNA) stated as I (V4) entered the room behind V3, she began to yell she jumped out of the window and V4 observed the window was up, and the oxygen tubing was hanging across it. V4 said R1 had been ambulatory earlier on the shift. V4 said the window in R1's room had not been open earlier in the shift.On 7/31/2026 at 9:39 AM, V5 (Registered Nurse) stated on 7/29/2026 at 5:05 AM, she (V5) returned to R1's room; noticed the window appeared open much wider than usual about 12 inches or more; typically, it opens about 4 inches, but the screen was torn, the bracket broken, R1's oxygen concentrator was near the window and R1's nasal canula tubing was hanging out of the window; she began the understand why V3 (CNA) was yelling she jumped out of the window; unsure how the resident was able to open the window that wide; did not hear any noise or the window opening earlier; she (V5) looked out and saw the resident on the ground, face down, part way on her head with blood coming from her head and abdomen area; immediately called 911.On 7/31/2026 at 10:37 AM, V9 (Social Services Director) stated that on admission, R1 was calm but confused; R1's BIMS (Brief Interview Mental Status) score was 2; R1 knew her name but not her location; although she (R1) had no history of attempting to leave the unit, V9 classified her (R1) as an elopement risk due to her low BIMS and significant confusion; when I (V9) arrived on 7/29/26 at 9:30 AM, she (V9) saw V2 (Director Of Nursing) and corporate staff speaking with police; staff never told me the details of what happened during R1's incident; the windows have stoppers that normally limit opening to about 2-3 inches; if the black stopper is not present, a screw is used instead; when I open the windows, the stoppers move into place and prevent them from opening beyond a few inches.On 7/31/26 at 11:06AM V10 (CNA) said I have seen R1 on the first floor before, attempting to leave the building; the nurse redirected R1 when she (R1) tried to exit through a door that triggered an alarm; unsure of who the nurse was; not sure if R1 was moved to the third floor because she (R1) tried to exit through the door; and have witnessed R1 going to the window but not trying to exit through the window.On 7/31/2026 at 11:28 AM, V8 (Maintenance Director) provides his supply of replacement window stoppers on hand at the facility before placing a new order and an invoice for 60 fasteners (window stoppers per V8) dated 7/29/2026 at 9:54 AM. On 7/31/2026 at 11:40 AM, V8 (Regional Maintenance Director) stated the window should have 2 window stoppers and if one breaks, we put a screw in place of the stopper if the plastic becomes stuck in the slot to install another window stopper; it makes it more secure with adding a screw; since the incident screws have been placed in all the windows. Observed V8 (Maintenance Regional Director) and V7 (Maintenance Director) counted out 13 window guides in stock and 12 window stoppers in stock. On 7/31/2026 between 2:49 PM and 3:13 PM, 8 windows observed on the 3rd floor unit that were missing one or both safety latches from the window frame. The facility had installed one or two screws below the window safety latches.On 8/3/26 at 1:36PM V14 (Licensed Practical Nurse) stated regarding the windows, some only open a few inches, while others-such as those at the end of the hallway-can open fully; have never received an in service on window safety; has been R1's nurse and R1's behavior was quiet, confused, and R1 identified as an elopement risk.On 8/5/2026 at 9:25 AM, V19 (Administrator in Training) stated V19 had been at the facility for about a month and had not yet evaluated window safety. V19 said he was informed that a resident had jumped from a window after apparently forcing it open; not aware of any past environmental safety non compliance; an in service on window safety was conducted on 7/29/26 and all windows were checked the same day; any window missing a screw had one installed; and he (V19) could not verify how many windows were missing screws that screws were added to the window.On 8/5/2026 at 10:40 AM, V2 (Director of Nursing) stated, observed oxygen tubing hanging from R1's window viewing the room from the doorway; the window appeared open approximately the width of the length of a ruler; in her experience, windows typically open about four inches and do not open fully.On 8/6/2026 at 1:30 PM, V20 (R1's Primary Physician) stated he (V20) could not answer questions about the windows, noting that rooms usually have air conditioning and windows are typically not open; windows should have some form of safety feature but that he is not involved in window safety procedures.R1's social services comprehensive evaluation dated 7/1/26 documents, in part R1 can physically leave the building on her own, is independently mobile via ambulation, R1 has a diagnosis of dementia and has a history of elopement attempts and R1 exhibits pacing behavior and attempts to exit unit or facility.Facility's Homelike Environment policy dated 3/2014 with a revision date of 11/2020 documents, in part, residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Facility's Policy titled Equipment and Building Maintenance with a revised date of 12/2024 documents, in part, the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The following functions are performed by maintenance but are not limited to: maintaining the building in compliance with current federal, state, and local laws, and regulations and guidelines; maintaining the building in good repair and free from hazards; and maintenance of equipment according to manufacturer recommendations. Facility's Director of Plant Operations Policy undated documents, in part, the Director of Plant Operations serves as the department head of the maintenance department. This position may also be required to oversee both the housekeeping and laundry department, if needed. The Director of Plant Operations works alongside maintenance and operation leadership to ensure their assigned facility is safe, compliant, efficient, and well maintained, meeting all regulatory, accreditation, and organizational standards.Repairs and replaces door and window hardware.Facility's Elopement Risk assessment dated [DATE] documents, in part, it is the policy of this facility that all residents are provided with adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors or conditions that put them at risk of elopement. All residents assessed to be at risk of elopement will have this issue addressed in their plan of care. Facility's Standard Supervision and Monitoring Policy with a revised date of 4/10/2023 documents, in part, this guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the residents is an essential part of nursing care in which standard approaches are successful in meeting the residents' physical and psychosocial needs.

Based on observation, interview and record review, the facility failed to ensure that medications were stored at the proper temperature and failed to ensure that a multiple dose vial was dated as per facility policy which affected 6 residents (R3, R16, R44, R71, R94, R103) of 6 residents reviewed for medication storage in a sample of 50. This deficiency also has the potential to affect all new admissions on all three resident units in the facility. Findings include:On 4/20/26 at 11:40am, there was one multi dose vial of Tuberculin in the 1st floor medication refrigerator that was not labeled with an open date or use by date. V26 (LPN-Licensed Practical Nurse) confirmed that the medication is used for all new admissions and that the vial did not have a label with the dates. The facility's 2nd and 3rd floors did not have a multi dose Tuberculin vial in their refrigerators. On 4/20/26 at 11:50am, V27 RN (Registered Nurse) was scheduled on the 2nd floor and stated, If we need the (tuberculin) medication, we get it from downstairs. On 4/20/26 at 11:58am, V21 (RN) indicated that 3rd floor does not have Tuberculin medication and stated, We get it from downstairs if we need to give it. On 4/20/26 at 11:40am, the internal temperature of the 2nd floor medication refrigerator read 52 degrees Fahrenheit. This temperature was confirmed with V27 (RN) who also stated that none of the floor staff had recently accessed the refrigerator. The following medications were stored inside the refrigerator: R103's unopened/sealed Lantus insulin pen, R44's two unopened/sealed Lantus insulin pens, R16's unopened/sealed Novolog insulin pen and R71's unopened/sealed Humulin N insulin pen. On 4/20/26 at 11:58am, V21 (RN) confirmed that the internal temperature of the 3rd floor medication refrigerator read 28 degrees Fahrenheit. There was a large amount of ice build up around a smaller compartment that was affixed to the interior upper right-hand corner of the refrigerator. There was also a thin film of ice build up on the plastic bags that the medications were stored in. The medications that were stored in this refrigerator: R3's unopened/sealed Lispro insulin pen and R94's Epoetin medication. R3, R16, R44, R71 and R102's current Physician Order Sheets (POS) indicate active orders for insulin pens and R94's Epoetin medication. On 4/20/26 at 12:15pm, regarding Tuberculin multidose vial, V11 (Infection Preventionist) stated, Once opened, date it for thirty days. Once thirty days is up, discard it. Once opened, it has to be dated for that date that it was opened. The risk if not dated is that it may not be potent. On 4/22/26 at 1:55pm, V3 ADON (Assistant Director of Nursing) was asked why facility policy reads that medication refrigerators should be kept between 36 to 46 degrees Fahrenheit (F). V3 stated, To keep the efficacy of the medications.On 4/22/26 at 2:07pm, V31 (Pharmacist) indicated that insulin pens and Epoetin infusion medications should be held between 36 F to 46 degrees F. V31 stated, Below 36 F, it says that the medication can freeze and cannot use if frozen. Any medications stored at temperatures below 36 F and above 46 F should not be used.There were several requests made on 4/20/26 through 4/22/26 for a Tuberculin medication policy. On 4/22/26 at 1:45pm, V1 (Administrator) provided a policy that read multidose vial storage. V1 indicated that there was no specific policy for Tuberculin medication. Procrit (Epoetin alfa) medication specifications insert dated 11/19/08 reads: Store PROCRIT in the refrigerator between 36 F to 46 F. Humulin N (insulin isophane human) medication specifications insert dated 1982 reads: Unopened Humulin N (insulin pens) are to be refrigerated 36 F to 46 F.Novolog (insulin aspart injection) medication specifications insert dated 2000 reads: 16.2 Recommended storage: Store unused Novolog in a refrigerator between 2 degrees Celsius and 8 degrees Celsius (36 F to 46 F).Insulin Lispro medication specifications insert dated 1996 reads: 16.2 Storage and Handling: Unopened insulin lispro should be stored in a refrigerator 36 F to 46 F but not in freezer. Lantus (insulin glargine injection) medication specifications insert dated 2000 reads: 16.2 Storage: Not in use (unopened) prefilled pen refrigerated 36 F to 46 F. A facility policy with a revision date of 12/2017 and titled, Storage of Medications and Medical Supplies documents, in part: Policy Statement: The facility shall store all drugs and biologicals and medical supplies in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 4. The nursing staff shall be responsible for maintaining medical supply storage and medication storage AND preparation areas in a clean, safe, and sanitary manner. 13. The temperature in the refrigerator should range between 36 to 46 degrees F. If the temperature falls outside of this range medications may be damaged. Notify your pharmacy for directions as different medications have different temperature storage ranges. All medications will be discarded that are not stored properly within their range. 14. Multiple dose vials such as insulin shall be dated the day they are opened and with the expiration date.

Based on observation, interview, and record review, the facility failed to ensure proper food safety practices by permitting a dietary aide to continue working with an expired food handler certification. This failure has the potential to affect 111 residents receiving regular oral diets out of the facility's 112 total residents, with one resident receiving a strict NPO/tube feeding diet. On 4/21/2026 at 10:18 AM, V28 (Dietary Supervisor) stated the facility has a registered dietitian and provided the license along with certifications of all dietary staff. Surveyor observed V19's (Dietary Aide) Illinois Food Handler Training Certificate expired 3/13/2026. On 4/22/2026 at 11:04 AM, V28 (Dietary Supervisor) provided V19's work time sheet which indicated V19 has worked the following days between 6 to 7 hours after the expiration of his (V19's) food service handling certification expired on 3/13/2026: 3/16/2026, 3/17/2026, 3/18/2026, 3/21/2026, 3/30/2026, 3/31/2026, 4/1/2026, 4/4/2026, 4/13/2026, 4/14/2026, 4/15/2026, an 4/18/2026.On 4/22/2026 at 1:50 PM, V28 (Dietary Supervisor) stated dietary aide's are required to have a food handling certification before working in the kitchen; V19's certification expired and he last worked on 4/18/2026; V19 is in the process of obtaining his food handling certification but he (V19) is having problems logging in; the purpose of the food handling certification is for staff to be properly trained in handling food in the kitchen to prevent food borne illness; and dietary aide's with an expired training certification can cause cross contamination in food preparation resulting in resident's becoming sick. Facility Policy titled Food Handler Training dated 2017 documents, in part, the healthcare community stores, prepares, distributes and serves food in a sanitary manner to prevent foodborne illness. Employees are re-trained in basic food handling principles every three years.

Based on observations, interviews and record review, facility failed their infection control and prevention policy and failed to perform hand hygiene before entering and after exiting resident's room on Enhanced Based Precautions (EBP); Failed to wear proper Personal Protective Equipment (PPE) while cleaning resident's room on EBP; Failed to wear proper PPE while entering resident room on Contact Isolation; Failed to ensure placement of isolation waste bins for trash and linen inside a resident room on Contact Isolation; Failed to ensure placement of waste basket/bin in the resident room on EBP; Failed to ensure that clean resident's clothing and linen is covered at all times in the clean laundry area; Failed to ensure that soiled linen was securely tied in plastic bag prior to throwing in the laundry chute and failed to ensure that soiled linen in the collection bin under the laundry chute was placed in a tied plastic bag. These failures affected six residents (R12, R36, R53, R64, R73 and R108) reviewed for Infection prevention and control and have the potential to affect all residents living in the facility.Findings include: R36's admission record includes but is not limited to Chronic Obstructive Pulmonary Disease (COPD), Respiratory failure, atrial fibrillation, fluid overload, end stage renal disease, and hypertension. R36's Minimum Data Set (MDS) dated [DATE] documents, in part, Section C. Brief Interview of Mental Status (BIMS) score is an 8. R36 has moderate impairment. On 4/20/26 at 10:45 am, The door to R36's room displayed a contact isolation sign and an EBP (Enhanced Barrier Precautions) sign on R36's door leading into R36's room. V24 License Practical Nurse (LPN) stated that R36 has MRSA (Methicillin Resistant Staphylococcus Aureus) in the nares. V24 went into R36's room and did not put on PPE (Personal Protective equipment). V24 wore a mask that he had previously had on. Surveyor asked V24 about what PPE is required when entering a contact isolation room? V24 stated, I do not have to put on any PPE because I'm not doing any care. I just need a mask on because of the MRSA in the nares. Surveyor referred to the contact isolation sign on the door to V24, that documents, in part, Contact Precautions: Providers and Staff Must: put on gloves before room entry. Discard gloves before exits room. Put on gown before room entry. Discard gown before exit room. V24 stated, I only need PPE if I'm doing care. On 4/20/26, 4/21/26 and 4/22/26 observations made at different times of R36 room not having any bins for disposals of garbage and linen in the room. On 4/22/26 at 10:20 am, V25 LPN stated that staff should put on PPE when going into a contact isolation room and there should be two bins in an isolation room to dispose PPE, garbage, and linen. On 4/22/26 at 1030 am, V6 Housekeeping Manager stated, The isolation rooms should have two red bins in the rooms. One bin is for linen, and one bin is for garbage disposal. I do not know how long he (R36) has been in isolation. I was just notified today that he does not have any red bins in the room. On 4/22/26 at 10:40 am, V11 Infection Preventionist Nurse stated, If staff go into a contact isolation room they should be dressed in a gown and gloves. R36 has MRSA in the nares. If not dressed it can cause contamination. The isolation room should have red bins for disposing garbage and linen, because it's a different treatment for washing linens from isolation rooms. V11 pulled the EBP sign off R36's door and stated, This should not be on the door. On 4/22/26 at 10:56 am, V2 DON (Director of Nursing) stated that all staff should have PPE on before entering a contact isolation room. If there are two signs on the door, the contact isolation sign supersedes the EBP sign. Both signs should not be on the door. There should be two red isolation bins in the isolation room. Garbage and linen should be discarded in a red bin to prevent transmission to staff and other residents. On 4/22/26 at 1:59 pm, V3 ADON (Assistant Director of Nursing) stated that if staff are not doing any care, in contact isolation rooms, they do not have to wear PPE. Surveyor asked ADON, is staff expected to follow the contact isolation sign on the door? V3 Stated that staff are expected to follow what is on the door, R36's active orders as of 4/22/26 documents, in part, Strict Contact Precaution for MRSA of the nares. R36's care plan dated 4/19/26 documents, in part, Focus: Infection with TBP (Transmission Based Precautions), R36 has active infection MRSA of the nares and requires contact transmission-based precautions. Interventions: Instruct visitors to wear PPE upon entering room and to wash hands before leaving room. Transmission Based Precautions as ordered. Facility's policy titled Contact Precaution and dated 5/22, documents in part, Contact Precautions: In addition to Standard Precautions, use contact precautions to prevent nosocomial spread of organisms that can be transmitted by direct resident contact.or by indirect contract of environment surfaces or contaminated resident care equipment. Contact Precautions requires the use of gown and gloves on every entry into a resident's room.Procedure for Contact Precautions: Gloves: 5. Wearing gloves is not a substitute for hand antisepsis. Gloves will be removed and discarded before leaving the residents room in isolation bins. Gowns: 1. [NAME] gown upon entry into the room or cubicle. 5. The gown will be removed and appropriately discarded in isolation bins before leaving the residents environment. Facility's job description titled, Infection Preventionist documents, in part, Duties/Responsibilities: Implements standards of nursing practice in infection prevention reviewing and revising as necessary to reflect changes in nursing practice and resident population. Ensure clear, concise and current written policies and procedures are available to assist the staff and minimize risk factors in infection prevention. R12's Face Sheet documents a diagnosis of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hidradenitis suppurativa, unsteadiness on feet, and unspecified severe protein-calorie malnutrition. R12's Physician Order Sheet dated 4/22/2026 documents an active order dated 1/28/2026 for Enhanced Barrier Precautions. R12's Physician Order Sheet dated 4/22/2026 has an active wound care order to the left foot (2nd) Toe to cleanse wound site with Dakin's solution apply Dakin's moistened gauze/dry gauze and cover with dry dressing as needed change dressing if soiled/saturated. R12's Physician Order Sheet dated 4/22/2026 has an active wound care order dated 4/3/2026 to the left second toe to cleanse wound site with betadine solution and cover with dry dressing every day shift Monday, Wednesday, and Friday. On 4/20/2026 at 11:18 AM, V29 verified R12 has an Enhanced Barrier Precaution bin outside of his (R12's) room but not garbage can to dispose of Personal Protective Equipment. On 4/20/2026 at 11:18 AM, V29 stated there should be garbage cans in all rooms and all rooms with Enhanced Barrier Precaution signs to maintain infection control. R108's Face sheet dated 4/22/2026 documents rhabdomyolysis, peripheral vascular disease, cellulitis of left lower limb, venous insufficiency, non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, and non-pressure chronic ulcer of unspecified lower leg with unspecified severity. R108's Physician's order dated 4/22/2026 documents an active wound care order dated 4/20/2026 for Right knee: Cleanse with Betadine solution. R108's Physician's order sheet dated 4/22/2026 documents an active wound care order dated 4/21/2026 for left leg: Cleanse with wound cleanser. Apply xeroform dressing to wound bed then dry gauze/ABD padding and wrap with bandage roll and secure with tape. R108's Physician's order sheet dated 4/22/2026 an active order 4/21/2026 Left Foot: Cleanse affected areas with Betadine solution. Apply ABD padding and wrap with bandage roll gauze and secure with tape R108's Physician's order sheet dated 4/22/2026 an active order 4/21/2026 Right Leg: Cleanse affected areas with Betadine solution. Apply ABD padding and wrap with bandage roll gauze and secure with tape. R108's Physician's order sheet dated 4/22/2026 an active order 4/21/2026 Right Foot: Cleanse affected areas with Betadine solution. Apply ABD padding and wrap with bandage roll gauze and secure with tape On 11/18/2026 at 11:16 AM, this surveyor observed R12 and R108 had Enhanced Barrier Precaution signs on their doors, but no garbage cans to dispose of personal protective equipment. On 4/22/2026 at 10:46 AM, V2 (Director of Nursing) stated the residents on Enhanced Barrier Precautions should have two garbage cans, one for garbage and a larger lined trash can near the exit door of the room for discarding used Personal Protective Equipment (PPE) before exiting the resident's room. V2 stated the purpose placing garbage cans in resident's rooms specifically for discarding PPE before exiting a resident's room is to prevent the transmission of diseases and cross contamination to a resident's roommate. On 4/22/2026 at 11:05 AM, V2 (Director of Nursing) verified R12 and R108 has an Enhanced Barrier Precaution sign on their room door with no garbage bin to dispose of personal protective equipment before exiting a resident's room. On 4/22/2026 at 11:13 AM, V11 (Infection Preventionist) stated personal protective equipment (PPE) should be worn by nurses and other clinical staff in contact isolation rooms and the dirty PPE is discarded in a garbage bin lined with a red biohazard bag; residents on Enhanced Barrier Precautions should have a garbage bin to discard PPE before the staff member exits the room; and the purpose of having a garbage to discard PPE is to prevent contamination. Facility's policy titled Enhanced Barrier Precautions dated 5/2022 documents position a trash can inside the resident room and near the exit for discarding PPE (Personal Protective Equipment) after removal, prior to exit of the room or before providing care for another resident in the same room. Findings include: On 4/20/2026 at 10:33 AM, the census in the facility was 112 residents. V14 (Certified Nursing Assistant/CNA) stated that the census for the 3rd floor unit is 36 residents. On 4/20/2026 at 11:36 AM, on the 3rd floor unit, observed V4 (Housekeeper) cleaning R53 and R64's room (floor, bedside table and bathroom) that is on Enhanced Barrier Precautions (EBP) without wearing proper Personal Protective Equipment (PPE). V4 was observed wearing only gloves, no gown. On 4/20/2026 at 12:05 PM, V4 (Housekeeper) stated that V4 is new employee at the facility and that the housekeeping staff should wear proper PPE when cleaning a room on Contact Isolation or EBP. V4 stated that PPE's include gowns, gloves and mask. V4 affirmed that V4 should have worn gown and gloves during cleaning of R53 and R64's rooms or any other resident's room that is on EBP or other isolation. V4 stated that V4 did not notice the EBP sign on R53 and R64's wall next to the door before V4 entered to clean the room until walked out of room. V4 said that wearing proper PPE's is important to help prevent spreading of infection and that staff should follow the isolation sign that shows the necessary PPE that should be used. V4 stated that the PPE is located in the clear plastic bins in the hallways and V4 pointed out the PPE bin that was outside of R53 and R64's room in the hallway. On 4/21/2026 at 10:02 AM, in the clean laundry area of the facility, observed with V5 (Laundry Aide) three hamper stands with clean resident's clothing hanged on the metal rod of the hamper, not covered. Observed a clean linen cart filled with clean linen (bed sheets, gowns, pillow cases) open to air, not covered. Observed additional smaller plastic cart with clean folded towels, washcloths and pillow cases open to air, not covered. Observed next to the dryer machines on the metal cart a pile of clean folded blankets and resident's blankets, open to air and not covered. Surveyor also noticed during observation of the clean laundry area, a strong breeze from a nearby standing fans that were in the separate soiled laundry room, but the breeze was felt blowing and circulating in the clean laundry area. The clean laundry area room was separated from the soiled laundry area room, but the rooms were connected and there was no door attached so the breeze was felt in both rooms. On 4/21/2026 at 10:16 AM, observed with V5 (Laundry Aide) a soiled laundry washing room with a laundry chute in the room. Observed under the laundry chute a collection bin with multiple loose soiled clothing and linen items (incontinent bed chucks, sheets, blankets, towels, shirts, washcloths) inside of the bin, not covered and not placed in plastic bags. Observed the collection bin filled to the top with loose soiled linen. Observed opened plastic bag falling through the laundry chute and into the collection bin with soiled linen falling out of the bag, touching the laundry chute's walls and landing on top of the collection bin with already soiled loose linens inside of the bin. On 4/21/2026 at 10:18 AM, V5 (Laundry Aide) stated that all clean linen including the clean resident's clothing should be covered at all times to prevent dust particles or other bacteria to get on the clean linen and to prevent cross-contamination. On 4/21/2026 at 10:22 AM, V6 (Housekeeping and Laundry Manager) stated that clean linen should always be covered, because the dust particles could get on the line and cause airborne contamination which could lead to infection and diseases spreading. V6 also said that all of the clean linen and the washed resident's clothing should be covered at all times including during transportation and distribution to the floors and resident rooms. V6 also stated that soiled linen falling through the laundry chute should always be placed in the plastic bag and tied securely, so the soiled linen does not come out of the bags because it could cross-contaminate the laundry chute which then could potentially contaminate the whole facility's linen and resident's clothing. V6 also said that loose linen items should never be thrown into the laundry chute and the collection bin under the chute should not have loose soiled linen inside. The soiled linen should stay in the plastic bags until is removed and separated in a separate area. V6 also said that the housekeeping staff should be always wearing gloves and gowns when cleaning isolation rooms including the room on EBP. On 4/21/2026 at 11:13 AM, V21(Registered Nurse/RN) stated that soiled linen should be placed in the plastic bags, tied securely and thrown into the laundry chute. V21said that placing soiled linen in plastic bags and tying them securely prevents cross-contamination and infections spreading. On 4/21/2026 at 11:19 AM, observed V8 (Certified Nursing Assistant/CNA) to enter R73's room without performing hand hygiene. Observed on R73's room wall an EBP sign. Observed V8 picking up R73's cell phone to check if working and if charging, then placing the phone on R73's window ledge to charge and walk out of the room. V8 did not perform hand hygiene upon exiting room, nor at any time did V8 wore PPE. V8 stated that hand hygiene should be performed when changing gloves and changing resident. V8 stated that V8 should have perform hand hygiene before entering and after exiting R73's room. On 4/21/2026 at 11:26 AM, V8 stated that all soiled linens should be placed in the plastic bags and tied securely prior throwing to the laundry chute. V8 said that loose soiled linen should never be thrown into the chute without being in the tied plastic bag to help prevent infection and cross-contamination. On 4/21/2026 at 11:37 AM, V9 (CNA) stated that the staff should place all soiled linen into the plastic bag and should tie the bag before throwing to the laundry chute. V9 said that this is important to prevent germs and virus to contaminate other linen and helps prevent infection spread. V9 also said that performing frequent hand hygiene is important to help prevent infection spreading to the residents or the staff. On 4/21/2026 at 12:29 PM, V11 (Infection Control Nurse/ Infection Preventionist/IP/ Licensed Practice Nurse/LPN) stated that handwashing is number one tool to prevent infection spread and everyone should be washing hands or perform hand hygiene before entering and after exiting resident's room. V11 said that hand washing should be performed for at least 20 seconds and for residents on Enhanced Barrier Precautions (EBP) the staff should perform hand hygiene before entering room, don gown and gloves and after care, remove gown and gloves and perform hand hygiene prior exiting the room. V11 stated that housekeeping staff should always wear gown and gloves when cleaning resident room that has EBP or Contact isolation precautions. V11 stated that in Contact isolation rooms there should be separate bins with red plastic bags for linen and waste and those would get collected by the house keeping staff. V11 said that soiled linen from regular resident rooms or EBP rooms, should be placed in the clear plastic bag and should be tied up securely, prior throwing into the laundry chute. V11 said that the reason why the soiled linen should be in the plastic bag and tied before throwing into the laundry chute, is to prevent cross-contamination of the chute and therefore the linens for the whole facility. V11 stated that no linen should be placed in the laundry chute without being in the plastic bag. V11 stated that in the soiled area of the facility's laundry, inside of the collection bin under the laundry chute, there should be no loose soiled linen, and should not be without being bagged. V11 also said that the clean washed linen in the laundry area should be stored on clean linen cart which should be covered at all times. V11 also said that the cleaned washed resident's clothes should be hung on the hamper rack and should be covered with a sheet or a blanket to prevent airborne particles to deposit on the line and cause cross-contamination and spreading infection. On 4/21/2026 at 4:53 PM, V17 (CNA) stated that handwashing is important in spreading infection to residents or to self and the staff should be wearing gowns and gloves when providing direct care for residents on isolation precautions including EBP. V17 also said that soiled linen gets placed in the linen bins with a plastic bag and when filled, the plastic bag should get tied securely and then tossed to the laundry chute. V17 said that the bags must be tied well, otherwise the bags with soiled linen could open and cross-contaminate the laundry chute. R53's diagnosis include but is not limited to unspecified Asthma; Intervertebral disc degeneration of lumbar region; Benign Lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck; Alcohol use; Chronic Kidney disease; Paroxysmal Atrial fibrillation; Heart Failure; Respiratory Disorder; Acute kidney failure; Hydrocele; Nephrotic syndrome with Unspecified morphologic changes and history of falling. R53's Minimal Data Sheet (MDS), (1/20/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 9 which indicated impaired cognition. R53's Care Plan, (4/22/2024), showed in part that R53 has ADL abilities deficit and requires staff assistance due to history of falling and Intervertebral disc degeneration and had bladder and bowel incontinence and should be monitored and provided incontinence care. R53's CP also showed that R53 has potential for skin integrity impairment due to heart failure, Chronic Kidney disease. R64's diagnosis include but is not limited to Fracture of Nasal Bones, Lack of Coordination, Muscle Wasting and Atrophy, Unsteadiness on feet, Abnormal posture, Peripheral Vascular Disease, Hydronephrosis with renal and ureteral calculous obstruction, Heart failure, Fall from bed, Laceration without foreign body of nose and right eyelid, tobacco use, Other cervical disc degeneration, spinal stenosis. R64's Minimal Data Sheet (MDS), (2/25/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 12 which indicated impaired cognition. R64's MDS (2/25/2026) in section GG for Functional abilities showed that R64 is dependent on lower body dressing and putting on footwear, uses wheelchair to get around and needs maximal assistance for personal hygiene, shower and toileting. R64's Care Plan, (3/1/2026 ), showed in part that R64 has actual skin breakdown due to diagnosis of PVD and has right heel and right leg vascular wounds. R64's Active Orders (1/28/2026) showed in part that R64 is on Enhanced Barrier Precautions due to wounds. R73's diagnosis include but is not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side; Chronic obstructive pulmonary disease; Muscle wasting and atrophy; Unsteadiness on feet; Abnormal posture, Anemia; Psychoactive Substance abuse; Depression; Essential Hypertension; Overactive Bladder; History of Venous thrombosis and embolism, history of falling, and history of healed traumatic fracture. R73's Minimal Data Sheet (MDS), (3/2/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 12 which indicated impaired cognition. R73's MDS (3/2/2026) in section GG for Functional abilities showed that R73 needs maximus assistance for lower body dressing and putting on footwear, uses wheelchair to get around and needs moderate assistance for personal hygiene, shower and toileting. R73's Care Plan, (1/11/2026), showed in part that R73 has potential risk for pressure ulcer development related to impaired mobility, altered sensation and bowel/bladder incontinence and the staff should follow policies and protocols for prevention of skin breakdown. Facility's document titled Infection Control Plan (6/2022), showed in part a mission statement that the infection control plan is in place to ensure a safe, sanitary and comfortable environment for residents and personnel, to help prevent the development and transmission of disease and infection. The program includes in part a group of activities to ensure that recommended practices for the prevention of healthcare-associated infections are followed and implemented by personnel to make the healthcare setting safe from infection for residents. The program should ensure in part that the facility has process in place to control outbreaks, to intervene directly to prevent infections and interrupt the transmission of infectious diseases and to demonstrate proper storage and handling of linens to minimize contamination. Document showed in part that essential areas of impaction include but not limited to Environmental services, Linen management and Infection prevention during transitions of care. Emergency preparedness section of document showed in part that infections are a significant source of morbidity and mortality for residents in long term care facilities and that some institutional factors that support transmission of infections among the resident's population of the facilities include but are not limited to nosocomial pathogen exposure such as shared communal living space, common air circulation, direct/indirect contract with healthcare personnel, direct/indirect contact with resident care/facility's equipment. Document also showed in part that microorganisms could enter residents through different points of entry such as handshake, a dressing change of open wound without proper hand washing, incontinent care without proper hand washing and food handling with soiled hands. Document disclosed in part that an effective infection control program is necessary to control the spread of infections and that the components of infection control program are crucial to the operations of the facility and that some of the components include but not limited to review of the laundry practices, monitoring facility's wide environmental infection prevention practices and monitoring isolation precaution techniques and procedures to ensure that all personnel follow the established infection control/prevention practices. Facility's document titled Infection Control Manual, Linen and Laundry Policy (5/2022), showed in part the purpose is to provide a process for safe and aseptic handling and storage of linen and to handle all potentially contaminated linen with appropriate measures to prevent cross-transmission. Document also showed in part that if linen chutes are used, no lose items should be placed in the chute and bags should be closed before tossing into the chute. Documents also showed in part that clean linen should be transported from the laundry to the linen room in a clean, covered cart and linen should be covered during transport to prevent contamination while moving through facility; linen should remain covered at all times until placed into resident rooms. Facility's document titled Handwashing/Hand Hygiene (3/2020), showed in part that the facility considers hand hygiene as the primary means to prevent the spread of infections and all personnel should follow the handwashing/hand hygiene procedures to prevent infections spreading to residents or other personnel. Document showed in part that employees must wash hands in situations including but not limited to before and after entering isolation precaution settings, before and after direct contact with resident and assisting with resident's needs and after contact with objects in the immediate resident's area. Facility's document titled Enhanced Barrier Precautions (5/2022), showed in part that everyone must clean hands before entering and after leaving a room and that is critical for staff to have awareness of the facility's expectations about hand hygiene and gown/glove use when implementing Enhanced Barrier Precautions and clear signage on the door or wall outside of resident room should be posted indicating type of Precautions and required PPE such as gown and gloves. Facility's Sign titled Enhanced Barrier Precautions (Undated), showed in part that for EBP everyone must clean hands, including before entering and when leaving the room and that the providers and staff must also wear gloves and gown for high-contact resident care activities including but not limited to transferring, device care or use and changing linen. Facility's document titled Laundry (Undated ) showed in part that lids or covers must be kept on hampers at all times and that laundry area should be kept clean and unobstructed. Facility's document titled Housekeeping and Laundry Service Distribution (Undated), showed in part under Operational procedures that clean linen should be covered and keep covered during transportation to other areas and to keep lean laundry carts covered during transporting. Facility's document titled Cleaning and Disinfection Residents Rooms (1/2014) showed in part that housekeeping staff should use heavy-duty gloves and other Personal Protective Equipment (PPE) for performing of housekeeping tasks to reduce exposure to chemicals or to blood or other body fluids during cleaning and that the housekeeping staff should perform hand hygiene after glove removal. Document also showed in part that PPE such as gowns, gloves and masks are necessary to use during cleaning procedures and PPE should be worn when cleaning resident rooms that are on isolation precautions. Facility's document titled Housekeeper Job Description (Undated), showed in part that the housekeeper should maintain assigned areas are clean, sanitary, and safe at all times and should use proper Personal Protective Equipment (PPE) and should follow established sanitation and safety standards. Facility's document titled Laundry Aide Job Description, (Undated), showed in part that the Laundry aide should provide a variety of laundry duties in a sanitary condition and deliver laundry to various locations, including resident rooms. Facility's document titled Certified Nursing Assistant (CNA) Job Description, (Undated), showed in part that CNA helps residents with comprehensive and personalized health care needs under the supervision of a nurse and CNA assists resident with activities of daily living (ADL). Document also showed in part that CNA's responsibilities include but are not limited to answering resident's calls and needs and providing physical support for resident's ADLs and personal hygiene. Facility's document titled Registered Nurse (RN) Job Description, (Undated), showed in part that some of the responsibilities of a RN are including but not limited to Directing and supervising the day-to day Certified Nursing Assistant (CNA) services to ensure that care is being provided in accordance of federal, state and local standards, guidelines and regulations; Providing required assessments/observations and interventions to ensure appropriate care; Ensuring resident's environment is free from accidents and immediately corrects potential safety risks and Ensuring that all aspects of resident care plans are implemented and maintained. Facility's document titled Housekeeping Manager Job Description, (Undated), showed in part that the housekeeping manager manages the housekeeping and the laundry staff and ensures a clean facility and laundry and enforces facility's policies with the responsibility to issue couching or corrective action as needed. The Housekeeping manager also should provide staff with in-services on housekeeping and laundry department's policies and procedures, infection control and safety as appropriate. Facility's document titled Infection Preventionist LPN Job Description, (Undated), showed in part that the Infection Preventionist (IP) assists with organizing and administering areas of Resident Care Services and infection prevention and ensures that programs and procedures are developed to assess, evaluate and meet the needs of residents and IP implements standards of nursing practice in infection prevention and assists with implementation of effective, ongoing program that measures, assess and improves the quality of nursing care and infection control delivered to residents. IP should also monitor and direct non-licensed ancillary staff to meet professional standards and maintain highest level of residents care and should ensure compliance with infection control standards and immediately corrects/addresses instances of non-compliance. Facility's document titled Directo of Nursing RN Job Description, (Undated), showed in part that the Director of Nursing (DON) is responsible for direction and supervision of all the nursing services provided in the facility and DON should ensure nursing department compliance with federal, state and local regulations and implementation of facility's nursing programs. Document also showed in part some of the DON's responsibility including but are not limited to Managing the nursing staff and enforcing policie

Based on observation, interview and record review the facility failed to ensure that a resident's indwelling catheter drainage bags were covered. This failure affected one resident (R1) reviewed for dignity in the sample of 50 residents.Findings include:R1's admission record includes but is not limited to Chronic Obstructive Pulmonary Disease (COPD), Benign prostatic hyperplasia, retention of urine, urinary tract infection, hypertension, heart failure, urethral fistula, and malignant neoplasm of prostate. R1's Minimum Data Set (MDS) dated [DATE] documents, in part, Section C. Brief Interview of Mental Status (BIMS) score is a 12. R1 is cognitively intact. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling catheter.On 4/20/26 at 11:41 am, surveyor observed (R1) indwelling catheter drainage bag not covered in a privacy bag. The privacy bag was noted on the floor next to the bed. On 4/22/26 at 10:40 am, V11 Infection Preventionist stated that the indwelling catheter should be in a privacy bag, for dignity.On 4/22/26 at 10:56 am, V2 Director of Nursing (DON) stated that the Indwelling catheter should be covered in a privacy bag to ensure the dignity of the resident.On 4/22/26 at 1:59 pm, V3 Assistant Director of Nursing (ADON), stated that the Indwelling catheter should be in a privacy bag to maintain the dignity and privacy of the resident.R1's Active orders as of 4/22/26 documents in part, Indwelling catheter size 16 fr. (French) Balloon 5-10 ml (milliliters) for diagnosis of Chronic Urinary Retention. R1's care plan dated 1/23/26 documents, in part, Focus: R1 requires use of an indwelling catheter related to diagnosis of Urine Retention. Intervention: Keep draining bag covered to promote privacy. Facility's policy titled Urinary catheter Care Policy and Procedure and dated 3/2014, document, in part, 17. Place urinary bag in urinary bag holder. 23.Infection Control Measures: Make sure the catheter tubing and drainage bag are kept off the floor. Use a drainage bag holder.Facility's policy titled, Quality of Life- Dignity, dated 12/2016 documents, in part, policy Interpretation and Implementation 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered.

Based on observation, interviews, and record review, the facility failed to follow the Wound Assessment/ Breaks in Skin Policy, to document assessment of wound in the resident chart and to ensure skin assessments were performed for 1resident (R26) of 4 reviewed for wounds in a total sample of 50.Findings include:(R26's) face sheet revealed pertinent diagnoses including Acquired absence of left above knee, Peripheral Vascular Disease, Cerebral Infarction, Dementia, and Major depression. (R26) was admitted on [DATE].On 4/20/26 at 12:15 PM (R26) was in bed sleeping with multiple uncovered wounds noted on the right leg. One wound was large with a red wound bed. The surrounding skin around the was dark in color. The second wound was circular in shape and looked like a ruptured blister. No drainage was seen. Multiple smaller wounds were scattered on the right leg, some with scabbing. (R26's) Physician Orders Sheet dated 4/16/26, reads Bacitracin External Ointment 500 UNIT/GM. Apply to Left Lower Leg topically every day and evening shift for old scar X 10 days until 04/26/2026. [The order was for the left leg although the wounds were on the right leg.]A progress note dated 4/20/26, indicates that (R26) was seen by the (V39) nurse practitioner on 4/16/26. V39 (Nurse practitioner -NP) documented abrasion and scratches to right lower leg and instructions to monitor, evaluate, assess, treat, keep skin clean and dry. It was also documented to assess right lower leg of signs of erythema, edema and or drainage and to notify the provider if noted.(R26's) electronic medical record revealed from 4/16/26 through 4/20/26 , there was no documentation of skin assessments or notification of the wound care nurse. From 4/17/ 26 through 4/20/26, V20 (Registered Nurse-RN), V21(RN), V24 (Licensed Practical Nurse- LPN), V27 (RN), V36 (LPN), and V37 (LPN), provided (R26's) wound treatment and failed to document the skin assessments.Multiple requests were made from 4/21/26 through 4/22/26, to obtain the Shower sheets for the month of April. On 4/22/26 3:26PM, V22 (wound care nurse) provided one shower sheet dated 4/6/26, and stated this is all I have. The shower sheet provided documented dry skin. On 4/21/26 at 10: 42 AM, V21 (RN) stated I don't know where the wounds came from, he wasn't always up here (on then 3rd floor). I know we are treating it with antibiotic ointment.On 4/21/26 at 2:25 PM, V22 (Wound Care Nurse) stated I'm not aware of any wounds for R26. Normally the staff will let me know if they find any issues. I would have to look into it. They call me for everything if the dressing comes off or if they have a skin tear.On 4/22/26 at 10:30 AM, V22 indicated (R26), does have peripheral vascular disease. V22 stated I am not sure if he banged his leg. I did talk to the V40 (wound doctor), and he said we are going to get doppler on the leg today. I did not know about the wound until you mentioned it. V22 indicated (R26) will be seen by the wound care doctor on 4/24/26. V22 stated the leg does have discoloration. I am not sure how long he had the wound. Maybe a couple of days but I can only go by the order V38 (LPN) put in. If I had found out earlier the treatment plan would have been the same (Bacitracin). If I had gotten the call and they told me, it was discoloration I would have called the doctor for a doppler order. Treatment would not have been Bacitracin it would have been Betadine. The nurse may have put Bacitracin because she did not know or if the primary doctor prescribed it. I plan to in-service staff on notifying wound care of any skin alteration.(R26's) Medication Administration Record (MAR) for April 2026, documented V20 (Registered Nurse/RN), V21(RN), V24 (Licensed Practical Nurse/ LPN), V27 (RN), V36 (LPN), and V37 (LPN), applied Bacitracin to (R26's) leg. There was no documentation in (R26'S) progress notes V22 (wound care) was notified.(R26's) initial skin assessment was performed on 4/22/26 by V22 (wound care nurse). (R26's) wound care assessment date 4/22/26 at 6:16 AM, documented (R26) had two right lower leg wounds, type: vascular, classification Arterial insufficiency, source: facility acquired and measured 20cm length x 12cm width x 0.10 depth and 9cm length x 4cm width x 0.10cm depth, indicating a worsening of both wounds compared to V39 nurse practitioner initial progress note.On 4/22/26 at 3:11 PM, V3 (Assistant Director of Nursing- ADON) stated the protocol for skin injuries is the staff has to report it to the nurse which is then reported to the wound care nurse. V3 continued to state V22 nurse reports to me. V3 confirmed that any staff member can report it to V22 wound care nurse.(R26's) electronic medical record documents V38 (LPN) was the staff member that addressed (R26's) right leg wound. On 4/23/26 at 10:59 AM, V38 stated the V39 nurse practitioner (NP) was here to see R26 and gave me the order for the treatment. V38 indicated that she did not tell V22. V38 said It wasn't on me to do so (tell the wound care nurse) because the V39 (NP) was there and gave me the order. I just put the order in so that nurses could do the treatment. V38 indicated the policy is if the nurse is informed of skin injuries, the nurse assesses the patient and calls the doctor and let V22 (wound nurse) know. If there are any wounds, I will notify wound care myself to let them know.Review of the facility's Shower/Skin Assessment Policy dated 5/2022 reads: Residents will have their skin assessed during showers/baths, peri care, upon admission/readmission, and other times that residents are dressed and undressed. During the completion of showers and baths, any abnormal findings will be documented on an assessment shower sheet/form. The licensed nurse will verify skin assessments that are completed during showers and bathing. Skin alterations that are identified at times other than bathing will be reported to the nurse immediately for further assessment.Review of the facility's Wound Assessment/Breaks in the Skin Policy dated 5/2022 reads: Documentation Record the following information in the resident's medical record: 1. Complete in-house investigation of causation, 2. Document assessment of wound in PCC or Wound Rounds, 3. Document physician and family notification, and resident education (if completed) in medical record.

Based on observation, interview, and record review the facility failed to ensure staff follow established facility policies and procedures related to respiratory equipment care with nebulizer masks not contained and safe oxygen administration with a resident not receiving oxygen concentration per liter in accordance with the physician's order. This failure affected 2 of 2 (R74 and R126) reviewed for respiratory/tracheostomy care and suctioning.Findings include: R74's admission record includes but is not limited to chronic heart disease, peripheral vascular disease, hypertension, heart failure, chronic kidney disease stage 4 and a prosthetic heart valve. R74's Minimum Data Set (MDS) dated [DATE], documents, in part, Section C. Brief Interview of Mental Status (BIMS) score is a 7. R74 has severe impairment. On 4/20/26 at 10:15 am, R74 in room lying in bed receiving oxygen through a nasal cannula at 3 liters. R74's nasal cannula tubing was not dated. On 4/21/26 at 12:10 pm R74's nebulizer mask noted on the floor next to the nightstand uncontained. On 4/21/26 at 12:20 pm, V27 Registered Nurse stated that the nebulizer mask should be in a bag when not in use, to prevent it from getting dirty and being contaminated. On 4/22/26 at 10:46 am, Director of Nursing (DON) stated that oxygen tubing and mask are changed every Thursday night. The nasal cannula should be dated when it is changed. The oxygen mask should not be on the floor it should be in a bag. It could cause an infection in the nose, because of being on the floor. On 4/22/26 at 1:59 pm, V3 Assistant Director of Nursing (ADON) Oxygen mask for the nebulizer treatment should be dated and put away in a bag. It put in a bag to avoid being contaminated. The nasal cannula is changed weekly and PRN (As Needed). When it is changed it should be dated then. R74 Active orders as of 4/22/26 documents, in part, change oxygen tubing and humification bottle every week on Thursday night and PRN (As Needed) .Respiratory: Administer oxygen at 3L (Liters)/min (minute) per nasal cannula every shift for dyspnea. R74's care plan dated 2/4/26 documented, in part, Focus: R74 has potential for difficulty in breathing related to CHF (Chronic Heart Failure). Interventions: Administer oxygen as ordered. Facility policy titled, Oxygen Administration dated 3/20, documents, in part, General Guidelines: d. Oxygen tubing and humidification bottles are to be changed weekly and as needed. Tubing and humidification bottles are to be dated at the time they are changed. E. Oxygen tubing will be covered and stored when not in use. R126's Face Sheet dated 4/22/2026 documents a diagnosis of but not limited to acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified asthma, and essential hypertension. R126's Physician's order sheet dated 4/22/2026 documents an active order dated 4/11/2026 for oxygen per nasal cannula at (3) Liters/minute continuous. On 4/20/2026 at 11:59 AM, R126's oxygen concentrator was observed set at 4 liters/minute. V30 (Licensed Practical Nurse) stated R126 has a physician's order for oxygen per nasal canula at 3 liters/minute continuous; V30 verified R126's oxygen concentrator was set a 4 liters/minute; the night nurses are responsible for setting the oxygen concentrators; and purpose of setting oxygen at the prescribed levels is maintain oxygen saturation that promotes breathing. On 4/22/2026 at 10:53 AM, V2 (Director Of Nursing) stated oxygen concentration therapy levels should be set a the physicians prescribed order; oxygen concentration therapy set higher than the prescribed order can cause improper carbon dioxide gas exchange or hyperoxygenation and is ineffective in residents with diseases such as chronic obstructive pulmonary disease; and all nurses are responsible for ensures oxygen concentration therapy setting are set in accordance with the physician's order. Facility's policy titled Physician's Order to ensure physician orders are obtained, documented, verified, and carried out accurately and in a timely manner to support safe resident care. Facility's Registered Nurse Job description undated documents provides licensed care to assigned residents as ordered by physician and in accordance with facility, federal, state, and local standards guidelines and regulations.

Based on observations, interviews and record review, facility failed their Call light policy and failed to ensure that resident call light bell was within a reach and accessible for one resident (R76) while in the bed. This failure affected one resident reviewed for resident call system in the final sample of 50 residents.Findings include:On 4/20/2026 at 10:33 AM, the census in the facility was 112 residents. V14 (Certified Nursing Assistant/CNA) stated that the census for the 3rd floor unit is 36 residents.On 4/20/2026 at 11:02 AM, observed in R76's room, R76 laying in the bed covered with blanket. Observed R76's call light tied up to the back of the right bed rail, hanging down almost touching the floor. When asked R76 if R76 could reach the call light bell button, R76 was observed looking around for the call light, but could not see it and R76 stated that R76 does not know where the call light bell is. When pointed to the right bed railing of R76 bed, and asked if R76 could reach the call light, R76 was observed to try to reach and grab the call light but could not. R76 stated that R76 is unable to reach the call light bell.On 4/21/2026 at 10:48 AM, observed in R76's room, R76's call light bell hanging on the right side of the bed rail, almost touching the floor, while R76's laying in the bed turned towards the left side, away from the call light. R76 stated that R76 could not reach the call light, because R76 does not know where the call light is. When instructed to try to reach the call light on the right side of the bed rail, R76 could not physically reach the call light. R76 stated that R76 would have to yell out to get assistance since R76 can't reach the call light bell button.On 4/21/2026 at 11:13 AM, V21 (Registered Nurse) stated that residents call light bells should always be within resident's reach and usually are attached to the patient with a clip or to the residents pillow or linen.On 4/21/2026 at 11: 20AM, V8 (Certified Nursing Assistant/CNA) stated that resident call light bells should always be within resident reach and that V8 usually pins the call light bell with a clip on resident's clothing or linen such as pillow or fitted bed sheet. V8 stated that the call light bell should not be tied to the side of the bed railings, because the resident would not be able to reach and access the call light bell and call for assistance.On 4/21/2026 at 11:37 AM, V9 (CNA), stated that resident's call light bells should always be within the resident's reach and that there is a clip that is being used to clip the call light bell to either resident's gown, sheet or pillow. V9 stated that the call light bell should never be hanging on the side rail of the bed, because resident could not reach it and be able to call for assistance.On 4/21/2026 at 4:53 PM, V17 (CNA) stated that resident's call light bell should be clipped on the bedsheet or on the resident's clothing for easy access. V17 also stated that resident should always see where the call light bell is and should always be able to easily reach the call light bell button.On 4/22/2026 at 10:26 AM, V2 (Director of Nursing/DON), stated that call light bells should always be within resident's reach. V2 stated that reachable call light is important so the residents could access it and be able to call staff for assistance. V2 also said that the call light should be clipped to the linen such as resident's pillow, gown or sheet and should not be on the floor or curtains or just hanging tied to the bed rails, because the resident could not reach the call light bell button and therefore call for assistance. V2 also said that residents should be always aware of the location of the call light bell button, especially the bedbound residents.On 4/22/2026 at 12:23 PM, V1 (Administrator) stated that resident's call light bells should not be on the floor, the call light bells should aways be within resident's reach. V1 also said that the call light bell buttons should be attached to the bed sheet or pillow case , anywhere where resident would be able to comfortably reach and know their call light location.R76's diagnosis include but is not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting left side, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Anemia, Anxiety disorder, Seizures, Essential Hypertension, History of Venous Thrombosis and embolism, Chronic Kidney disease, Chronic Atrial Fibrillation and Benign Prostatic Hyperplasia with lower urinary tract symptoms.R76's Minimal Data Sheet (MDS), ( 2/5/2026) in section C for Cognition Patterns showed in part the Brief Interview of Mental Status (BIMS) score of 7 which indicated impaired cognition.R76's MDS (2/5/2026) in section GG for Functional abilities showed that R76 is dependent on staff's assistance for lower body dressing and putting on footwear, using wheelchair to get around and needs maximal assistance for personal hygiene, shower and toileting and that R76 is always incontinent with urine and bowel.R76's Care Plan (CP), (2/9/2026 ), showed in part focus that R76 uses bilateral side rails for bed mobility and R76 should have a call light withing reach while R76 is in bed. R76's CP (2/9/2026) also showed in part that R76 has ADL deficit and requires staff assistance, and that call light should be within reach and answered in a timely fashion and that R76 should be educated on the use of call light for assistance.Facility's document titled Answering the Call Light (11/2013), showed in part the purpose is to respond to the resident's needs and that when resident is in bed or confined to a chair, the call light should be within easy reach of resident.Facility's document titled Resident Rights (4/2017), showed in part that federal and state laws guarantee basic rights to all resident of the facility and include but are not limited to the right to be treated with respect, kindness and dignity; be free from abuse, neglect, exploitation and misappropriation of property; be supported by the facility in exercising rights and to be informed of and participate in care planning and treatment.Facility's document titled Certified Nursing Assistant (CNA) Job Description, (Undated), showed in part that CNA helps residents with comprehensive and personalized health care needs under the supervision of a nurse and CNA assists resident with activities of daily living (ADL). Document also showed in part that CNA's responsibilities include but are not limited to answering resident's calls and needs and providing physical support for resident's ADLs and personal hygiene.Facility's document titled Registered Nurse (RN) Job Description, (Undated), showed in part that some of the responsibilities of a RN are including but not limited to Directing and supervising the day-to day Certified Nursing Assistant (CNA) services to ensure that care is being provided in accordance of federal, state and local standards, guidelines and regulations; Providing required assessments/observations and interventions to ensure appropriate care; Ensuring resident's environment is free from accidents and immediately corrects potential safety risks and Ensuring that all aspects of resident care plans are implemented and maintained.Facility's document titled Directo of Nursing RN Job Description, (Undated), showed in part that the Director of Nursing (DON) is responsible for direction and supervision of all the nursing services provided in the facility and DON should ensure nursing department compliance with federal, state and local regulations and implementation of facility's nursing programs. Document also showed in part some of the DON's responsibility including but are not limited to Managing the nursing staff and enforcing policies with the responsibility to issue coaching and corrective action when needed; Ensuring necessary equipment, supplies and staff are available to deliver prescribed resident care and Completing facility's rounds daily to ensure compliance with all policies, procedures and regulations.

Based on interview and record review, the facility failed to ensure physician-ordered laboratory tests were completed and followed up in a timely manner for one resident (R2) out of three residents reviewed for improper nursing care. Findings include:Record review of R2's face sheet reads medical diagnoses that included but are not limited to other seizures, vascular dementia, and liver disease. R2's care plan reads in part R2 presents with a diagnosis of seizures (date initiated 9/17/25). One intervention includes lab tests for therapeutic monitoring of medication levels per MD (Medical Doctor) orders. Notify MD of subtherapeutic or toxic levels.Record review of R2's hospital discharge instructions dated 12/10/25 shows R2 was hospitalized due to seizure disorder with instructions to obtain Valproic Acid level in one week.R2's Physician's orders printed on 3/10/26, document that R2 was admitted on [DATE] with the orders to receive Valproic Acid Oral Solution 20 milliliters (ml) two times a day related to seizures (order date 12/10/25). The Physician's orders also document that orders received on 12/10/25, 2/12/26, and 2/24/26 to obtain the Valproic Acid laboratory values. R2's medical records have no documentation of these laboratory values being obtained. R2's progress notes from 12/10/25 to 3/9/26 have no documentation of R2's refusals with blood draws or if V25 (Physician) was notified.On 3/10/26 at 1:17 PM, V2 (Director of Nursing) stated that R2 had no laboratory results on file since October 2025. V2 reported attempting to contact the laboratory to determine the status of R2's lab work. V2 further stated that the facility had no information confirming whether the laboratory tests were completed, as there was no documentation indicating that R2 refused the labs or explaining why the labs were not performed. V2 stated that the laboratory previously provided notification forms to nursing staff when a resident refused lab work so the nurse could notify the physician; however, no such documentation was available for R2.On 3/10/26 at 2:44 PM, a phone interview was conducted with V7 (Licensed Practical Nurse/LPN). V7 stated she followed up on the laboratory order in December, but she could not recall the exact date of the follow-up. V7 stated that staff informed her R2 was very combative, and staff were unable to obtain the blood specimen. V7 stated she notified V25 (Physician), who instructed staff to continue attempting to obtain the blood draw. V7 further stated that she had not followed up since then because lab technicians come early in the morning when she is not yet working in the facility.On 3/11/26 at 11:55 AM, a follow-up interview was conducted with V2. V2 stated that V25 (Physician) orders laboratory tests, which are entered into the physician order system. V2 reported that nursing staff contact the clinical laboratory, and laboratory draws are routinely scheduled on Mondays and Wednesdays in the facility, unless the order is STAT (immediately), in which case the specimen is collected the same day. V2 stated that once results are available, they are entered into the system, reviewed by nursing staff, and communicated to the physician. V2 further stated that if a resident refuses a laboratory draw, the nurse is expected to notify the physician and document the refusal. V2 stated they were still attempting to determine why R2's laboratory orders from December had not been completed and reported being informed that the resident refused the blood draws.The facility's Laboratory and Diagnostic Procedures policy and procedures (6/26/16) documents in part: To ensure that the resident's attending physician and representative is notified of abnormal lab values. To ensure that any labs that are to be completed immediately are relayed to the MD as soon as possible. Ensure that lab or diagnostics are completed per MD order.

Based on interview and record review, the facility failed to notify a resident's family member in a timely manner when a change in condition occurred. This failure affected 1 resident (R1) reviewed for changes in condition. Findings include: On 4/13/2025 at 8:06 AM, R1's progress notes document in part, (R1) was noted with change in condition. upon assessment SPO2 89% oxygen given at 2L, SPO2 94% on 2L Oxygen. HOB elevated 30dg. Hospice notified. On 4/13/2025 at 12:40 PM, R1's progress notes document in part that R1's family member (V11) was made aware of the change in R1's condition at 11:15 PM. On 5/5/2025 at 11:05 AM, V11 (R1's Family Member) stated that on 4/13/2025 at around 11:00 AM, V11 received a phone call from the facility around and informed V11 that R1 had taken a turn for the worst and that R1 was in distress since 7:00 that morning. V11 recalled that V5 (Registered Nurse) had told V11 that R1 was having abnormal vital signs, vomiting, and difficulty breathing. V11 explained that the nurse on night shift that was responsible for R1's care had left without letting V11 know the change in condition. V11 stated that it is the facility's policy to notify both the provider and the family when a change in condition is identified. On 5/6/2025 at 11:17 AM, V4 (Registered Nurse) affirmed that V4 was assigned to care for R1 on 4/13/2025 and noted a change in R1's condition around 7:00 AM. V4 described R1's change in condition as, (R1) using accessory muscles to breathe (respiratory distress) and noted R1 to have hypoxia. V4 affirmed that when R1's change in condition was notified, V4 called hospice. V4 stated, (the facility staff) notify the doctor immediately. The family can come last when everything is taken care of. The family is not the priority, the patient is. V4 affirmed that V4 did not notify R1's family with the newly identified change in condition. V4 stated, I endorsed calling (V11) to (V5- Registered Nurse), it was the end of my shift. On 5/6/2025 at 12:45 PM, V5 (Registered Nurse) affirmed that V5 was assigned to care for R1 on the day shift of 4/13/2025. V5 affirmed that V5 notified V11 of the change in condition at 11:15 PM. V5 stated that V5 was reviewing (V4's) charting and noticed that (V4) had not called (V11) to report the change in condition, so I (V5) did. V5 denied that calling V11 was endorsed to V5 by V4. V5 recalled, (V4) told me that (V4) notified everyone that was supposed to be notified. V5 stated that the standard of practice is that resident family members are notified promptly of any change in condition. On 5/7/2025 at 10:53 AM, V2 (Director of Nursing) affirmed that the facility policy is to notify the physician and family whenever there is a change in condition as soon as a change is identified. V2 affirmed that V4 should have notified V11 promptly regarding R1's change in condition. Facility policy titled, Change in a Resident's Condition or Status (4/2018) documents in part, Our facility shall promptly notify the resident, his or her Physician, Nurse Practitioner, or Hospice Service as applicable, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (eg. changes in level of care, billing/payments, resident rights, etc.) .

Based on interview and record review, the facility failed to report allegations of misappropriation of property for one (R1) out of three residents reviewed for misappropriation of resident property in a total sample of three residents. Findings include: On 02/22/2025, at 12:07 PM, V4 (Social Services Director) states she recalls having a conversation with V9 (R1's Family Member) and educating V9 about filling out an inventory list whenever new items or valuables are brought into the facility for R1 in case something comes up missing. V4 states V9 informed her that R1 had a diamond ring and bracelet on when R1 was admitted to the facility. V4 states she informed V9 that these items were not inventoried but V9 was insistent that R1 had these items. V4 states she searched for R1s' inventory list but could not find one and states the facility does not have an inventory list of R1s' diamond ring or bracelet. V4 states an inventory list should be completed by staff upon admission for all residents but she does not have an inventory list for R1. V4 states she does not remember seeing R1 with a ring or bracelet. V4 states she informed V3 (Assistant Administrator) about the allegations and V3 reimbursed V9 for the ring and bracelet items. V4 states this incident occurred approximately in late 2023 or early 2024. On 02/22/2025, at 1:07 PM, V3 (Assistant Administrator) states he is aware of the allegations of R1s' missing ring and bracelet. V3 states this incident happened late in 2023 and was handled by V8 (Former Administrator). V3 states he remembers V8 having a meeting with V9 (R1s' family member) and V8 paid V9 approximately 200 dollars to replace R1s' missing items. V3 states R1s' missing items should have been reported and he will gather as much information that he can find that is related to the allegations. V3 states he is aware that the facility should retain documentation of resident files for a time period even after they are discharged from the facility. Facility reported incident for misappropriation of property for R1 was requested from V3 (Assistant Administrator) on 02/22/2025 at 1:07 PM. On 02/22/2025, at 2:20 PM, V3 provides surveyor with a form titled Petty Cash Reconciliation Form and states R1s' initials are located at the bottoms of the list and R1 was reimbursed 180 dollars for her missing items. V3 also provides surveyor a document dated 12/17/2023, titled Final investigation- Missing bracelet for R1 and a document titled Fax Initial Reportable Accident/Incident to IDPH (Illinois Department of Public Health) Regional Office. V3 states this was the only documentation that he could find regarding R1s' misappropriation of property allegations. Surveyor makes V3 aware that there is no documentation to show that the initial and final reports were faxed/submitted to the state agency. V3 observes the final report and is made aware that there is no fax confirmation and no date to show proof of when/if the misappropriation of property report was submitted to the state agency. Surveyor inquires to V3 about documentation of proof of an investigation and proof of submitting a report to the state agency for R1s' allegations. V3 states the investigation was handled by V8 (Former Administrator) and V3 is unable to find the folder containing those documents. V3 states he will search again for the documents containing the full investigation and reporting documents. On 02/23/2025, at 12:04 PM V3 (Assistant Administrator) states he could not find any more documents related to the allegations of misappropriation of property for R1. Surveyor requests a contact telephone number for V8 (Former Administrator) and V3 states he does not have a contact number for V8. V3 states while working at the facility, V8 used a company phone for contact purposes and since V8 no longer works for the facility, V8 no longer has the company phone. V3 states he does not have any other way to contact V8. V3 states V8 stopped working at the facility approximately in June 2024. There is no documentation presented during this survey to show that R1s' belongings were inventoried upon admission or while R1 resided in the facility. Facility policy dated 10/2022, titled Abuse Prevention Program documents in part, Facility affirms the right of the residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary, or permanent use of a residents' belongings or money without the residents' consent. V. Internal reporting requirements and identification of allegations: Reports will be documented and a record kept of the documentation. Upon learning of the report, the administrator or designee shall initiate an incident investigation. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately .Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. Facility policy dated 11/08/2011, titled Resident Personal Clothing and Belongings Handling documents in part, Procedure: Upon admission- Personal belongings are to be listed on the Belongings List in the residents' chart. New items brought to the facility other than during the admission process, should also be added to this list.

Based on interview and record review, the facility failed to follow their abuse prevention program and conduct a thorough investigation for one (R1) out of three residents reviewed for misappropriation of property in a total sample of three residents. Findings include: Record review documents that R1 was admitted to the facility on [DATE] and discharged from the facility on 11/23/2024. R1s' Facesheet documents that R1 has diagnoses not limited to: Parkinson's Disease, neurocognitive disorder, essential hypertension, bilateral knee osteoarthritis, venous thrombosis, schizoaffective disorder, bipolar disorder, visual hallucinations, long term use of anticoagulants, and chronic heart failure. R1s' MDS/Minimum Data Set, dated dated dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status of 08/15, indicating that R1 is cognitively impaired. On 02/22/2025, at 12:07 PM, V4 (Social Services Director) states V9 (R1s' Family member) informed her that R1 had a diamond ring and bracelet on when R1 was admitted to the facility. V4 states she informed V9 that these items were not inventoried but V9 was insistent that R1 had these items. V4 states she informed V3 (Assistant Administrator) about the allegations and V3 reimbursed V9 for the ring and bracelet items. V4 states this incident occurred approximately in late 2023 or early 2024. On 02/22/2025, at 1:07 PM, V3 (Assistant Administrator) states he is aware of the allegations of R1s' missing ring and bracelet. V3 states this incident happened late in 2023 and was handled by V8 (Former Administrator). V3 states he remembers V8 having a meeting with V9 (R1s' family member) and V8 paid V9 approximately 200 dollars to replace R1s' missing items. V3 states R1s' missing items should have been reported and he will gather as much information that he can find that is related to the allegations. V3 states he is aware that the facility should retain documentation of resident files for a time period even after they are discharged from the facility. Facility reported incident for misappropriation of property for R1 was requested from V3 (Assistant Administrator) on 02/22/2025, at 1:07 PM. On 02/22/2025, at 2:20 PM, V3 provides surveyor with a form titled Petty Cash Reconciliation Form and states R1s' initials are located at the bottoms of the list and R1 was reimbursed 180 dollars for her missing items. V3 also provides surveyor a document dated 12/17/2023, titled Final investigation- Missing bracelet for R1 and a document titled Fax Initial Reportable Accident/Incident to IDPH (Illinois Department of Public Health) Regional Office. V3 states this was the only documentation that he could find regarding R1s' misappropriation of property allegations. Surveyor makes V3 aware that there is no documentation to show that the initial and final reports were faxed/submitted to the state agency. Surveyor inquires to V3 about documentation of proof of an investigation and proof of submitting a report to the state agency for R1s' allegations. V3 states the investigation was handled by V8 (Former Administrator) and V3 is unable to find the folder containing those documents. V3 states he will search again for the documents containing the full investigation and reporting documents. On 02/23/2025, at 12:04 PM V3 (Assistant Administrator) states he could not find any more documents related to the allegations of misappropriation of property for R1. Surveyor requests a contact telephone number for V8 (Former Administrator) and V3 states he does not have a contact number for V8. V3 states while working at the facility, V8 used a company phone for contact purposes and since V8 no longer works for the facility, V8 no longer has the company phone. V3 states he does not have any other way to contact V8. V3 states V8 stopped working at the facility approximately in June 2024. There is no documentation presented during this survey to show that the facility conducted a thorough investigation to include information such as resident and staff statements/interviews detailing names, dates, times, and other allegation details. Facility policy dated 10/2022, titled Abuse Prevention Program documents in part, Facility affirms the right of the residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary, or permanent use of a residents' belongings or money without the residents' consent. Upon learning of the report, the administrator or designee shall initiate an incident investigation.

Based on observations, interviews, and record reviews, the facility failed to: 1-Perform proper hand hygiene when passing food tray, after handling soiled dishes, and before handling clean dishes. 2- Properly label perishable items inside the walk-in fridge 3- Prevent personal food items inside the walk-in fridge. These failures have the potential to affect all 110 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:50 AM, during initial round with V9 (Director of Dietary), surveyor observed the prepared apple sauce dated [DATE], concord grape jelly without a discard date, and a personal bottle of energy drink and water inside the walk-in fridge. V9 stated that the apple sauce is over six days and it is expired, and every item should have an in and out date, and serving residents with an expired food without proper storage could make resident sick with food borne illness. V9 stated that personal/staff food or drink should not be inside the walk-in fridge. V9 stated there is only one resident who receives nothing by mouth (NPO). On [DATE] at 9:53 AM, V10 (Dietary Aide) stated that V10 kept V10's personal bottle of energy drink and a bottle of water inside the walk-in fridge. V10 stated that keeping personal items in the fridge could cause cross contamination. On [DATE] at 11:35 AM, V9 stated it is V9's expectation that staff will perform proper hand hygiene in dish room when moving from a dirty area to a clean area to prevent cross contamination. On [DATE] at 12:47 PM, surveyor observed V12 (Certified Nursing Assistant/CNA) passing lunch tray to residents without performing hand hygiene after knocking at the door to pick another lunch tray from the tray cart. V12 stated that V12 should have sanitized V12's hand in between each resident to prevent cross contamination. On [DATE] at 11:00 AM, observed V10 (Dietary Aide) and V16 (Dietary Aide) working in the dish room. V10 and V16 stated that whoever is on the clean side should be wearing gloves. Observed V16 was breaking down soiled resident trays scraping food debris from the trays into the garbage. At 11:10 AM, observed V16 moved to the clean side of the dish machine and pull out the rack containing cleaned trays from the dish machine without hand hygiene and gloves. V16 stated that V16 should have washed V16's hand and wear new gloves before touching clean trays to prevent cross contamination. At 11:23 AM observed V10 returning rack to the soiled area with sanitized trays and placed the same sanitized trays on an open cart to air-dry. V10 stated that V10 should not have taken the sanitized trays to the dirty area and back to the clean side. V10 returned the sanitized trays for a rewash. On [DATE] at 2:26 PM, V3 (Administrator in Training) stated it is V3's expectation that staff will perform proper hand hygiene by using the hand sanitizer in between residents when passing food tray to prevent cross contamination. Documents Reviewed: Diet type report as of [DATE] shows one resident who receives nothing by mouth (NPO). Facility's policy titled Dish Room Safe Food Handling revision dated 2017 documents in part: If there is only one person working in the dish room, the person will remove their gloves, wash their hands, and put on fresh gloves whenever they cross over to the clean side of the dishwashing machine to unload the sanitized dishes and utensils. Facility's policy titled Hand Washing/Hand Hygiene dated ,d+[DATE] documents in part: The facility considers hand hygiene the primary means to prevent the spread of infection. Facility's policy titled Refrigerated Food dated 2017 documents in part: Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. The discard/use by date will be a maximum of six days after preparation. Facility's policy titled, Labeling and Dating Foods dated 2021 documents in part: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded.

Based on observations, interviews, and record reviews, the facility failed to (1) dispose of kitchen garbage properly in a contained dumpster, (2) failed to keep the dumpster area clean free of debris, the garbage area was not maintained in a sanitary condition to prevent harborage and feeding of pest. These failures could affect all 111 residents that reside in the facility. Findings Include: On 2/5/25 at 9:16 AM, During the initial facility tour, with V20 (Director of Maintenance) and V19 (Assistant Maintenance) observed the outside dumpster area where kitchen garbage is disposed with the large dumpsters uncovered with lids. All around the dumpsters were food garbage, papers, and foul odors. V19 stated that the dumpster is open, but it should be covered. V20 stated that the uncovered plastic bags in the dumpster are from the kitchen, and the housekeeping. V20 stated that when the lids to the two dumpsters are not properly covered, it could invite pest, racoons to the facility. V20 stated that V20 will call the garbage pick-up company to pick up the dumpsters. Facility policy titled Waste Disposal dated 01/2014 documents in part: Regulated waste shall be handled and disposed of in a safe and appropriate manner. The area surrounding the dumpster is maintained clutter free, the dumpsters lids are closed after disposal of the waste.

Based on observations, interviews and record review, the facility [A] failed to ensure shared equipment were cleaned and decontaminated between each use for 4 [R61, R68, R72, R263] and [B] failed to follow their infection control procedures to post Enhanced Barrier Precautions (EBP) signage outside 1 [R39's room] resident with active right subclavian perma catheter for dialysis in a sample of 23 residents. Findings Include: On 2/4/25 at 9:42AM, V8 obtained R61's blood pressure [103/69] with a manual blood pressure device placed on R61's bed linen, that was on top of the medication cart. After use, V8 then placed the manual blood pressure device back on top the medication cart and did not sanitize the blood pressure device. On 2/4/25 at 10:11 AM V8 obtained R72's blood pressure [130/73] with the same blood pressure device, sitting on the bed side, without sanitizing the device blood pressure. On 2/4/25 at 10:20 AM V8 obtained R263's blood pressure [123/71] used the manual blood pressure cuff sitting on R263 legs to obtain R62's blood pressure without sanitizing the device. On 2/4/25 at 10:38 AM, V8 obtained R68's blood pressure [145/103] used the manual blood pressure cuff, to obtain R68's blood pressure without sanitizing the device. On 2/4/25 at 11:00 AM, V8 stated, I forgot to sanitize the blood pressure cuff between each resident, and that could cause a spread of infection. On 2/6/25 at 2:44PM, V2 [Director of Nursing] stated, All resident's shared equipment such as blood pressure cuff must be sanitized between each resident to prevent the spread of infection. It could potentially cause an infectious outbreak. Policy documents in part: Resident care equipment including reusable items and durable medical equipment will be cleaned and disinfected. 49486 R39's face sheet shows R39 is a [AGE] year-old male. R39's electronic medical record (EMR) revealed R39 was admitted to the facility on [DATE] with diagnoses not limited to end stage renal disease (ESRD), dependence on renal dialysis, cardiac tamponade, malignant neoplasm of prostate, malignant neoplasm of colon, secondary malignant neoplasm of unspecified lung, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of bone, and tinea pedis. On 2/4/25 at 11:53 AM, R39 received up in chair in room with an active right subclavian Catheter with no EBP signage on R39's door. R39 stated that R39 goes out for dialysis three times a week, and R39 is not sure if the staff wear gown when staff inspect R39's catheter dressing. On 2/5/25 at 1:15 PM, V18 (Licensed Practical Nurse/LPN) stated that V18 has been in the facility for eight years. V18 stated that Enhanced Barrier Precautions (EBP) signage should be posted outside the door of any resident with wounds, feeding tube, Foley Catheter, Dialysis Perma catheter, central line, and other isolation. V18 stated it is important to have EBP signage to ensure that staff are wearing the necessary Personal Protective Equipment (PPE) required before providing care for R39. On 2/5/25 at 2:26 PM, surveyor V2 (Director of Nursing) stated that there should be a EBP signage by the door of any resident with Foley Catheter, Dialysis Perma catheter, and wound to alert staff to know the type of PPE to wear before providing care to the resident. V2 stated that not having the signage by the door of resident with dialysis Perma catheter, is a potential for transmission of infection. On 2/5/25 at 2:35 PM, V4 (Infection Preventionist/LPN) stated that the EBP should be on the door of a dialysis resident (R39) so that staff will put on appropriate PPE like gown and gloves before providing care for R39 to prevent transmission of infection. Documents Reviewed: R39's Minimum Data Set (MDS) dated [DATE] shows R39 is cognitively intact. R39's Physician Order Sheet (POS) with active orders as of 2/5/25 shows orders: EBP due to dialysis, monitor for signs/symptoms of infection-right chest permcath every shift, and may go to dialysis 3x/week at Fresenius kidney care. R39's Care plan dated 12/18/24 documents in part: R39 is receiving hemodialysis treatments related to ESRD, potential risk for complications. R39 has a dialysis shunt and requires advanced barrier precautions. Monitor right chest permcath site for any sign/symptoms of infection. The facility policy titled Enhanced Barrier Precautions (EBP) dated 5/2022 documents read in part: Post clear signage on the door or wall outside of the resident room indicating the type of precautions, and required Personal Protective Equipment (PPE) (e.g., gown and gloves) A copy of EBP signage documents in part: Providers and staff must wear gloves and a gown for high-contact resident care activities; central line, any skin opening requiring a dressing.

Based on observation, interview, and record review the facility failed to follow their policy to ensure that call lights are within easy reach for two (R25, and R58) residents out of 8 residents reviewed for call lights in a sample of 23. Findings Include: 1. R25's face sheet shows R25 is an [AGE] year-old male. R25's electronic medical record (EMR) revealed R25 was admitted to the facility on [DATE] with diagnoses not limited to: Chronic obstructive pulmonary disease, age related nuclear cataract, left eye, blindness left eye, history of falling, presence of pacemaker, wedge compression fracture of third lumbar vertebra, anxiety disorder, and atrial fibrillation. 2. R58's face sheet shows R58 is a [AGE] year-old male. R58's electronic medical record (EMR) revealed R58 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, repeated falls, Chronic obstructive pulmonary disease, epilepsy, dizziness/giddiness, and hypertension. On 2/4/25 at 12:10 PM, R58 was observed in bed, and call light was under the bed. R58 stated that R58 could not reach the call light. V8 (Registered Nurse/RN) stated that R58's call light is not reachable because the call light is under the bed. V8 stated that R58's call light should be reachable so that R58 could call for help as needed. V8 stated that failure to keep the call light within reach could cause R58 to fall. On 2/4/25 at 12:22 PM, R25 was observed in bed, and the call light was not within reach. R25 attempted to reach the call light, R25 stated that R25 could not reach the call light because the call light is far from R25. V11 (Certified Nursing Assistant/CNA) stated that all call lights should be within reach, but R25 call light is not within reach. V11 stated that R25 would not be able to call staff for help to use the washroom and could cause skin breakdown. On 2/5/25 2:26 PM, V2 (Director of Nursing) stated that it is V2's expectation that staff will place the call light within the reach of the resident while in bed or in chair, and not under the bed. V2 stated that when staff fails to keep call light within reach, the need of the resident will not be met, and could lead to skin break down or fall for bed bound resident. R25's Minimum Data Set, dated dated dated [DATE] shows R25 is cognitively impaired. R25 functional assessment shows R25 requires extensive assistance with transfers and toileting. R58's Minimum Data Set, dated dated dated [DATE] shows R58 is moderately cognitively impaired. R58 functional assessment shows R58 requires assistance with transfers and toileting. Facility's Policy titled: 'Answering the Call Light' dated 11/2013 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 follow their policy to ensure code status should be consistent with plan of care and physician order for one (R29) resident reviewed for advance directives in a sample of 23. The findings include: R29's admission record documented initial admitted on [DATE] with diagnoses not limited to Chronic obstructive pulmonary disease with (acute) exacerbation, Dysarthria following cerebral infarction, Ataxia following cerebral infarction, Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Unspecified osteoarthritis, Age-related osteoporosis without current pathological fracture, Foot drop right foot, Chronic kidney disease stage 3, Essential (primary) hypertension. On [DATE] At 1:01 pm V2 (Director Of Nursing / DON) stated each resident should have an advance directive whether DNR (Do not Resuscitate) or Full code and have an order. V2 said care plan should be developed for advance directives and make sure that resident's wishes are consistent or match with plan of care. She said if the code status is not consistent with plan of care and physician order, staff could make a mistake during emergency or could create confusion. V2 said staff could perform CPR (Cardiopulmonary Resuscitation) for resident who is DNR. On [DATE] At 10:09 am V6 (Social Service Director / SSD) stated Advance Directives include code status of the resident whether full code or DNR. She said it is important to determine the code status of every resident so when emergency arises staff would be able know what steps to make or proceed if to resuscitate or perform CPR (cardiopulmonary resuscitation) for full code or not to resuscitate resident if DNR is in place. V6 said code status needs an order and should be care planned. She said resident's wish for code status, physician order and care plan should match to avoid confusion and to properly care for the resident during emergency. MDS (Minimum Data Set) dated [DATE] showed R29's cognition was moderately impaired. R29's order summary report dated [DATE] with active order not limited to POLST (Physician Orders for Life-Sustaining Treatment): Do Not Attempt Resuscitation/DNR - Comfort Focused Treatment. R29's care plan documented in part: R29 requested to be a Full code. R29 requires all life saving measures and treatment in the event of any emergency. Perform CPR (Cardiopulmonary Resuscitation) for medical emergency if needed. Staff will inform caregivers of full-code status. R29's POLST form dated [DATE] showed DNR (Do Not Attempt Resuscitation), comfort measures only. Facility's Advance Directives policy dated ,d+[DATE] documented in part: The plan of care for each resident will be consistent with his or her documented treatment preferences and / or advance directive.

Based on observation, interview and record review the facility failed to follow their peripheral inserted central catheter line dressing change policy, [A] failed change the line catheter dressing when not intact or compromised in any way, [B] failed to label the dressing with date or time, and [C] failed to enter physician orders of dressing changes and intravenous flush orders for one [R61] resident in a sample of 23. Findings include: On 2/4/25 at 9:34 AM, Surveyor observed V8 [Registered Nurse] during medication administration observation. On 2/4/25 at 9:42A M, V8 obtained R61's blood pressure [103/69] with a manual blood pressure device that was on top of the medication cart. After use, V8 then placed the manual blood pressure device back on top the medication cart and did not sanitize the blood pressure device. Surveyor observed R61 resting in bed with left arm midline intravenous catheter dressing halfway lifted completely on one side with no date. V8 [Registered Nurse] stated, I noticed the midline dressing was completely lifted on one side, upon making rounds this morning around 7:30 AM, I have been busy and did not have the time to change the dressing. I am not sure when the midline dressing was last changed, there is no date on the dressing. On 2/4/25 at 1:40 PM surveyor observed the midline dressing was still lifted dressing on R61. V8 stated, I was busy but will change the dressing. On 2/4/25 at 1:43 PM V8 stated, There is no physician order placed for an intravenous catheter dressing change nor any flush orders. The intravenous catheter dressing change should be changed twenty-four hours after the line was inserted, every seven days and or when ever the dressing in not intact. I will place in the standing physician orders now. On 2/625 at 1:22 PM, V2 [Director of Nursing] stated, The midline intravenous or peripheral central catheter line catheter should have the dressing changed twenty-four hours after insertion, then every seven days and when ever the dressing is not intact or compromised in any way. Once the dressing is noted compromised the nurse should immediately change the dressing and label with date and time. If not, the compromised dressing could potentially cause an infection. There should be required physician orders for a mid or central line should include the following: dressing changes, flush orders, and monitor the site for infections should be on the resident's medication administration sheet. If the dressing is not labeled with date, time and there is no physician orders the nurses staff would not know the last time the dressing was changed, which could cause an infection. Policy document in part: Picc Line Dressing Changes dated 3/2014. The purpose of this procedure is to prevent catheter related infections associated with contaminated, loosened, or soiled catheter site dressings. Change picc/mid line catheter dressing twenty-four hours after catheter insertion, every seven days, or if it is wet, dirty, not intact, or compromised in any way. The following information should be recorded in the resident's medical record. Date and time dressing was changed.

Based on observation, interview and record review, the facility failed to follow plan of care and physician order to apply hand roll or splint on right hand for 1 (R29) resident. This failure could potentially affect 1 (R29) resident reviewed for range of motion in a sample of 23. The findings include: R29's admission record documented initial admitted on 12/3/18 with diagnoses not limited to Chronic obstructive pulmonary disease with (acute) exacerbation, Dysarthria following cerebral infarction, Ataxia following cerebral infarction, Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Unspecified osteoarthritis, Age-related osteoporosis without current pathological fracture, Foot drop right foot, Chronic kidney disease stage 3, Essential (primary) hypertension. On 2/4/25 at 11:03 AM Observed R29 sitting up on wheelchair in the dayroom, alert and verbally responsive, right hand contracted, fist closed, no device in placed. On 2/5/25 At 1:01pm V2 (Director Of Nursing/ DON) stated splint / any device should be applied as ordered by physician to prevent contracture. She said it is important to follow resident's plan of care for splint / device use to prevent further contracture. On 2/5/25 At 1:47pm V14 (Restorative Nurse, LPN / Licensed Practical Nurse) stated R29 has contracture on right hand due diagnosis of Hemiplegia right dominant. She said R29 uses Right hand roll or resting splint from 8:30am to 12:30pm every day to prevent further contracture on right hand. V14 said if splint / hand roll was not applied as ordered by physician could potentially lead to further contracture. MDS (Minimum Data Set) dated 1/7/2025 showed R29's cognition was moderately impaired. She needed Substantial / maximal assistance with oral, toileting and personal hygiene, shower / bathe self, lower body dressing. MDS showed R29's had functional limitation in range of motion or impairment on side of the upper extremity (shoulder, elbow, wrist, hand). R29's order summary report dated 2/6/25 with active order not limited to May apply right hand roll / splint for 4 hours, then remove. R29's care plan documented in part: R29 needs to wear right hand splint daily for 4 hours. Apply hand roll to right hand. Replace hand roll as often as needed after patient removes. Facility's Range of Motion exercises / Splinting policy dated 10/2020 documented in part: The splint should be applied for time frame designated in physician order as tolerated.

Based on interview and record review the facility failed to ensure that one of three residents (R1) was free from abuse. This failure affected R1 who was attacked by another resident R2. As a result, R1 sustained a human bite, had to get a tetanus shot and was treated with antibiotics as a prophylactic for infection. this as the potential to affect all 41-resident residing on the 2nd floor. Findings include: On 09/18/24 at 10:25am, R2 observed in bed. R2 was unable to recollect what happened on 08/14/24. R1 stated I'm fine. At 10:28am, R1 stated that on (08/14/24), R2 was in the room stealing from R1 and R3 drawer. R1 stated I (R1) was out of the room for a minute and when I came back, I (R1) saw R2 taking my stuff, food from my drawer and from R3's drawer who was at the hospital at the time. R1 stated when I (R1) asked R2 to put the things back, R2 attacked me (R1). R2 tried to hit me with a walker pointing to the walker in the room. R1 stated so I tried to defend myself and R2 bit me on my fingers and I had to take tetanus shot and I was in pain for couple of days and take antibiotics. R1 stated R2 has been moved from the room but (R2) is still on this floor down the hall. I (R1) do notice that my food (Snacks) was missing but I will never think R2 was the one stealing them. R1 stated I (R1) was calling, and no one (referring to the facility staff) came for a while. At 10:30am, R3 stated that I (R3) was at the hospital when it happened and when I came back some of my food (Snacks) and (beverages) were missing but I did not report it I just let it go because (R2) has moved from the room. On 09/18/24 at 11:38am, V5 (Social Services Director) stated that she is familiar with both resident R1 and R2. V5 stated that all I (V5) know is that the two gentlemen got into altercation. The ADON (V3) took R2 down to the first floor and was sent out for psych-evaluation. I was told R2 is getting assigned to a new room. The surveyor asked about following up with the resident on the cause of the altercation, V5 stated No, I did not. Then the surveyor asked about the facility protocol/policy on resident-to-resident altercation. V5 stated that I really don't know, when the V2 (DON) and V3 (ADON) are handling the situation, I (V5) step back. V5 stated that all I asked R2 was you okay and R2 said I'm okay. V5 stated I did not write any-thing (referring to documentation) in R1 and R2 medical record. On 09/18/24 at 1:40pm V2 DON (Director of Nurse's) stated that R2 tried to hit R1 they have some words for what I don't know why. It is possible R1 was just irritated by R1 going back and forth because R2 is a very quiet resident and may be R1 bumped into R2. V2 stated that R2 normally stays to self. The surveyor asked V2 whether V2 asked the residents R1 and R2 about what caused the altercation. V2 stated I did not. V2 stated that R1 can express self but R2 cannot explain self. At 11:38am V12 CNA (Certified Nurse's Aide) stated that I was on the floor attending to other resident when I had the noise, I did not really see them (Referring to R1 and R2) fight but I heard it. V12 stated by the time I got to the room the fight was over the nurse was trying to calm them down. On 09/18/24 at 2:00pm, V7 CNA (Certified Nurse's Aide) assigned to R1 and R2 stated that on 08/14 24 she worked with R1 and R2. V7 stated that I came in at the end of the incident. I went on lunch and was coming back to the floor and one of the CNAs told me both residents got into an altercation. It was a surprise to me because they never argue or fight before that day. The surveyor asked V7 did you ask the residents R1 and R2 or the roommates what happened or what they saw. V7 stated No, I did not ask because I came in at the end of the altercation. On 09/19/24 at 11:42am, V8 LPN (Licensed Practical Nurse) stated that I was coming off (returning from) lunch break, when V17 RN (Registered Nurse) told me that R1 and R2 got into a fight. V8 stated I called V2 and V3, while V17 was holding R1, and I was holding R2. I did not witness the fight I was on break; the fight was over when I got to the floor. When asked what was the cause of the physical altercation V8 stated I did not ask because I was not on the floor when it happened, and it is not in my place to ask this question. At 12:00pm, V3 stated that I (V3) was called to the room by staff that there was an altercation between (R1) and R2, when I got there (referring to the room). I (V3) immediately separated R1 and R2. I (V3) took R2 downstairs. The surveyor asked whether V3 asked the residents about the cause of the physical altercation. V3 stated that she cannot remember what R1 said (R1) just said R2 came to his side of the room, R2 was unable to recall the cause of the altercation, R1 resides in the room on bed one across from R2's bed. V3 stated that R1 had a bite mark and I (V3) asked V17 (RN) to clean up the wound and we got an order from the physician to give tetanus shot. V3 stated that she did not document the incident stating that V2 (DON) did all the charting after she was made aware of all that happened. V3 stated R2 was petitioned to the hospital for evaluation. On 09/19/24 1:50pm, V2 stated that the expectation from the staff on the floor is to arrange the lunch time and break times to accommodate the resident mealtime for lunch time. The staff are to take their lunch time and break time between 10:30am and 11:30am because the resident's lunch time (on the floor) is between 12:00pm and 1:00pm. The incident happened around 1pm. I was not aware that V17 (RN) was not on the floor because V8 (LPN) told me she was the nurse on break. V2 stated both nurses should not be on lunch break at the same time leaving the residents unsupervised, two CNAs should at least be present on the floor with the nurse. V2 stated that on (08/14/24) V17 did not document on the incident, and I (V2) did the documentation. On 09/25/24 at 4:00pm, V1 stated that the staff have the right to go on their breaks. Then the surveyors asked whether they should all take a lunch break at the same time. V1 did not answer the question. V3 then stated that her office is on the second floor, but she was not on the floor to supervise but they (Staff) can easily call her to help in supervising the floor because they all know not to go out on lunch at the same time. R1's medical record admission record showed that R1 was admitted to the facility on [DATE] with diagnosis that includes but not limited to unspecified viral hepatitis C without hepatic coma, Acute posthemorrhagic anemia, weakness, pain right lower leg, pain left lower leg, open wound of right arm and other disorders of veins. R2's medical record admission record showed that R2 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction and chronic ischemic heart disease unspecified. R1's assessment tool used in assessing facility residents MDS (Minimum Data Set) dated 08/02/24 section C scored R1's BIMS (Brief Interview for Mental Status) as 14 indicating cognitively intact. R2's assessment tool used in assessing facility residents MDS (Minimum Data Set) dated 06/27/24 section C scored R2's BIMS (Brief Interview for Mental Status) as 7 indicating that R2 has a severe impairment cognitively. R2's medical record hospital record showed documentation that haloperidol tablet 5mg, give 1 (one) by mouth every 8 hours as needed for agitation for 10 days. On 09/25/24 at 12:53pm, V18 (Physician) stated that he is familiar with both R1 and R2. Because they are his patients. When asked about the incident of 08/14/24. V18 stated that the only thing I (V18) can remember is that one of the residents (R2) bite another resident (R1) on the finger. V18 stated that R2 is aphasic due to stroke, R2 have problem with communication and can be irritable, R1 is in the same room with R2. V18 stated that the nurse called that they both (Referring to R1 and R2) had altercation between themselves. I (V18) asked for them to be separated, petitioned R2 to be sent to the hospital for psyche-evaluation. The one with the human bite (R2) to be treated with antibiotics and follow up. V18 stated that all human bites are to be treated with antibiotics as a prophylactic for infection. There are so many bacteria in the mouth that can cause infection. Facility Abuse Prevention Program policy dated 10-2022 documented in part that the facility affirms the right of the residents to be free from abuse that includes mistreatment of resident, exploitation, misappropriation of property. The facility therefore prohibits abuse that includes mistreatment of resident, exploitation, misappropriation of property. To do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of the policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse that includes mistreatment of resident, exploitation, misappropriation of property. Facility job description for both LPN (Licensed Practical Nurse) and RN (Registered Nurse) presented documented in part that the primary purpose of a RN 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. Essential duties and responsibility include but not limited to delivering nursing care to patients/residents requiring long-term or rehabilitative care, directs and supervises care given by other nursing personnel. The facility Resident-to-Resident Altercations policy presented with no date documented under policy statement that all altercations, including those that may represent resident-to-resident abuse, shall be investigated, and reported to Nursing supervisor, the director of Nursing Services and to the administrator. Listed actions to be implemented includes but not limited to identify what happened, including what might have led to aggressive conduct on the part of one or more individuals involved in the altercation. The facility Accidents and Incident policy presented with revision date 5/2015 under supervision indicated that monitoring there is sufficient staff based on residents' needs which can vary. Such needs could include behaviors and behaviors leading to altercations with others.

Based on interview and record review the facility failed to develop and implement appropriate measures to ensure that adequate supervision is provided to two of three residents (R1 and R2) reviewed for supervision. This failure affected R1 and R2 who had an altercation that resulted in R1 having a human bite. R1 had to get a tetanus shot and was treated with antibiotics as a prophylactic for infection. this has the potential to affect all 41-resident residing on the 2nd floor. Findings include: R1's medical record admission record showed that R1 was admitted to the facility on [DATE] with diagnosis that includes but not limited to unspecified viral hepatitis C without hepatic coma, Acute posthemorrhagic anemia, weakness, pain right lower leg, pain left lower leg, open wound of right arm and other disorders of veins. R2's medical record admission record showed that R2 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction and chronic ischemic heart disease unspecified. R1's assessment tool used in assessing facility residents MDS (Minimum Data Set) dated 08/02/24 section C scored R1's BIMS (Brief Interview for Mental Status) as 14 indicating cognitively intact. R2's assessment tool used in assessing facility residents MDS (Minimum Data Set) dated 06/27/24 section C scored R2's BIMS (Brief Interview for Mental Status) as 7 indicating that R2 has a severe impairment cognitively. On 09/18/24 at 10:25am, R2 observed in bed. R2 was unable to recollect what happened on 08/14/24. R1 stated I'm fine. At 10:28am, R1 stated that on (08/14/24) (R2) was in the room stealing from R1 and R3 drawer. R1 stated I (R1) was out of the room for a minute and when I came back, I (R1) saw R2 taking my stuff, food from my drawer and from R3's drawer who was at the hospital at the time. R1 stated when I (R1) asked R2 to put the things back, R2 attacked me (R1). R2 tried to hit me with a walker pointing to the walker in the room. R1 stated so I tried to defend myself and R2 bit me on my fingers and I had to take tetanus shot and I was in pain for couple of days and take antibiotics. R1 stated R2 has been moved from the room but (R2) is still on this floor down the hall. I (R1) do notice that my food (Snacks) was missing but I will never think R2 was the one stealing them. R1 stated I (R1) was calling, and no one (referring to the facility staff) came for a while. According to the facility presented investigation interview with the staff on duty on 08/14/24, interview statement showed that V17, V7, V12 assigned to the floor were not present on the floor at the time of incident. Surveyor's interview with staff assigned to the floor on 08/14/24 also showed that both licensed nurses assigned to the floor V17 (RN) and V8 (LPN) and two of the CNAs V7 were not present on the floor leaving only one staff V12 (CNA) to supervise all the residents. At 11:38am V12 CNA (Certified Nurse's Aide) stated that I was on the floor attending to other resident when I had the noise, I did not really see them (Referring to R1 and R2) fight but I heard it. V12 stated by the time I got to the room the fight was over the nurse was trying to calm them down. On 09/18/24 at 2:00pm, V7 CNA (Certified Nurse's Aide) assigned to R1 and R2 stated that on 08/14 24 she worked with R1 and R2. V7 stated that I came in at the end of the incident. I went on lunch and was coming back to the floor and one of the CNAs told me both residents got into an altercation. It was a surprise to me because they never argue or fight before that day. The surveyor asked V7 did you ask the residents R1 and R2 or the roommates what happened or what they saw. V7 stated, no, I did not ask because I came in at the end of the altercation. On 09/19/24 at 11:42am, V8 LPN (Licensed Practical Nurse) stated that I was coming off (returning from) lunch break, when V17 RN (Registered Nurse) told me that R1 and R2 got into a fight. V8 stated I called V2 and V3, while V17 was holding R1, and I was holding R2. I did not witness the fight I was on break; the fight was over when I got to the floor. When asked what the residents caused the physical altercation V8 stated I did not ask because I was not on the floor when it happened, and it is not in my place to ask this question. At 12:00pm, V3 stated that I (V3) was called to the room by staff that there was an altercation between (R1) and R2, when I got there (referring to the room). I (V3) immediately separated R1 and R2. I (V3) took R2 downstairs. The surveyor asked whether V3 asked the residents about the cause of the physical altercation. V3 stated that she cannot remember what R1 said. R1 just said R2 came to his side of the room, R2 was unable to recall the cause of the altercation, R1 reside in the room on bed one across from R2's bed. V3 stated that R1 had a bite mark and I (V3) asked V17 (RN) to clean up the wound and we got an order from the physician to give tetanus shot. V3 stated that she did not document the incident stating that V2 (DON) did all the charting after she was made aware of all that happened. On 09/19/24 1:50pm, V2 stated that the expectation from the staff on the floor is to arrange the lunch time and break times to accommodate the resident mealtime for lunch time the staff are to take their lunch time and break time between 10:30am and 11:30am because the lunch time is between 12:00pm and 1:00pm. The incident happened around 1pm. I was not aware that V17 (RN) was not on the floor because V8 (LPN) told me she was the nurse on break. V2 stated both nurses should not be on lunch break at the same time leaving the residents unsupervised, two CNAs should at least be present on the floor with the nurse. V2 stated that on (08/14/24) V17 did not document the incident, and I (V2) did the documentation. According to the facility presented investigation interview with the staff on duty on 08/14/24, interview statement showed that V17, V7, V12 assigned to the floor were not present on the floor at the time of incident. Surveyor's interview with staff assigned to the floor on 08/14/24 also showed that both licensed nurses assigned to the floor V17 (RN) and V8 (LPN) and two of the CNAs V7 were not present on the floor leaving only one staff V12 (CNA) to supervise all the residents. On 09/25/24 at 12:53pm, V18 (Physician) stated that he is familiar with both R1 and R2. Because they are his patients. When asked about the incident of 08/14/24. V18 stated that the only thing I (V18) can remember is that one of the residents (R2) bite another resident (R1) on the finger. V18 stated that R2 is aphasic due to stroke, R2 have problem with communication and can be irritable, R1 is in the same room with R2. V18 stated that the nurse called that they both (Referring to R1 and R2) had altercation between themselves. I (V18) asked for them to be separated, petition R2 to be sent to the hospital for psyche-evaluation. The one with the human bite (R2) to be treated with antibiotics and follow up. V18 stated that all human bites are to be treated with antibiotics as a prophylactic for infection. there are so many bacteria in the mouth that can cause infection. On 09/25/24 at 4:00pm, V1 stated that the staff have the right to go on their breaks. Then the surveyors asked whether they should all take a lunch break at the same time. V1 did not answer the question. V3 then stated that her office is on the second floor, but she was not on the floor to supervise but they (Staff) can easily call her to help in supervising the floor because they all know not to go out on lunch at the same time. The facility Accidents and Incident policy presented with revision date 5/2015 under supervision indicated that monitoring there is sufficient staff based on residents' needs which can vary. Such needs could include behaviors and behaviors leading to altercations with others. Facility job description for both LPN (Licensed Practical Nurse) and RN (Registered Nurse) presented documented in part that the primary purpose of a RN 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. Essential duties and responsibility include but not limited to delivering nursing care to patients/residents requiring long-term or rehabilitative care, directs and supervises care given by other nursing personnel.

Based on observation, interview and record review, the facility failed to follow their policy to maintain acceptable parameters of nutritional status as evidenced by an unrecognized significant weight loss, failed to serve food desired by a resident and failed to care plan weight loss for one resident (R57) in a sample of 26 total residents. This failure resulted in R57 experiencing a 17% weight loss that was not recognized and addressed by the facility. Findings: On 04/16/24 at 12:30 PM, R57 was observed in his wheelchair in dining room. V16 (CNA) presented lunch and said that it was a cheeseburger. R57 looked at the meal and said I want a cheeseburger. Not this. V17 (CNA) stated It is a chicken patty. He wants two peanut butter and jelly sandwiches. That is what he likes. On 04/16/24 at 12:50 PM, R57 was observed in the dining room eating a sandwich with a second sandwich wrapped on the plate. On 04/17/24 at 8:46 AM R57 was observed in his wheelchair in the hallway. When asked if he had eaten breakfast, he responded No. I'm hungry. V29 (CNA) was asked if R57 had eaten breakfast. V29 responded that she was getting ready to feed him. On 04/17/24 at 8:54 AM V29 was observed returning R57 to his room where she fed him breakfast. R57 stated that he did not like eggs and hot cereal. V29 stated that never eats his eggs and that she would ask the nurse to ask the kitchen for cold cereal. On 4/18/2024 at 9:52 AM, V29 (CNA) and V34 (LPN) were asked if R57 ate breakfast. V29 stated Yes. He ate 75-100% of his breakfast. When R57 was asked by surveyor if he ate breakfast, he stated I want water. V34 stated that she would get him water. On 04/17/24 at 11:05 AM the weight record of R57 was reviewed in the electronic health record: Weight 4/12/2024 - 145.6 pounds Weight 3/20/2024 - 143 pounds (20.73% decrease since 11/7/2023 and a 10.18% decrease since 2/9/2024) Weight 3/13/2024 - 140.2 pounds (22.28% decrease since 11/7/2023 and an 11.93% decrease since 2/9/2024) Weight 3/7/2024 - 149 pounds (17.41% decrease since 11/7/2024 and a 6.71% decrease since 2/9/2024) Weight 2/28/2024 - 148.6 pounds Weight 2/9/2024 - 159.2 pounds (11.75% decrease since 11/7/2023) Weight 1/4/2024 - 157.6 pounds Weight 12/28/2023 - 155.2 pounds Weight 12/21/2023- 158.6 pounds Weight 12/14/2024 - 160.7 pounds Weight 12/7/2023 - 163.5 pounds (9.37% decrease since 11/7/2023) Weight 11/23/2023-166.2 pounds (7.87% decrease since 11/7/2023) Weight 11/23/2023-162.8 pounds (9.76% decrease since 11/7/2023) Weight 11/16/2023 - 171.6 pounds Weight 11/7/2023 - 180.4 pounds On 04/17/24 at 11:39 AM V26 (Registered Dietician) was interviewed. V26 stated that she has worked at the facility for 6 years. V26 works once a week / thirty-two hours a month. V26's process for evaluating residents includes seeing any high risk residents which V26 described as residents with tube feedings, TPN, bed sores and anyone that the staff ask V26 to see. V26 runs reports out of the electronic health record such as the diet report, enteral feeding report and wound rounding report. V26 meets weekly with the multidisciplinary team which V26 described as the restorative nurse, administrator, director of nursing, corporate nurse, corporate lawyer and corporate wound nurse. The multidisciplinary team meets virtually and usually on Friday of each week. V26 stated that nurses do not have specific criteria which would require a consult to V26. The dietary manager reviews weight loss and communicates to V26 any residents who triggered concern about weight loss. V26 described a weight loss concern as a five percent weight loss within one month or a ten percent weight loss within six months. V26 stated that if there was a weight loss, the actions would include an assessment and documentation in the electronic health record, discussion with the resident or resident representative to understand possible causes or concerns, and that the issue would be addressed at the multidisciplinary meeting on Friday. V26 would also speak with staff to understand the cause of the weight loss. V26 stated that V26 relies on staff to understand what is going on with the resident and what is triggering the weight loss. V26 reviewed the list of residents on the third floor who V26 had concerns about relative to weight loss. R57 was not on that list. When asked if each resident with weight loss would have a care plan specific to the weight loss, V26 stated that V26 is not involved in minimum data set documentation or care planning. When V26 was asked about R57, V26 stated that He pulled up on my report for this month. I had not seen him previously . Yes, he has a loss. She described R57's weight loss as 17% loss between November 2023 and March 2024. V26 stated Actions should have been taken. V26 reviewed the care plan and stated I see a care plan, but it has nothing to do anything .The dietary care plan only says his diet and that he has cardiovascular disease .When there was a 17% weight loss in March, he should have been seen by me to figure out what is going on. During Interview with V3 (Director of Nursing) on 4/18/2024 at 8:57 AM, V3 stated that the restorative team takes residents' weights every month. The Restorative Nurse, Director of Nursing, Dietician, Wound Care Nurse, nurse consultant, corporate lawyer and wound care consultant meet weekly on Friday at 12:30 PM to discuss wounds and any resident changes, resident weights, or whether a resident would benefit from supplements. It is everyone's responsibility to identify a weight change. That means that the floor nurse will raise a concern if there is a change in a resident's eating. The restorative nurse will raise any concern about weight loss. V26 (Dietician) will then evaluate the situation and chart about any changes. If a weight changes, the physician is notified because the doctor may want to change something in the orders. The initial care plan begins upon admission. The Nurse doing the admission starts the care plan. The MDS Coordinator will then go an fix it, personalize it. Each department does their own care plan. MDS Coordinator does the nursing care plans. During a clinical meeting each morning care plans are discussed. If V3 does not see something in the care plan, she will notify the MDS coordinator. Social Services Department conducts a care plan meeting with the resident and family. During interview with V33 (Minimum Data Set (MDS) coordinator) on 4/18/2024 at 9:36 AM, V33 described the process of care planning and MDS documentation. When the resident is admitted , V33 looks at the paperwork from the transferring facility and puts the diagnoses into PCC. V33 introduces herself to the resident within 24-48 hours. V33 uses day eight as the admission assessment date and alerts all departments of the assessment reference date. V33 then starts the care plan process based on the diagnoses and documents from the sending facility. V33 develops the care plans, and the Social Services Department notifies the family to schedule a care plan meeting. All departments are involved in the care plan process including restorative, therapy, nursing, dietary, social services. V33 stated that she reviews information in PCC every day. V33 looks at every resident's twenty-four-hour report from nursing which includes any admissions, discharges, any changes in provider orders, antibiotic initiation, room changes or any change in condition. Weight change is not included in that report. V33 stated that she would be aware of a change in resident weight by getting ready for quarterly. V33 stated that she bases her MDS coding on progress notes or assessments. V33 would not code a weight change in MDS if the only documentation was the documented weight and there was no nursing note or dietician note in the electronic health record. V33 reviewed the MDS of R57 dated 3/5/2024. Section K stated no weight loss. V33 stated that if she had looked at R57's weight, she would have used the 2/28/2024 weight of 149.6 pounds to determine weight loss, but V33 would still have wanted to see a note from the Dietician or Dietary Manager before documenting a weight change in MDS. V33 stated that if she is not sure about coding, V33 can reach out to the Restorative Nurse. If V33 sees a weight that V33 is concerned about, V33 reaches out to the restorative nurse and asks for a reweight. If it is a big change in weight, V33 would suggest doing weekly weights. V33 stated that the Restorative Nurse is out sick and V33 is not sure who is covering for her while she is out. On 4/17/2024 at 3:27 PM, record review included a note from V26 dated 4/17/2024 at 14:11 which stated in part: Resident needs assistance from staff to complete meals. Resident often eats fifty percent or more of meals. Current weight on 4/12/2024 is recorded as 145.6 pounds. Weight at one month is 140.2 pounds (3.85% decrease) on 3/13/2024. Weight at three months is 157.6 pounds (7.6% decrease) on 1/4/2024. Significant weight loss over 3 months. Resident went to the hospital in February and there is a question if hospitalization is related to some of the weight loss. BMI is 25.0 and considered overweight. Goal is for weight maintenance. No edema noted. Skin intact. No new labs to report on. Medications were reviewed. Secondary to weight loss, will recommend to add HiCal 60ml 1x/day for additional kcals and protein. Goal at present time is for weight maintenance. Will follow as needed. On 4/18/2024 at 10 AM, the electronic medical record contained an order dated 4/18/2024 at 9 AM for house supplement H.Cal 60 ml once a day ordered by V26 (Dietician). On 4/18/2025 at 10 AM, review of R57's dietary care plan dated 11/7/2024 and revised on 2/28/2024 states in part: Goals (Date initiated: 11/7/2024, revised on 3/12/2024, target date 6/5/2024): The resident will maintain adequate nutritional and hydration status as evidenced by maintaining stable weight, no signs/symptoms of malnutrition, and consuming at least 75% of meals daily throughout the review date. Review of policy titled Weight Assessment and Intervention dated March 2014 and revised October 2020 stated in part: Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation 3. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing staff will immediately notify the Dietician. Verbal notification must be confirmed in writing. 4. The Dietician will response within 24 hours of receipt of written notification. 5. The Dietician will review the unit weight record monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant' weight change has been me. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss equals usual weight minus actual weight divided by usual weight times one hundred): a. One month - 5% weight loss is significant; greater than five percent is severe. b. Three months - 7.5% weight loss is significant; greater than 7.5% is severe. c. Six months - 10% weight loss is significant; greater than 10% is severe. Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician or licensed independent practitioner, nursing staff, the Dietician, the consultant Pharmacist, and the resident or resident's representative. Review of policy titled Care Plan, Comprehensive Person-Centered dated 11/2013 and revised 4/2017 stated in part: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timelines to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 2. 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: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. g. Incorporate identified problem areas 9. Areas of concern that are identified during resident assessment will be evaluated before interventions are added to the care plan.

Based on interview and record review the facility failed to adequately supervise 1 of 3 residents (R2) reviewed for elopement. This failure resulted in R2 leaving the facility unsupervised through an exit door. R2 was found hours later by the police, taken to the hospital by EMS (Emergency Medical Services), and admitted with a diagnosis of hypothermia. This situation was identified as an immediate jeopardy. The Administrator was notified and presented with the immediate jeopardy template on [DATE] at 11:24 AM. The immediate jeopardy began on [DATE] and removed on [DATE]. The facility presented an acceptable removal plan on [DATE]. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. Findings Include: On [DATE] R2 was observed to be missing from the facility-by-facility staff. R2 was not found after a facility and community search was conducted by the facility. Per facility documentation the Chicago Police department was notified and participated in the community search. R2 was later identified at the Hospital after arriving via EMS (Emergency Medical Services) and admitted with a diagnosis of hypothermia. R2 was admitted to the facility on [DATE] with diagnosis not limited to Dysarthria Following Cerebral Infarction, Dysphagia Following Cerebral Infarction, Essential (Primary) Hypertension, Personal History of Transient Ischemic Attack, Cerebral Atherosclerosis, Psychoactive Substance Abuse, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction Due To Thrombosis of Left Anterior Cerebral Artery, Cerebral Infarction Due To Thrombosis of Right Posterior Cerebral Artery, Cerebral Infarction Due To Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Unsteadiness on Feet and Weakness. R2 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 7 indicating severe cognitive impairment. R2's Care plan documents in part: have been assessed to be at risk for elopement. R2 may be confused at times and express the desire to leave/go home and also R2 is a recent admit in the last 30 days. R2 may become agitated and combative with redirection attempts. On [DATE] at 12:59 PM V22 (Social Service Director) stated I did R2 assessment. R2 was not adjusting to placement here and this was new to R2. R2 told me I want to go home. R2 went in his roommate stuff one time. R2 told me that he had never been to a place like this before. By the paper R2 was considered an elopement risk but never went to the elevator and never packed his things. R2 triggered as an elopement risk because of the questions. Narrative of Investigation dated [DATE] documents: on Sunday [DATE]th at approximately 4:15 PM, it was noted R2 was missing from the facility. The resident was last seen at 2:55 PM in his room by nurse aids rounding. The resident was in bed most of the day and did not exhibit any wandering behaviors during the shift. Resident has diagnosis of cerebral infarction, dysphasia, hypertension, hemiplegia left side. Resident has a BIMS score of 7 (assessed on [DATE]). The facility immediately started a community search contacted the police, POA (Power of Attorney) and resident's physician. The police located the resident at 7:30 PM and brought him (R2) to the hospital where he was admitted with a diagnosis of hypothermia. Investigation started including staff interviews. It was determined the resident left the second floor and went to the basement back door and exited the facility at approximately 3 PM. The door alarmed but staff did not respond to the alarm immediately and the alarm disengaged after 10 minutes. The resident was assessed as an elopement risk on [DATE] by social service and care plan in place. The root cause: 1. The back door alarmed, and staff did not respond. R2's Progress note dated [DATE] 16:15 documents: Nurses Note Text: Resident noted not to be present in facility. Staff notified and conducted a facility wide search. R2's Progress note dated [DATE] 17:40 documents: Nurses Note Text: Writer called police (911) as staff participated in a community search. R2's Progress not dated [DATE] 17:45 documents in part: Nurses Note Text: V6 (R2 Family Member) notified of resident being out of facility and that staff was doing community search and police notified. R2's Progress note dated [DATE] 17:50 documents in part: Nurses Note Text: Area hospitals called, and resident is not in any hospital at this time. R2's Progress note dated [DATE] 19:45 documents in part: Nurses Note Text: Resident later identified at Hospital. Resident arrived via EMS. R2's Progress note dated [DATE] 16:14 documents in part: Nurses Note Text: Writer called V6 (R2 Family Member). Per V6, R2 has been extubated but is still in ICU (Intensive Care Unit). Interview statement written by V9 (Registered Nurse) documents in part: At 02:55 PM writer was alerted by CNA (Certified Nurse Assistant) of resident (R2) not being in the room upon CNA last rounds before the end of the shift. Writer did not hear the alarm go off. Investigation statement dated [DATE] written by V16 (Licensed Practical Nurse) documents in part: I did not hear any alarms going off on the second floor during my shift. Interview statement written by V23 (Licensed Practical Nurse) documents in part: [DATE] at 02:30 second-floor staff started buzzing around and making notice that one of their residents was missing. Floor count was done, and we searched all over the building looking for resident. At 3:00 PM supervisors were continuously looking for resident. Back hallway alarm, we did not notice alarm going off. At 3:30 PM resident was not found as I left building. Document titled On-Line Communications dated [DATE] documents in part: work was completed for back door facing driveway with alarm and keypad entry and push button exit. A missing person report was filed with CPD (Chicago Police Department) on [DATE]. Hospital records dated [DATE] documents in part: date and time of arrival [DATE] at 1840. Discharge Summary: at the time of admission: #Acute encephalopathy with accidental hypothermia, #Acute ventricular fibrillation cardiac arrest status post CPR (Cardiopulmonary Resuscitation) with ROSC (Return to Spontaneous Circulation), #Acute circulatory shock, #Acute on chronic heart failure with reduced EF (Low Ejection Fraction), #Multiple bilateral rib fractures due to CPR likely, #Acute respiratory failure and #Sepsis due to aspiration pneumonia. Patient was initially brought to the ED (Emergency Department) by EMS after he was found wandering outside, confused with minimal clothing. There was a report for a missing person from a nursing home/assisted living facility which was confirmed to be our patient. Presentation is concerning for early onset vascular dementia and accidental hypothermia. While in the ED, patient decompensated into V-fib (Ventricular fibrillation) cardiac arrest. Noted in detailed cardiac arrest while in the emergency department. Patient is status post CPR requiring shock x 3 with successful return of spontaneous circulation. S/p (status post) hypothermic protocol. CTA Computed Tomography Angiography) chest abdomen and pelvis on admission showed multiple bilateral rib fractures. Echo ejection fraction is 35% and akinesis of the mid anteroseptal, mid inferoseptal, apical anterior, septal, apical inferior, and apical lateral walls and the apex. CTA head and neck (,d+[DATE]) with bilateral pleural effusion and bilateral lung infiltrates or pulmonary edema s/p cardiac cath. Patient initially seen on admission hypothermic with leukocytosis and lactic acid of 7.7. CTA chest showed large areas of consolidation in the lower lobes may be aspiration. Clinical history: SP cardiac arrest, on vent. [AGE] year-old male who presented unresponsive and subsequently had a cardiac arrest. Chief Complaint Patient presents with * Altered Mental Status The pt is a 59 y/o (year old) male that presents to the ED with a chief complaint unresponsiveness. The pt (patient) was found by CPD (Chicago Police Department) on the curb. On arrival, pt had no coat and was 32.4C. ED (Emergency department) Triage Vitals Group Temp [DATE] 1903 (!) 89.6 F (32 C). Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Cardiac failure and respiratory failure. During interview on [DATE] at 01:06 PM V46 (Primary Physician) stated I am aware of R2's elopement. It was a cold day and R2 went to the hospital with hypothermia. When asked by the surveyor how long it would take for a person to get hypothermia V46 stated I don't know because I don't know what R2 was wearing or R2 comorbidities. When asked by the surveyor if a person gets hypothermia can they go into cardiac arrest. V46 responded If a person gets hypothermia that could send them into cardiac arrest, that I do know. On [DATE] at 01:44 PM Per telephone interview V6 (R2 Family Member) stated V3 (Director of Nursing) called me at home and said I want to inform you that R2 left the facility. It was almost 06:00 PM. V3 said that R2 left out through the employee entrance. V6 never told me what time R2 left out. It was cold outside. I called some family members, and they went looking for R2. The police found R2 sitting on the curb. They found out that R2 was so cold that he coded when I was on my way to the hospital. It took the hospital 10 minutes to get R2 back. They said R2 had a heart attack because his body was 32 degrees, and his body did not know how to react. R2 was in the hospital for 2 weeks. During interview on [DATE] at 09:43 AM V3 (Director of Nursing) stated On [DATE] it was at about 02:50 when staff were doing their last rounds and noticed R2 was not there. They checked the floor and called the supervisor then called a code purple (to say a resident is missing). They called me and I came. They checked the floor and did a head count. When I came everything was in motion. I called 911 to report R2 missing then I called V6 (R2 Family Member) to let her know. V6 said that she was coming and came to the building. When she came to the building, I was waiting for the police to come. V6 called some family members and V6 left. When V6 was leaving the police pulled up, I gave them a description of R2 when the sergeant came to see what was going. The sergeant said I think I saw your guy, but I can't be for sure, but I saw the red shirt. The sergeant said let me call my squad and send them over to the hospital to see if that is your man. The squad went over there and radioed back to confirm that was R2. I called V6 and told her R2 was located at the hospital. The sergeant said R2 was found on 83rd and south shore. I don't know the exact locating some passer [NAME] called 911 that is what the sergeant said. I was writing things down as they happened, and my documentation is for the time stamp as things happened. It was approximate 3.5 - 4 hours that R2 was missing. In my book it was cold outside the day that R2 was missing. R2 only had a tee shirt, sweatpants, socks, and shoes on but no coat. In the morning on [DATE] it was 34 degrees, and, in the evening, it was 32 degrees outside. It was cold that is what possibly caused the hypothermia. In the [NAME] of all this not reporting this to the state was just an oversight on my part. I called the hospital, and they told me R2 was on a ventilator, R2 was cold, and they were treating R2 for hypothermia. When I called V6 she also told me R2 was on a vent and in ICU (Intensive Care unit). The alarms were low. R5 told the staff that your man (R2) went out the back door. The cameras do not record. R2 would lay in the bed and sleep all day. R2 had one aggressive moment with staff, and I had psych to see R2. On [DATE] The facility provided surveyor with a binder containing in service documentation: Record of In-Service Education Offering dated [DATE], [DATE], [DATE] documents in part: Summary of Presentation: 1. Code Purple for missing persons/Elopement. 2. Follow protocol of checking census/people on each floor and then search facility and grounds. 3. Notify Supervisor, Manager on Duty, or DON (Director of Nursing). If/when resident returns to facility staff must monitor 1:1. Record of In-Service Education Offering dated [DATE] and [DATE] documents in part: Summary of Presentation: Code Purple for Elopement/missing person. Elopement Book Front Desk - 1st floor - 2nd floor - 3rd floor - Therapy Office. Follow protocol check census, do rounds on floors and throughout the building. Notify Manager on Duty, DON, nursing supervisor. 1:1 monitoring if/when patient returns. Surveyor did not observe any documentation of the event being reported to Illinois Department of Public Health (IDPH). In servicing documentation also did not include reporting procedures to IDPH. On [DATE] at 2:15 PM V3 (Director of Nursing) stated R2 did not have a reportable for the elopement. We called a code and attempt to look for the resident, if we don't locate the resident, we call the family and search the facility. We also notify the police for a missing person at the beginning, the staff notify the administrator and director of nursing. On [DATE] at 03:18 PM V1 (Administrator) stated this incident was not reported to IDPH (Illinois Department of Public Health) to my knowledge. It was not reported because R2 was found. Usually, it would be the Director of Nursing in conjunction with the administrator that is responsible for reporting it. My expectations are to make sure the staff immediately check the surrounding area, listen to cues if alarm doors go off, check doors, check surroundings and report to the Director of Nursing who would report to me. I am aware R2 was admitted to the hospital with hypothermia. We do not have any video footage. R2 left the facility through the exit door at the basement level. That door is not typically used. That was the only alarm door that went off. The alarm is one of the things we changed. Staff have to put in a code to disarm the alarm. We changed all of the alarms and we put in what ever did not happen is happening now. We did not have codes on each of the floors prior to this incident. I was not here when the incident happened. There are drills in the binder and in services. On [DATE] at 12:18 PM V21 (Vice President of Operations) stated when we identified the noncompliance for the elopement the binder is to show that we are in compliance prior to (referring to me the surveyor) entering the building on yesterday [DATE]. We talked about the root cause analysis, and we took the steps to remedy the issue of a resident leaving the building. I was not here at the time of the elopement. I was made aware sometime on the evening that it occurred. I did not come to the building, and I don't remember when I came to the building. I consulted with V1 (Administrator) and V3 (Director of Nursing) over the phone. The elopement should have been reported to the state. I was not aware that it was not reported. I am just merely a consultant. It was a past noncompliance (the elopement that happened that day) for immediate jeopardy. That is what a past noncompliance is and we have a form in the binder (referring to document titled Elopement PNC documenting in part: Item, Action, Person, Target date and Progress). V21 stated PNC stands for Past noncompliance. We did it at the time of the incident. We fixed the noncompliance prior to anyone asking us to fix it. The binder was put together as a team. The alarm was working, and it was not obviously that loud at the time of the elopement. We enhanced the alarm system based on the events that occurred. On [DATE] at 01:10 PM V9 (Registered Nurse) stated I was R2's nurse. I did my rounds between 02:00 PM - 02:30 PM and R2 was in his room sleeping. At 02:55 PM I ask the aide to do the rounds and V12 (Certified Nurse Assistant) said that R2 was not in his room. When V12 told me, we all started looking for R2 in the building and outside. We did not find R2, and we had to alert management. When we started looking for R2 the whole building was alerted. I did not do any documentation. I had to call my Director of Nursing and she said that she would take care of it. My shift was over, and I had to leave for the day. This happened on [DATE]. They found R2 but I don't know specifically where he was found. V35 (Licensed Practical Nurse) relieved me. When surveyor asked V9 was R2 an elopement risk V9 responded Not that I know of. On [DATE] at 12:15 PM Per telephone interview V51 (Nurse Manager) stated I was there when R2 exited the facility. I was sitting at my desk on the desk 4th floor and got a call from V16 (Licensed Practical Nurse) that they could not find one of the residents, it was about 02:43 PM close to 03:00 PM. I called the Director of Nursing and began searching the facility. They had already begun searching for R2. Staff were driving the neighborhood in search of R2. I did not here any alarms. V9 (Registered Nurse) said the last time that she saw R2 in his room was at 02:15 PM. The certified nurse assistants were not sure the last time that they saw R2, but it was earlier that day. I am not sure who discovered R2 was not in his room. We did not find R2 in the building or neighborhood. We called hospitals and the police were notified by the director of nursing. The protocol if a resident is missing is to notify department heads, notify the director of nursing, search every room, make sure they check that all of their residents are accounted for, search the facility top to bottom and outside the facility. I received the in service for code purple, which is made over the intercom, take a census, look for the residents on the floor and notify department heads. If the resident is found we call an all clear, do 1:1 supervision and notify the doctor. There is an elopement book on each floor with the resident picture and care plan. I have been involved in the drills when I hear the alarm, I go into action like everybody else. On [DATE] at 02:30 PM V11 (Certified Nurse Assistant) stated I was already gone when R2 left the facility. I was here that day, but I left early. Before I left between 9 AM and 10 AM R2 was here. R2 wandered the floor but not to leave the facility. R2's gait was steady enough to walk without a walker. I believe R2 was an elopement risk but not 100% sure. On that day they would only have had 2 certified nurse assistants because I went home. On [DATE] at 03:43 PM V28 (Environmental Service Director) stated I did not see when R2 left. The other staff looked for R2. I looked for R2 in the car. V28 walked with the surveyor to the north end of the basement then V28 stated this is the fire exit door. The delivery door is by the vending machines where we receive deliveries and take out the garbage. There is an emergency exit by the elevator. The alarm went off at the northwest door for 15 seconds. The southeast door is near the parking lot. I believe that R2 came all the way to the basement. The staff went room to room looking for R2. On [DATE] at 03:51 PM V29 (Maintenance Director) stated I was not here when R2 left the building. They called me and I came in. The exit door alarms go off and stays on until you enter a code. The alarm sounds at every nurse station. V29 walked to the first floor and north end of the facility basement. V29 opened the northwest exit door to demonstrate how the alarm is activated. On [DATE] at 04:21 PM Per telephone interview V12 (Certified Nurse Assistant) stated I was there when R2 left the facility. I was doing my rounds at 02:55 PM and I did not see R2. I let the nurse know and they called a code purple. I was doing patient care about 02:30 PM. R2 was in the room and was able to walk. I saw R2 walking around earlier during the shift. It was two Certified Nurse Assistant and two nurses on the floor. Sometimes we may have more CNA' (Certified Nurse Assistants), sometimes there are call offs and we have to work with what we have. We looked for R2. I did not know R2 was an elopement risk. They call a code purple and search the facility. I did not hear any alarms going off because I had the door closed doing patient care. On [DATE] at 05:44 PM per telephone interview V13 (Certified Nurse Assistant) stated I was there on [DATE] and there were 2 CNA's (Certified Nurse Assistant) on the floor because V11 (Certified Nurse Assistant) went home. I was asked to work the second floor because I usually work on the third floor. After doing last rounds we discovered that R2 was missing, and we let the nurse know. We searched everywhere. I drove the neighborhood and did not see R2. I did not hear any alarms because I was in a resident room with the door closed providing care. There is no way that we can supervise residents when we are giving patient care. They never found R2, and it was cold outside. Eight camera screens were observed behind the receptionist desk. The camera screen listed as C-4 was not operating. On [DATE] at 08:40 AM V30 (Office Manager) stated I don't work on the weekends and was not here when R2 eloped. V48 (Weekend Receptionist) works on the weekends. The gate on the west parking lot is always locked and we don't ever use it. V30 Stated that camera has been broken for a while. The camera with Camera C-1 is for the northwest of the building. The two cameras with Camera C-2 one is for the front door and the other is for the third floor. The two cameras with Camera C-3 one is for the first floor and the other is for the third floor. On [DATE] at 08:48 AM V2 (Business Office Manager/Assistant Administrator) stated the alarm system has been upgraded. We watch the parking lot, hallway, and main entrance. The cameras are recording over what was on there. On [DATE] at 09:12 AM V18 (Certified Nurse Assistant) stated I work on the 3rd floor. I saw the second-floor nurse then the supervisor said to check all the rooms. I did not hear the alarm go off. It was towards 03:00 pm. On [DATE] at 09:15 AM V17 (Certified Nurse Assistant) stated When R2 eloped, it was on a Sunday. I worked on the third floor when we heard the code purple, we had to start searching all the rooms. I did not hear the alarm go off. The nurses from the second floor were on the third floor to start searching the floor. It was after lunch, and it was supposed to be three Certified Nurse Assistants on that floor. V13 (Certified Nurse Assistant) was looking for R2 also but we did not find R2. I looked in the basement, laundry and did not find R2. When someone go out of the exit doors the alarm sound. On the third floor there was no alarm. Most of the residents know how to stop the alarm. On [DATE] at 09:32 AM V9 (Registered Nurse) stated I did not hear the alarm because that would have alerted me that something was going on. I am aware that R2 ended up in the hospital with hypothermia. The last time I saw R2 he had a tee shirt, pajama bottoms and socks on. R2 gait was a little wobbly but R2 did not use any assistive devices. I did my last rounds around 02:00 PM - 2:30 PM and R2 was sleeping. It is possible R2 left the facility after I did my rounds. I never saw R2 walk the stairs. R2 gait is not bad enough for him not to be able to walk the stairs. On the door at the end of the hallway there is no code, it is a little alarm that is audible enough and sometimes it is heard at the nurse station. Once the door closes the alarm goes off. On [DATE] at 09:43 AM R7 stated we (R7) and (R2) were watching the bears game on Sunday [DATE] and R2 walked out of the back door. It was about half time around 02:00 when R2 left. I saw R2 wander in other people rooms and R2 tried to leave before. They have alarms on all the doors. I heard the alarm ,d+[DATE] minutes, but it goes off. As soon as they change the door code the staff do it in the open and the residents see the code anyway. On [DATE] 09:57 AM R5 stated R2 would come out of his room and go down the back stairs. The alarm would alarm when you open the door but when the door closes the alarm go off. I was watching the bears game on Sunday [DATE] and it was about 15 minutes before the shift got ready to change. R2 timed that just right. R2 is the only one that did that. R2 would wander the floor and go in other resident rooms. I did not hear any other alarm. On [DATE] at 10:05 AM V16 (Licensed Practical Nurse) stated I was working the day that R2 eloped. They did the elopement code purple and staff started searching the building. R2 nurse said R2 is not in the room, and we started searching the floor to make sure R2 did not go into another resident room. I did not hear any alarms go off. If I hear an alarm, I will get up and check. On [DATE] at 10:18 AM V14 (Licensed Practical Nurse) stated I was here when R2 eloped, but I was on break and was in my car. I did not know what was going on. When I came back in from my break, they were searching the building. I never saw R2. I leave at 3:00 PM and I did not hear alarms going off. On [DATE] at 10:31 AM V15 (Certified Nurse Assistant) stated I was here when R2 eloped, and I was on the 1st floor. The staff were looking for R2 but could not find him. During the search the front door alarm was going off because everyone was going in and out looking for R2. Alarms go off all day. On [DATE] at 02:10 PM per telephone interview V23 (Licensed Practical Nurse) stated The staff from the second floor came down to the first floor and started about 02:30 PM checking all around the building. At 02:45 PM the supervisor came down continued to search. At 03:00 PM R2 had not been located. They continued to look for R2, the shift changed at 3pm and I left at 03:30 PM. I am not sure if the alarm went off. The staff was running all around and it was almost time for the shift to be over. They searched all around the building. I did help them search in the basement and outside. R2 may have gone out of that Northwest door. We are supposed to hear the alarm if someone went out of the door. On [DATE] 02:29 PM Per telephone interview V25 (Certified Nurse Assistant) stated I work on the first floor. When R2 eloped, we searched the facility. I did not hear any alarms. Someone from the second floor came and said someone was missing and we started searching together. On [DATE] at 02:42 PM V26 (Certified Nurse Assistant) stated I was at the facility when R2 eloped. R2 was not a resident from my floor, I work the first floor. R2 had on a red shirt. R2 was found and was taken to the hospital due to it being cold outside. It happened at the middle of the shift change. I looked on my floor and I told them I did not know what the person looked like. They did not have a book with residents that were elopement risk at the desk. They talked about designing one after the fact. I am not going to lie. I did not hear any alarm prior to them calling a code purple. On [DATE] at 02:52 PM Per telephone interview V27 (Licensed Practical Nurse) stated I got there when they were looking for R2. Everyone was searching the rooms and outside. To my understanding it had to be right before I got there. I got there a little before 3 pm and they were already checking. I don't remember a book with a list of residents at risk for elopement being at the nurse stations if it was, I am not aware. R2 wanders and would go through any doors he came across; other resident rooms and we would redirect R2 to his room. There were no alarms going off when I came in. I heard from R5 that R2 went out the back door of the hall. On [DATE] at 03:34 PM V35 (Licensed Practical Nurse) stated I work the pm shift. When I came in on [DATE] they could not account for R2. They checked in every room and outside. R2 was always in his room, confused and able to ambulate without assistance. I assisted in the search for R2. On [DATE] at 03:45 PM V32 (Licensed Practical Nurse) stated I worked that evening when R2 eloped. When I came in the search was over. One day R2 left the second floor and came to the first floor down the back stairs, and I call the nurse to come get R2. I did not know there was a book with a list of the residents at risk for elopement there on the first floor. On [DATE] 11:32 AM V29 (Maintenance Director) stated the northwest door has an alarm that go to the nurse station and is faint, but you can hear it. The alarm to the northwest door was not that loud initially. Originally it goes off and you shut it off but after 15 minutes it goes off on its own. When I came in on [DATE] it was between ,d+[DATE] o'clock pm. On [DATE] at 12:56 PM per telephone interview V20 (On-Line Communications Low Voltage Technician) stated on [DATE] the facility requested to have alarms installed at the doors. We installed a door alarm to the northwest door. I am not sure if an alarm was there. We quoted an annunciator that will ring at the nurse station when the alarm goes off. On [DATE] at 11:52 AM V29 (Maintenance Director) stated the alarms were working but the old was not as loud. The old alarm is still there, and you can still hear it. If you open the door, both the old and new alarms are alarming at each nurse station. Policy: Titled Elopements revised ,d+[DATE] document in part: Policy Statement; Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 4. If an employee discovers that a resident is missing from the facility, he/she shall: b. If the resident was not authorized to leave, initiate a search of the building(s) and premises. c. If the resident is not located, notify the administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials and Emergency Management, Rescue Squads. 6. Procedures for Prevention of Missing Residents. a. all residents shall be assessed for behaviors that place them at risk of elopement utilizing an elopement risk assessment upon admission, quarterly, annually and upon significant change of condition. b. Any resident identified to be at risk of elopement will be placed on a resident AT Risk List which shall be posted at each nurse station and at the reception area. The At Risk List will be updated whenever a new resident safety concerns are identified. Residents with identified elopement risk will be documented in the resident plan of care. c. Pictures of the residents that are at risk of elopement will be posted at the reception area. d. unless otherwise identified in the plan of care, any resident at risk of elopement shall be accompanied by a responsible individual while outside the facility. e. Should an alarm on one of the exits to the outside of the facility sound, staff will immediately respond to determine the cause of the alarm. 7. For the Response to missing Resident, In the event a resident is discovered missing, the following procedure shall be followed. b. Should a search of the inside and outside of the facility prove to be unsuccessful in locating the resident, the immediate vicinity surrounding the facility shall be searched with interview of any potential witnesses conducted. Titled Accidents and Incidents: Supervision, Investigation and Reporting revised ,d+[DATE] document 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 the effectiveness, and modifying interventions when necessary. 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. Supervision: Monitoring there is sufficient staff based on residents' needs. Such needs could include behaviors such as unsafe wandering, elopement risk, l [TRUNCATED]

Based on interview and record review, the facility failed to protect a demented and cognitively impaired resident from physical abuse. The resident, (R2), was hit repeatedly in the head by R3 with R3's leg brace. This failure resulted in R2 sustaining multiple wounds to his head, requiring wound treatment and hospitalization . This failure affects one of four residents reviewed for physical abuse in a total sample of four residents. Findings include: R2 is an [AGE] year old male. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's BIMS (Brief Interview of Mental Status), dated 06/25/2021, notes that R2 is not alert or oriented. R2's care plan notes that R2 has impaired cognition, R2 needs supervision and care due to medical and psychological needs. R2 has an altered mental status and poor confusion. R3 is a [AGE] year old male. R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's BIMS (Brief Interview for Mental Status), dated 06/25/2021, notes R3 is alert and oriented. R3's care plan notes that R3 is able to make R3 needs known. Facility incident report dated 08/18/2021, notes V2 (Director of Nursing) was informed by a nurse that R3 hit R2 in the head with a leg brace because R2 had taken R3's doughnuts and cheese that was in R3's bag. R2 and R3 were immediately separated. R2 was noted with a laceration to the head. On 09/29/2021, at 11:23AM, R4 stated, I do not like going to the lunch room because I have almost gotten hit before. I saw R2 get hit before. I do not recall the resident's name. The resident hit R2 before because R2 was chewing too loud. The resident has thrown orange juice across the table. On 09/29/2021, at 11:40AM, R2 could not recall the incident or the name of the resident that hit him. R2 is very confused and could not recall the day of the week or where R2 is at. On 09/29/2021, at 11:47AM, R3 stated, R2 stole my food. I came back to the room and R2 had my stuff. I hit R2. Every time I tell someone they do not do anything about it. There was no staff around. I hit R2 in the head with my leg boot. I took matters into my own hands. On 09/29/2021, at 12:16PM, V2 stated, I was notified about the incident. I was not in the building at the time. R3 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was noted with a small opening on R2's head after the incident. When R3 hit R2, it was physical abuse. On 09/29/2021, at 1:32PM, V5 (Licensed Practical Nurse) stated, I recall the incident between R2 and R3. I did not witness anything. It occurred at the beginning of my shift. R2 was in the second bed. R3, his roommate, was in the first bed. After dinner, an aide called me. The aide stated that R2 was bleeding. I went to their room. I saw R2 bleeding. R2 could not verbalize anything. R2 does not say much. R2 is confused and wanders. R2 was bleeding from the right side of his head. R2 was also bleeding on the top and left side of the head. The right side wound was much bigger. I tried to stop the bleeding and asked what was going on. R3 stated when R3 came back to the room, R2 had his bag of doughnuts and cheese. R3 then grabbed R3's leg brace and beat R2 with it. I told R3 I could have gotten him more doughnuts. R3 stated I took matters into my own hands. Facility Abuse Policy, dated, 10/2017, notes abuse means any physical, mental, or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury. 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 interviews and record review, the facility failed to timely review and report the radiology result of a resident's fractured femur to the physician for one (R1) of three residents reviewed for improper nursing care. This failure resulted in a delayed hospital evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included: R1 is an [AGE] year old with a facility admitted [DATE]. R1's admission record documents, in part, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's brief interview for mental status (BIMS) score is assessed at 4 which indicates severe cognitive impairment. On 3/23/21 at 12:43 pm, V3 (Licensed Practical Nurse, LPN) stated R1 is alert, confused, walks slow and steady and will toilet herself. V3 stated on 3/10/21, at approximately 7:00 am to 8:00 am, he observed R1 sitting on the floor in her room near the foot of her bed with her legs extended out in front of her. V3 stated R1 was dressed, wearing rubber slip on shoes, and was alert. V3 stated he called immediately for assistance from V7 (Certified Nursing Assistant, CNA) and V8 (CNA). V3 stated he did a full body assessment of R1 by checking her neurological status, asking her to move her extremities, and performing vital signs. V3 stated R1 was able to move her legs; however, R1 was not compliant with his commands when he asked her to lift her legs. V3 stated R1 was not able to give a description of what happened and was not in pain. V3 stated he, V7, and V8 transferred R1 back to bed. V3 stated he medicated R1 prophylactic for pain because R1 was rubbing her hands on her right knee. V3 stated he called and notified V15 (Attending Physician) of his observation of R1 on the floor, or an unwitnessed fall, and that R1 was able to move her leg, but that he couldn't tell if her leg was broken. V3 stated V15 ordered an X-ray of R1's right knee. V3 stated he documented the telephone order in R1's chart, then called the external radiology company to place the X-ray order and received a claims number for the pending X-ray. V3 stated he also notified V10 (Family Member) of R1's unwitnessed fall. In R1's nurse's note, dated 3/10/21 at 8:02 am, V3 documented, in part, (R1) observed sitting on the floor on her buttocks, unable to give description of what happened. Upon assessment, (R1) remain at base line, able to move all extremities without limit . (V15) made aware with an X-ray to the right knee, claims # 303. R1's order summary report, dated 3/10/21, indicates a telephone order for R1's right knee X-ray. On 3/23/21 at 12:43 pm, V3 stated by the end of his shift at 3:00 pm, R1's X-ray had not been performed yet. V3 stated R1's right knee X-ray wasn't ordered stat, but he took the initiative to call them (external radiology company) to come as soon as possible. V3 stated he was told that the X-ray technician would come as soon as possible but provided no estimated time of arrival. V3 stated he told the on-coming nurse, V4 (LPN), during shift to shift report about R1's pending X-ray to be done, and to notify V15 of the results. V3 stated he also placed this information in the 24 hour report in the electronic charting system, which is reviewed by the nurses each shift. On 3/23/21 at 4:10 pm, V4 (LPN) confirmed V3 informed him the external radiology company was going to come and R1's right knee X-ray wasn't done yet when he started his shift at 3:00 pm on 3/10/21. V4 stated R1's right knee X-ray was done maybe at 5:00 pm to 6:00 pm on 3/10/21. V3 stated X-ray results are sent to the 1st floor receptionist via fax, and then the receptionist pages the nurse after the faxed X-ray results report come into the facility. V4 stated the receptionist only stays at the front desk until 7:00 pm where the fax machine is located on the first floor. V4 stated if the faxed results report don't arrive at the facility before the receptionist leaves at 7:00 pm, then he doesn't have access to the fax machine, so the nurses will follow up in the next morning. V4 stated when the on-coming nurse, V9 (LPN), came on her shift at 11:00 pm, he didn't have R1's X-ray results and told V9 to look out for (R1's) results. In R1's nurse's note, dated 3/10/21 at 8:42 pm, V4 documented, R (right) knee X-ray completed. F/U (follow up) with (V15) when results are in. R1's faxed radiology report for a right knee X-ray, with a date of service of 3/10/21 and a report date of 3/10/21 at 7:33 pm, documents an acute fracture involving right distal femur with modest displacement. V18 (Radiologist) electronically signed R1's radiology report on 3/10/21 at 7:33 pm. R1's faxed radiology report indicates in large print, ALERT, under V18's signed results, and the faxed time stamp on this document is 3/10/21 at 8:37 pm. On 3/24/21 at 12:30 pm, V9 (LPN) stated she worked the 11:00 am to 7:00 am shift the night of 3/10/21 and was R1's primary nurse. When this surveyor asked her about R1's unwitnessed fall that occurred earlier on 3/10/21, V9 stated, No, (R1) didn't fall. V9 stated R1 slept throughout the night on her shift, performed her vital signs, and she didn't bother (R1) too much. When this surveyor read V4's nursing note to V9 about R1 having a right knee X-ray done on his shift and to follow up with the X-ray results, V9 stated, I don't remember that. V9 stated nurses fill out the 24 hour report and make notes for report to next shift's nurse. V9 stated she didn't recall seeing anything in the 24 hour note about R1's pending X-ray results or an unwitnessed fall. V9 also stated X-ray results get faxed to the facility by the external radiology company, and the faxed results report comes in the main office on the first floor. V9 stated there's no receptionist in the main office overnight and the faxed results report will be pending until the morning shift comes in. V9 stated she did not call the external radiology company to follow up on obtaining R1's right knee X-ray results because she didn't know that the X-ray was taken. On 3/24/21 at 2:39 pm, V2 (Director of Nursing, DON) stated if an X-ray is ordered and still pending to be performed, the nurse will document the claim number for the X-ray in the resident's chart and on the 24 hour report. V2 stated X-ray results are faxed to the facility's front office, and no receptionist works the in the office after 8:00 pm. V2 stated nursing staff do not have access to this fax machine after 8:00 pm. Furthermore, V2 stated nurses can see X-ray results in the resident's electronic chart when it is loaded. V2 stated the external radiology company is electronically linked to the facility's electronic charting system. V2 stated she expects her nurses to be checking for pending results of an X-ray, or they can call the external radiology company for the results. On 3/24/21 at 1:40 pm, V13 (LPN) stated she had just started her 7:00 am to 3:00 pm shift on 3/11/21, when V16 (Nursing Manager) brought her a report of the X-ray results of R1's right knee showing a fracture. V13 stated, I didn't know. V13 stated she found out about R1's unwitnessed fall from 3/10/21 when V16 notified her of R1's right knee fracture. V13 said she immediately notified V15 (Attending Physician) and V11 (Family Member). V13 stated she and V16 then prepared R1 for ambulance transport and transfer to the hospital for evaluation and treatment. In R1's nurse's note, dated 3/11/21 at 8:35 am, V13 documented, in part, Received X-ray right knee (+) for fracture. (V15) made aware to send (R1) out to hospital for evaluation . 9:40 am: (Ambulance company) left with (R1) via stretcher accompanied by two attendants. On 3/25/21 at 10:54 am, V16 (Nursing Manager) stated she is the nursing manager for R1's floor in the facility. V16 stated on 3/11/21, at the start of her shift, she always checks the 24 hour nursing report to see if anything abnormal occurred and checks for any labs or X-rays that were done on her floor within the past 24 hours. V16 stated she noticed an X-ray result for R1 and it showed a fracture of her right knee. V16 stated she printed a paper copy of R1's X-ray results from 3/10/21 from the facility's electronic charting system, and hand delivered the X-ray report to V13 (LPN). V16 stated she did not work on 3/10/21 when R1 had an unwitnessed fall. Facility document printed from the electronic charting system documents, in part, the report information for R1's right knee X-ray (order number 303) as: Examination Date: 3/10/21 at 7:10 pm. Reported Date: 3/10/21 at 7:33 pm. On 3/24/21 at 5:15 pm, V14 (External Radiology Company Personnel) confirmed her company performed an X-ray of the right knee for R1 with a performed date of 3/10/21 at 7:10 pm, and a report date of 3/10/21 at 7:33 pm. V14 stated on 3/10/21 at 7:10 pm is when the technician started working the case in the facility, and at 7:33 pm is when he clocked out of case while in the facility. V14 stated the technician submits the X-ray film electronically as he's clocking out. V14 stated the radiologist then can view X-ray film for reading exactly at that instant when the technician electronically sends it. V14 stated the radiologist then reads the X-ray film on his remote screen, and will electronically sign his results, which get sent to the facility. V14 stated the facility can receive X-ray results via two methods. V14 stated the X-ray results come as an electronic file in facility's electronic charting system, and as a faxed paper report to the facility. On 3/25/21 at 10:11 am, V15 (Attending Physician) stated V3 (LPN) called him on 3/10/21, notifying him of R1's unwitnessed fall. V15 stated V3 informed him R1 was sitting on the floor and R1 complained of a little pain in her right knee. V15 stated he gave telephone orders to V3 to get a right knee X-ray as soon as possible, to have R1 stay in bed until we get the X-ray report, and to notify him of the X-ray results. V15 stated the next morning (3/11/21), V13 (LPN) called him with R1's X-ray results of a right femur fracture, and he ordered to send her out to the hospital emergency room for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . When this surveyor reviewed the time line with V15 about R1's right knee X-ray being performed on 3/10/21 at 7:10 pm, with it being resulted at 7:33 pm, and then he was notified of R1's femur fracture by V13 on 3/11/21 at 8:35 am, V1 stated he should have been notified of the X-ray results when the report was sent to the facility. V15 stated, This is important. This is a critical result, and I should have been notified when they (facility staff) received the X-ray report. A resident will automatically be sent out to hospital with a fracture. I am no expert in that (fracture care). That's why we send a resident with a fracture to the hospital to be evaluated and treated. On 3/25/21 at 10:54 am, V16 (Nursing Manager) stated the 24 hour report is the nursing shift to shift report. V16 stated when anything happens with a resident within your shift, the nurse must endorse to next nurse on 24 hour report. V16 added nurses can verbally tell next nurse too if it's important. V16 stated she expects all of her nurses to fill out the 24 hour report every time when they are leaving their shift and to read every time when they are coming on their shift. V16 stated then the nurse can't say, You didn't relay that to me. V16 stated staff nurses can check for X-ray results at any time in the electronic charting system, and nurses should be monitoring for pending results of a completed X-ray. Facility policy, titled Change in a Resident's Condition or Status, dated 11/2013, documents, in part: Policy Statement: Our facility shall promptly notify the . Attending Physician of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. If any direct care staff note a change in the residents' condition, they are to notify the nurse. The nurse supervisor/charge nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . A need to transfer the resident to a hospital/treatment center. Facility policy, titled Assessing Falls and Their Causes, dated 10/2020, documents, in part: Steps in the Procedure After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spin, and extremities . 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately . 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. Facility document, titled Licensed Practical Nurse Job Description and dated 3/2017, documents, in part: Job Title: Licensed Practical Nurse. Supervised by: Director of Nurses. Job Summary: Assesses, plans and implements the person centered nursing care of residents within the skilled nursing setting. Responsible for ensuring continuity of care of the residents between shifts by providing direct care as well as supervising the care given by CNA's and supported staff members . Duties and Responsibilities: Demonstrates Competency in the Following Areas: . Assesses the resident's condition and nursing needs, prescribes appropriate nursing action . Ability to interpret results of waived tests; take appropriate action on waived tests results . notifies physician of changes in resident's condition and follows through until appropriate action is taken . gives a thorough report to oncoming shift by participating in walking rounds and documenting appropriately on calendar for upcoming needs . consistently follows the policies and procedures of the facility.

Based on observation, interview, and record review, the facility failed to ensure safe/secured windows in rooms of one (R4) of three residents who had elopement risks behaviors in a sample of 3 residents reviewed for elopement. This failure resulted in R4 jumping from his bedroom window and being hospitalized for [REDACTED]. Findings Included: R4 was a [AGE] year old admitted to facility on 3/23/2020 with [DIAGNOSES REDACTED]. His mental status was mildly impaired as noted in the Brief Interview for Mental Status (BIMS) score of 10 out of 15, dated 3/30/2020. Acording to MDS(Minimum Data Set), dated 6/27/2020, R4 was ambulatory with extensive assistance of staff otherwise he used a manual wheelchair. Elopement risk assessment, dated 3/23/2020, noted R4 was low or no risk for elopement. There was no other elopement risk assessment until 7/17/2020. On 6/3/2020, nursing note documented,Resident dressed, ambulated to back of corridor attempting to leave the floor and said he was going home. On 6/4/2020, Psychiatry notes documented that R4 was very unhappy and said he did not want to be there. On 6/6/20 Psychiatry notes documented R4 noted with new wandering behaviors especially at nights. Stated his gait was steady. On 6/20/20, Psychiatry notes noted R4 said he wanted to leave and was depressed with interrupted sleep. Incident report for R4 on 7/17/2020 documented R4 allegedly jumped from the second floor unit through the window and was found on the ground outside under his room's window. The fall was unwitnessed. The incident was reported by neighbors in the community according to report. Investigation report by the facility documented one of R4's room mate (No longer there) said on the night of 7/17/2020 he saw R4 doing something at the window, but he thought R4 was turning the heat on or off. On 10/23/2020 at 12:10PM, V11(Nurse for R4) wrote that she saw R4 in the bed at 4:00AM, on the night of the incident. Unable to make contact with V11 during investigation. On 10/22/2020 at 11:00AM, the window in room where R4 resided could open only six inches high. On 10/22/2020 at 11:20AM, R6 (R4's) roommate said R4 always stated he was leaving the facility and would sometimes pack his belongings and waited at exits. He said he did not see him exit through the window. On 10/22/2020 at 11:40AM, V5(Assistant Director of Nursing/ADON) said R4 was not a risk for elopement. When asked if she was aware that there was psychiatrist documentation that R4 had exit seeking behavior, V5 did not answer. On 10/22/2020 at 10:50AM, V10(Maintenance Director) said after the incident, he checked the window where R4 allegedly jumped out. According to V10, the window could open all the way upwards and the screen was cut which could have allowed someone to through. He said he usually checked the windows at least every two weeks, but could not remember the last time he checked. He said the window was not supposed to be like that. According to V10, the window was supposed to be set so that it could only open about 6 inches and no one could have passed through. On 10/23/2020 at 1:40PM, V13(Certified Nursing Assistant/CNA) said she was the staff who took care of R4 on the night he assumedly went through the window. She said she made rounds at about 4:30AM, and R4 was asleep in the bed. She said she was not aware that R4 was at risk for elopement. emergency room records for R4 on 7/17/2020 documented, [AGE] year old s/p fall from 20 feet. Pt jumped out of window in a nursing home. Noted 3centimeter laceration to the right superior gum line , small abrasion to the posterior head. Clinical impression of Closed bilateral fracture of pubic rami. Facility did not present a policy on Accidents/Elopement.

Based observation, interview and record review, the facility failed to ensure that fall prevention policy was followed for 2 residents (R1,R12) in the sample of 19 and 1 supplemental resident(R20). This failure resulted in R20 experiencing multiple falls resulting in hematoma to the head and a head laceration requiring hospitilization and 8 sutures. Findings Include: 1. R20 has the following [DIAGNOSES REDACTED]. Per Incident reports and Nurse's Notes, R20 has fallen 7/10/2014, 9/8/2014, 12/24/2014, 12/27/2014 and 1/20/2015. R20 sustained injuries when she fell , 7/10/2014, 9/8/2014, 12/27/2014 and 1/20/2015. Nurse's Notes dated 12/24/2014 at 7:30pm, stated that R20 was found on the floor by staff. R20's Physician (Z2), Administration, and the Family were called. Vitals were taken. R20 was not injured. Z2 at 8pm, 12/24/2014, gave a telephone order to watch and monitor R20 at bedside for 72 hours. Monitoring was not updated in R20's care plan after this fall. Nurse's Notes dated 12/27/2014 at 7pm, state that R20 was found on the floor by her bed by CNA (Certified Nursing Assistant/E16). A written statement in the Incident Report dated 12/27/2014, from E16 states that she heard the bed alarm go off in room 302 and found R20 on the floor mat next to R20's bed. Nurse's Notes state that R20 sustained a bruise to the right side of her forehead. No bleeding was observed. Z2's office was called at 7:15pm, Z3 (Physician) ordered application of a ice pack to the Hematoma and 72 hour monitoring. Monitoring was not updated in R20's care plan after this fall. Nurse's Notes dated 1/20/2015 at 5:45pm, state that R20 fell out of a recliner in the hallway outside of room 302. R20 sustained a laceration to the left side of her forehead. 1/20/2014 at 6:08pm, the Hospice Nurse (Z4) okayed R20 being taken to the emergency room for evaluation. Nurse's Notes dated 1/21/2015 at 4:15am, R20 was admitted to the hospital with [REDACTED]. Also noted is R20 required 8 sutures to close the head laceration. E3 (Director of Nursing) stated that R20 was in a low bed with bed alarm and mats on the floor when R20 fell out of the bed on 12/27/2014. It was clarified that R20 was not in a recliner for the 1/20/2015 fall. R20 was in a specialized high back wheelchair given to R20 by Hospice. During the 1/29/2015 interview at 11am with E5(Nurse), R20's fall care plan was discussed. E5 confirmed that before the 12/24/2014 fall, R20 was in a low bed (added 7/10/2014) with a bed alarm (added 9/11/2014) and mats (added 7/10/2014). 12/24/2014, R20's fall care plan was updated with keeping the resident close to the nurse's station while up in recliner with chair alarm (added 7/17/2014). E5 was asked if the monitoring requested by Z2 and Z3 added to R20's care plan. E5 stated that Z2 and Z3's request was only for 72 hours and no adaptation was added to R20's care plan. After the fall of 12/27/2014, the staff increased telling R20 to ask for assistance. R20 has a care plan for cognitive impairment that was initiated, 4/29/2014. On her most recent Minimum Data Set ((MDS) dated [DATE], R20 was not given the Brief Interview for Mental Status (BIMs/Score = 00) because of the severity of her cognitive impairment. R20 cannot follow directions. R20's fall care plan contains interventions which R20 is incapable of doing based on her cognitive impairment. These interventions are safety training, education and calling for assistance. An individualized monitoring program was not initiated and put in place as apart of R20's fall care plan. Attempts to interview Z2 and Z3 were unsuccessful. 2. R12 was admitted to the facility in July 21, 2014. R12 has the following Diagnoses: [REDACTED]. 11/4/2014, a Psychiatric Progress note written Z5 (Psychiatrist) gave R12 the [DIAGNOSES REDACTED]. R12 has been 'at risk for falls' since his initial fall assessment, 7/21/2014. R12 has fallen 8/3/2014, 8/27/2014, 10/23/2014, 11/6/2014 and 12/4/2014. R12 sustained pain to his left hip after the 8/3/2014 fall. 1/29/2015 at 10:30am, R12 was observed sitting in a recliner during activities. R12 was not participating in the activity (Bingo). 1/29/2015 at 11am, R12's falls and fall care plan was discussed with E5. E5 stated that R12's falls occur in the evening, when he tries to get out of bed without assistance. After the 8/5/2014 fall, R12 was put in a low bed with alarm and mats on the floor. A chair alarm was added when up in a chair. R12's latest fall care plan was initiated 10/29/2014. R12 has fallen twice, 11/6/2014 and 12/4/2014. The fall care plan was not changed after the 2 additional falls. E5 was asked what was implemented to prevent R12 from falling after the last 2 falls. E5 said R12 was encouraged to ask for assistance more often. R12's BIMs score is 7/15 in his MDS assessment dated [DATE]. R12 is cognitively impaired which means R12 cannot take direction. Asking R12 to call for assistance is an inappropriate intervention. The facility's Fall Policy was reviewed. The policy states that residents are to be assessed after every fall. A Fall Committee will assess the effectiveness a resident's care plan as it relates to fall prevention. Tracking and trending of falls is to be done for each resident in order to discover the root cause of a resident's falls. Interventions are to be based on that cause. 1/29/2015 at 12:40pm, the facility fall policy was discussed with the Director of Nursing (DON/E3) and E5. E3 and E5 presented a log of falls for R12 and R20, but no documentation showing that a root cause for the falls were used to develop appropriate fall interventions for R12 and R20. Example: R1 was observed two days of the survey 01/26/15 and 01/27/15 in a recliner with back of chair reclined back seated at the entrance of room door (318) or in bed with [DEVICE] feeding in progress via pump. At no time during the observation period did R1 attempt to remove self from the recliner or bed. R1 remained quiet and immobile during the entire time. The resident requires extensive total care with activities of daily living (bed mobility, transferring surface to surface, toilet use and personal hygiene). During record review of (incident/accident reports), it was determined R1 had multiple falls in July 2014 as follows: - 07/05/2014 at 3:00pm on matt next to low bed - 07/12/2014 at 8:00pm on matt next to low bed - 07/25/2014 at 7:00pm on floor next to bed - 07/28/2014 at 6:00pm on floor with [DEVICE] pole next to resident Four episodes of falls (from a low bed onto matt in room) within a one month period of time, no injuries documented. R1's Fall Risk Screening Tool dated 05/22/2014 to 07/12/2014 indicated the resident is at risk for falls (scored from 19 to 20). "A score of 14 or greater means the resident is at risk for falls." In addition, R1 had six falls in a four month period time from August 2014 to December 2014 as follows: - 08/01/2014 at 7:10am face down on matt next to bed - 09/20/2014 at 1:20am on back on matt next to bed - 09/24/2014 at 6:30pm on the matt on the floor next to bed -11/04/2014 at 10:40pm on matt on floor next to bed -11/30/2014 at 9:15am on floor next to bed in room - 12/02/2014 at 6:40am on mattress on floor with small amount of blood on forehead. Although the "Unusual Occurrence Investigation Form" describe a left sided gash to the forehead, E5/nurse supervisor reports the wound was a small area. Interview with E5/nurse on 01/29/2015 at 1:30pm about the alleged gash to the forehead, E5's written statement is, "R1 had fall on 12/1/14, E15/nurse did do incident report and used term gash. Resident did have a small opening to forehead, however did not have gash, nothing with depth was noted with bleeding at time of fall. However, upon fall review area was healed on 12/2/14, no gash noted. E15/nurse did use inappropriate words for assessing resident." R1's Fall Risk Screening Tool dated 08/25/2014 to 12/02/2014 scored the resident from 18 to 23, at risk for falls. Based on the 06/28/2014 and 12/26/2014 Minimum Data Set (MDS) Section C, Brief Interview for Mental Status (BIMS), R1 is scored as 03. A (BIMS) score is classified as being severely impaired, according to E14/social services director. On 01/29/2015 at 12noon when questioned about the score, E14's/social service director written statement is, "severely impaired cognition. R1 has impaired insight, judgement and decision making skills. Due to R1's cognitive impairments, pulling resident call light may not be something R1 thinks to do mentally. Instead R1 may occasionally call out. Due to resident's cognitive impairments R1 doesn't understand safety issues. Due to the resident not understanding safety, R1 may continue to roll himself out of R1's bed." The resident's care plan reviewed from 07/05/2014 to 12/02/2014 and there is a problem "at risk for falls related to past history of falls." Several of the interventions are as follows: place resident near nurses station when not in bed/activities, continue to encourage resident not to roll out of bed, staff will monitor every 2 hours for signs/symptoms of restlessness, staff will provide safety training and education as needed, follow up to ensure understanding, and monitor for behaviors with interventions to reduce risk for falls. R1 is severely cognitively impaired. E5/nurse supervisor interviewed 01/29/2015 at 1:30pm about how R1 is being monitored related to the multiple fall events. E5's/nurse written statement is, "resident is being monitored every two hours and as needed, based on behavior. There is no rounding log used at this facility, however the facility does document in the kiosk behaviors and care concerning resident. Resident is not in a room close to nursing station because the facility will revisit with fall committee."

Based on interview and record review, facility failed to implement interventions to reduce the risk of falling for 1 of 3 residents reviewed for falls. This failure resulted in R10 falling to the floor and being transported to the hospital for evaluation and assess to have a left hip fracture. Findings include: R10 face sheet documents a date of birth of 6/17/17, making R10, [AGE] years old. [DIAGNOSES REDACTED]. Psychiatry note of 8/5/14 describes R10 as disoriented with impaired judgement. Annual minimum data set of 9/9/14 codes R10 as having a score of 3 out of 15 on the brief interview for mental status. R10 did not identify the correct year, correct month, or correct day of the week. R10 was coded as having behaviors of inattention which fluctuates and continuous disorganized thinking. In addition R10 was coded as having physical and verbal behavioral symptoms(E0200) directed toward others. Potential indicators of psychosis included delusions(E0100). Under E0500 of the M.D.S presence of identified symptoms was noted to place R10 at significant risk for physical illness or injury. R10 has 3 documented falls since May: 5/23/14, 7/11/14,9/8/14 and 9/29/14. Incident report for 5/23/14 with time of 7:45 pm indicated R10 fell because she slipped out of wheelchair. The fall was unwitnessed. 7/11/14 nursing note at 6:30 pm states R10 was found in her room on the floor next to her bed. Nursing note was not found for 9/8/14 fall incident. Incident report describes an unwitnessed fall in the hallway at 6:00 pm. The next fall was on 10/18/14 at 4:25 am in her room which resulted in a hip fracture. All reports were faxed to I.D.P.H (Illinois Department of Public Health) with appropriate physician notifications. R10 fall assessment on 7/11/14, 9/19/14 and 10/18/14 consistently codes her as at risk for falls with a score of 26. The fall screening tool notes Psychiatric/Cognitive/Behavior ' s contributing to risk for fall include: Dementia, depression, physical aggression and resistance. On 11/7/14 at 4:30 pm E10(nurse, falls coordinator) explained All falls for her were from wheelchair except for 10/18. When in sitting position she is at risk for fall. " R10 has care plans for behavioral symptoms related to Dementia with goal date of 12/19/14 and falls related to [DIAGNOSES REDACTED]. The goal for the fall care plan is to keep R10 free from injury related to fall. One approach in the care plan for behaviors is to " intervene when any inappropriate behavior is observed. " Level of supervision required is not addressed in either the fall or behavioral care plan. R10 had 2 hospitalization s in October . Hospital radiology report with a service date of 10/18/14 notes, " There is an impacted comminuted intertochanteric fracture of the left femur with medial displacement to the varus deformity. Vascular calcifications are seen. Z2(Admitting Physician) progress note from the hospital with an admitted [DATE] states, " [AGE] year old African American female nursing home resident recently discharged from hospital fracture left hip as p.o.a(power of attorney)declined surgery ... " Two staff members responsible for care of R10 on 10/18/14 when the fall with fracture occurred were E8(Licensed Practical Nurse) and E9(Certified Nursing Assistant). Nursing note of 10/18/14 at 4:25 am indicates E8(Licensed Practical Nurse) heard the R10 talking then heard a loud thump. R10 was found on the floor and complained of left thigh pain. Nursing note of 10/18/14 at 4:25 am states R10 body was inspected for injuries, " none were apparent when writer rendered passive range of motion to upper extremities, no c/o(complaints) was voiced. When writer began PROM to lower extremities, resident voiced pain to left thigh. Resident was cleaned and dressed and sat in her chair. " R10 was then sent to the hospital at approximately 8:20 am. Nursing note of 10/18/14 at 6:35 pm documents admitting [DIAGNOSES REDACTED]. E9(Certified Nursing Assistant) was the C.N.A on duty and in charge of R10 when she fell and fractured her hip. On 11/7/14 at 1:30 pm stated, " I had to keep putting her legs back in bed. I would put her back. She kept sitting up in the side of bed, facing towards roommate. Scared me because I didn ' t want her to fall. I have seen her sit on side of bed with no problem. She was sitting so close to foot of bed. Scooted to edge of bed. Twice I went into room to scoop. I don't want to lay down(she said). She didn ' t seem like confused. Not to my knowledge she hasn ' t fallen out of chair before. If had known she had fallen before then I would have thought of her as unsafe to sit on edge of bed. I would have put her in chair. " On 12/16/14 at 1:51 pm Z3(Attending Physician) stated, " if someone falls down, need to stay there and call 911, " and " Could cause more damage. Need assessment. With hip fracture can ' t move leg. " R10 was moved to a sitting position after " resident voiced pain to left thigh " according to the nursing note of 10/18/14 at 4:25am. Z3 continued, " It ' s more common sense. They should have said don ' t let her sit up or be there when sitting up alone. Can ' t leave alone. Risk for injury, " and " failed to give adequate supervision. Failed properly assess after fall. " On 11/7/14 at 4:30 pm (Director of Nursing) stated in regards to R10 behavior, " feet in and out of bed. Should have patient ' s nurse to see if can redirect or see what problem is. Intervention to prevent fall was not adequate. Going in and out of room not enough. "

Based on observation, interview and record review the facility neglected to provide a safe environment while leaving the maintenance cart unattended involving 2 of three sampled residents (R1,R2), reviewed for neglect. The facility's policy regarding supervision of maintenence equipment was not followed. This resulted in R1 being hit in the forehead with a wrench by R2. R1 was sent to the hospital and required 8 sutures to the forehead. The finding includes: An incident report submitted from the facility on 7/29/2014 reads, R1 was hit by R2 in the forehead during a verbal altercation with a wrench from the maintenance cart. R1 sustained two open areas approximately one inch in diameter and was sent to the hospital for evaluation. R1 required 8 sutures to his forehead. On 8/5/2014, R1 was observed in his room using a wheeled walker. No bruising was noted to R1's forehead. Sutures were removed. R1 stated he and R2 were roommates since February 2014. R1 said he and R2 got along all right and had no altercation in the past. R1 stated on 7/29/2014, he was coming from the dining room due to staff calling a warning drill. R1 said he knew he had to come back to his room and close the door. R1 ambulates with the use of a wheeled walker. R2, who uses a wheelchair, was going to the room also. R1 said he was trying to close the door and R2 was moving too slow. R1 stated he said " FU" to R2 while at the door. R1 said R2 picked up a wrench that was on the maintenance cart outside of the room and hit him one time in the forehead with the wrench. R1 said R2 was removed from the room and is now on another floor. R1 said he is not afraid of R2 or to be in the facility. Interview with (E3) Maintenance Director on 8/5/2014, (E3) said he was in the next room remodeling the two bathrooms that are connected. E3 said he heard the altercation and came to the room to see R1 bleeding and got help. E3 said during interview that the facility is currently under major construction and remodeling. R1 and R2 were out of their room as they normally are in and about the facility. E3 said while working in the rooms he left his cart unattended outside the door of R1 and R2 room. E3 said nothing like that had happen to him in the three years he has been at the facility. E3 said he knows he cannot leave his cart unattended. A review of the facility's undated policy for maintenance equipment states: " any maintenance equipment used in the building will be under the supervision of the maintenance staff".

Based on observations, record reviews and interviews the facility failed to assess and give medical treatments for 1 of 3 residents (R4) in the sample that sustained an injury (fractures) and failed to inform a physician of significant change of condition. R4 was transferred to the hospital for further medical/surgical interventions with the current [DIAGNOSES REDACTED]. Findings Include: R4 was observed on 2-15-13; R4 was in bed stating that he was put into the bed rough and heard a popping sound from his hip and experience pain on his left lower side. Observations of R4's right hip were swollen, red and R4 stated he has pain upon moving in and out of his wheelchair. R4 is a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the facility Concern/Complement Referral Form dated 2-1-13 notes the following, " reported resident concern of staff handling him roughly slinging him into bed and hurting his hip. Resident reported incident taking place on 3:00PM to 11:00PM shift." The Concern/Complement Referral Form is signed by the Social Service Director and the Director of Nursing, DON. The Social Service Director and the Director of Nursing are no longer employed at the facility. E1 (Director of Nursing) on 2-15-13 stated that the pervious DON handled the event(s) with R4 and there are no other or additional documentation for R1. E1 stated that she does not know why a concern from was done instead of a medical incident form. E12 (Nurse ' s Aide) stated on 2-19-13 at 3:30PM that she and another nurse's aide, E16 (Nurse's Aide) transferred R4 from his electrical wheelchair to the bed. After R4 was in the bed R4 began to complain about his hip. After about a week of hearing R4 complain to various people I spoke with E16 about the possibilities of R4 being seriously injured upon the transfer we did. I did not report R4's complaining of pain to anyone and I really do not know why I did not report it to anyone. R4 plays around a lot and I did not take R4 seriously. R4 is always crying wolf about something and I thought he was playing around and took his complaining as he was" crying wolf." E16 stated on 2-19-13 at 4:00PM, she was unaware of R4's being in pain after assistance with a transfer. E16 also denies having any conversation with E12 about any pain or discomfort R4 was experiencing. Z1 (Attending Physician) stated on 2-19-13 that R4 is always crying wolf. Something is always wrong with him, but the moment the nurse called me about R4 experiencing pain from an incident I immediately gave orders for x-rays. Radiology report dated 2-19-13 notes: Left Hip: there is an acute appearing oblique fracture for the proximal femur with lateral displacement of the distal fragment. Right Hip: lateral and superior dislocation of the femoral head in relation to the acceptable noted. R4 was transported to the hospital for treatment of [REDACTED]. days) after the initial incident on 1-31-13. The facility's abuse policy notes as follows: Protection of Residents and Staff: Employees are required to report any occurrences of potential mistreatment, they observe, hear about, or suspect to a supervisor or the administrator. E2 (Administrator) stated on 2-19-13 at 4:30PM that all of the employees in the building are required to report to the Director of Nursing or the Administrator. E1 (Director of Nursing) stated on 2-20-13 at 10:00AM that all of the employees are required to report any and all occurrences to administration. E1 had no comments as to why E12 and E16 said nothing about R4's discomfort/pain for the past few weeks.

Based on record reviews and interviews the facility failed to prevent the development of a pressure sore for a resident who was admitted to the facility without a pressure sore and failed to care for the pressure sore in a timely manner which resulted in a Stage III pressure sore, for one of three sampled resident (R3) reviewed for pressure sore, in the total sample of 30 Findings Include: R3 is a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R3's nursing admission records dated 11-14-12 notes the following: old healed scar sacrum, left AKA and a right BKA. Nursing Skin Assessment: The Integumentary (skin) system notes: color pink, intact. Z1 (R3's Attending Physician) stated on 4-5-13 at 10:00AM, that he cannot remember R3. Z1 stated that we must go by his admission notes about his care and assessment of R3. Z1 (Physician) admission notes dated 11-15-12 notes the following, skin: Nursing Skin Assessment Reviewed. Plan for R3 is nutritional support, skin care and fall precautions. Nursing notes dated 11-26-12 at 11:45AM notes the following: open area to sacral area, resident unable to explain what happen. R3's pressure sore is superficial and a stage II. Nursing notes dated 11-26-12 at 11:45AM notes physician called back made aware of occurrence, new orders. E16 (Treatment Nurse) Treatment records on 11-28-12 notes: slugging and necrotic tissue and a stage III. E16 stated on 4-5-13 at 9:30AM that her assessment was different from E30 (Staff Nurse) assessment on 11-2-13, 2 days earlier. E16 stated she requested an explanation from E30 because of the differences in characteristics of R3's wound. The vast differences were that R3's sacral pressure sore increased from a stage II to a stage III in 2 days. E16 gave no comments as to why and increase in characteristics of the pressure sore or the reasons as to why it developed in a short time (12 days) since admission. E1(Director of Nrusing) had no comments on 4-5-13 about R3's pressure sores

Based on observations, record reviews and interviews the facility failed to implement corrective and protective measures to prevent multiple falls to 1 of 3 sampled residents (R22) with multiple falls out of a total sample of 30 reviewed for falls. R22 has had multiple falls, which resulted in an injury on the third fall (fracture of cervical). The facility also failed to have the correct amount of persons to transfer 1 of 3 residents (R25) reviewed for transfers with a mechanical lift in the total sample of 30. The incorrect transfer resulted in R25 being hit in the face with part of the lift causing an injury below her right eye to be swollen and red, black and blue with pain. Findings Include: R22 was observed on 2-19-13 on the skilled nursing unit sitting in his wheelchair unable to speak with his helmet on and requesting to go to bed. R22 is a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Nursing notes dated 9-7-12 notes R22 was found on his knees beside his bed. R22 was unable to state what happened. Nursing notes for R22 dated 1-27-13 at 1:30 a.m. notes the following: while attempting to elevate the head of bed resident fell back hitting his back, found by the nurse's aide on the floor calling for help. X-ray result dated 1-27-13 notes: compression fracture of lumbar (L-1). Additional orders, transport to the hospital. Care plan dated 8-30-12 to current notes: fall screening done, and history of fall on 9-7-12 and 1-27-13. The plan is: prevention and to use safety devices/alarms on 1-28-13 and fall precautions, (The facility's Falling Star Program). The facility's Falling Star Programs Policy notes 4). Individualized care plan will be initiated and immediate intervention will be put into place. 8). Recommendations and updating of individualized interventions will be implemented and documented on the resident's care plan. Incident report dated 2-2-13 at 8:30AM notes R22 was found on the floor by his bed. when asked what happened he answered he attempted to get in the bed by himself. Observations of R22 room on 2-19-13, no alarms on his bed, no pads on the floor for his low bed, no alarm on his wheelchair. E23(Care Plan and Fall Coordinator) stated on 2-21-13 that R22 is always taking his alarms off of his bed and chair and does not follow directions. The pads on the floor beside the low bed are being ordered and have been off for the day. E23 had no comments as to why the care plan was not up-dated/re-assessed to prevent additional falls. Z5( Attending physician) stated on 3-7-13 at 1:45 p.m. that the facility should have put in place the fall precaution program to prevent the second and third fall so further injuries and complications will be prevented. Z5 had no comments as to why the fall precaution program was not implemented after a history of falls and a serious injury. E1(Director of Nursing) on 3-1-13 at 4:00PM had no comments why E23 did not discuss any problems related to fall prevention about R22 with her to stop R22 from falling. E1 up-dated the care on 3-7-13(after multiple falls with injuries), and arranged for additional equipment to aide with the prevention of fall for R22. 2). R25 was observed on 3-27-13 at 11:00AM, R25 was sitting in her wheelchair in the hallway with a blacken right eye which was swollen and red. R25 told surveyor that E21 was transferring her from the bed to the wheelchair alone. E21 hit me in the eye with the transfer belt and told me that she would take care of it and pay for any damage. R25's Minimum Data Set ((MDS) dated [DATE] notes the following: for transfers R25 is coded 3/3. Meaning extensive assistance and two plus persons for physical assist. E21 explained on 3-27-13 at 2:30PM in the front office, this incident happen at 7:00AM prior to breakfast. I hit R25 with the buckle belt while transferring her from bed to chair. I did transfer her alone without any assistance. E21 gave no comments as to why she did not follow the assessment in place of R21, being a 2 plus person transfer. E1(Director of Nursing) stated R25 transfer assessment was changed last month. The transfer assessment was not in the clinical records but on my desk. The reason for the change is because R25 does not need extensive assistance anymore based on her new assessments of 2-3-13. E1 gave no comments as to why this new information was not in the clinical records or why there was direct contrast with the current assessments for transfers.

Based on record review and interview facility neglected to obtain a physician order [REDACTED]. Findings Include: Record review of facility's policy for blood sugar parameters denotes, "Parameters: ask for specific range. The average is below 60 or above 400. Whenever the residents' blood sugar falls outside of the set range the nurse must follow orders and notify the physician. The notification and resulting orders must be documented in the clinical record ". Interview with E11 (Licensed Practical Nurse) on 12-20-11 at 1:15 PM, states she did not ask for a specific range for R1's blood sugar. E11 states it common sense/knowledge for any blood sugar below 60 and above 400 to let the doctor know. E11 states that she wrote the admission note for R1 on 10-25-11 in the nurse's notes. E11 states she informed the doctor that R1 was on insulin and the doctor did not request a specific blood sugar range. Record review of R1's physician order [REDACTED]. Record review of medication daily charting denotes at 11 AM on October 29th, glucometer (blood sugar) 352 and on the October 30th glucometer result 397 written by E9 (Licensed Practical Nurse). Interview with E9 on 12-16-11 at 3:20 PM, states she belived she notified the doctor of what was going on with R1. E9 states R1 had no signs of [MEDICAL CONDITION]. E9 states doctor was notified of elevated sugar but that she did not write in the nurse's notes "the doctor was notified". E9 states she did not ask the doctor for a specific blood sugar range to call him. Clinical review of nurse's notes October 29th thru 30th no glucometer results relayed to doctor. Record review of medication daily charting for November 2nd 2011 denotes glucometer result of 371, November 3rd glucometer results at 6 AM, 391 and on November 4th at 6 AM, glucometer results 300 written by E10. Interview with E10 on 12-20-11 at 1:00 PM, states R1 had no specific parameter range for blood sugar to call the doctor. E10 states she went according to the average range of below 60 or above 400 to call the doctor. E10 states R2 had no signs or symptoms of [MEDICAL CONDITION]. Record review of medication daily charting for November 6th at 4:00 PM denotes glucometer result of 376 and at 9:00 PM glucometer result of 324 written by E12 (Licensed Practical Nurse). Interview with E12 on 12-20-11 at 3:30 PM, states R1 did not have parameter specific for blood sugar. E12 states that on 11-6-11 blood sugar was 376 and after that she monitored resident for sign and symptoms of [MEDICAL CONDITION]. E12 states she rechecked R1's blood sugar, which was 324 at 9:00 PM and followed doctors' order as prescribed and gave insulin. E12 states the facility policy requires nursing to call doctor if blood sugar is below 60 and above 400. Record review of nurse's notes do not have any documentation that doctor was notified of blood sugar results from November 1st thru November 7th. Interview with Z1 (Medical Doctor) on 12-16-11 at 2:00 PM, states he should have been notified when R1' blood sugar was at 350 and above. Z1 states that if had been notified that R1's blood sugar was above 350 he would have sent resident out to the hospital. Record review of nurse's notes dated 11-8-11 at 2:45 PM, blood sugar done read " Hi" insulin given as ordered will monitor closely. Record review of nurse's notes 11-8-11 at 3:00 PM, R1's blood sugar rechecked continue to read "Hi" after insulin given. Doctor notified and order R1 to be sent out to emergency room . Record review of hospital record dated 11-8-11 at 6:30 PM lab results glucose level 600. Clinical record review of hospital records dated 11-9-11 R1 admitted to intensive care unit; Diagnosis: [REDACTED]. Record review of consultation report dated 11-9-11 at 2132 (9:32 PM) denotes Diagnosis: [REDACTED]. 1. Diabetes, uncontrolled 2. Pneumonia 3. Acute [MEDICAL CONDITION] Record review of hospital discharge summary report dated 11-14-11: The patient was evaluated and admitted with the impression of [MEDICAL CONDITIONS], pneumonia and acute [MEDICAL CONDITION]. Surgery was scheduled for excision of infected inclusion cyst on 11/14/11 but patient was discharged against medical advice on the 6th hospital day. Final Diagnosis: [REDACTED]. 1. [MEDICAL CONDITION] 2. Diabetes Mellitus Type II, Uncontrolled

Based on record review and interview facility failed to obtain a physician order [REDACTED]. Findings Include: Record review of facility's policy for blood sugar parameters denotes, "Parameters: ask for specific range. The average is below 60 or above 400. Whenever the residents' blood sugar falls outside of the set range the nurse must follow orders and notify the physician. The notification and resulting orders must be documented in the clinical record ". Interview with E11 (Licensed Practical Nurse) on 12-20-11 at 1:15 PM, states she did not ask for a specific range for R1's blood sugar. E11 states it common sense/knowledge for any blood sugar below 60 and above 400 to let the doctor know. E11 states that she wrote the admission note for R1 on 10-25-11 in the nurse's notes. E11 states she informed the doctor that R1 was on insulin and the doctor did not request a specific blood sugar range. Record review of R1's physician order [REDACTED]. Record review of medication daily charting denotes at 11 AM on October 29th, glucometer (blood sugar) 352 and on the October 30th glucometer result 397 written by E9 (Licensed Practical Nurse). Interview with E9 on 12-16-11 at 3:20 PM, states she belived she notified the doctor of what was going on with R1. E9 states R1 had no signs of [MEDICAL CONDITION]. E9 states doctor was notified of elevated sugar but that she did not write in the nurse's notes "the doctor was notified". E9 states she did not ask the doctor for a specific blood sugar range to call him. Clinical review of nurse's notes October 29th thru 30th no glucometer results relayed to doctor. Record review of medication daily charting for November 2nd 2011 denotes glucometer result of 371, November 3rd glucometer results at 6 AM, 391 and on November 4th at 6 AM, glucometer results 300 written by E10. Interview with E10 on 12-20-11 at 1:00 PM, states R1 had no specific parameter range for blood sugar to call the doctor. E10 states she went according to the average range of below 60 or above 400 to call the doctor. E10 states R2 had no signs or symptoms of [MEDICAL CONDITION]. Record review of medication daily charting for November 6th at 4:00 PM denotes glucometer result of 376 and at 9:00 PM glucometer result of 324 written by E12 (Licensed Practical Nurse). Interview with E12 on 12-20-11 at 3:30 PM, states R1 did not have parameter specific for blood sugar. E12 states that on 11-6-11 blood sugar was 376 and after that she monitored resident for sign and symptoms of [MEDICAL CONDITION]. E12 states she rechecked R1's blood sugar, which was 324 at 9:00 PM and followed doctors' order as prescribed and gave insulin. E12 states the facility policy requires nursing to call doctor if blood sugar is below 60 and above 400. Record review of nurse's notes do not have any documentation that doctor was notified of blood sugar results from November 1st thru November 7th. Interview with Z1 (Medical Doctor) on 12-16-11 at 2:00 PM, states he should have been notified when R1' blood sugar was at 350 and above. Z1 states that if had been notified that R1's blood sugar was above 350 he would have sent resident out to the hospital. Record review of nurse's notes dated 11-8-11 at 2:45 PM, blood sugar done read " Hi" insulin given as ordered will monitor closely. Record review of nurse's notes 11-8-11 at 3:00 PM, R1's blood sugar rechecked continue to read "Hi" after insulin given. Doctor notified and order R1 to be sent out to emergency room . Record review of hospital record dated 11-8-11 at 6:30 PM lab results glucose level 600. Clinical record review of hospital records dated 11-9-11 R1 admitted to intensive care unit; Diagnosis: [REDACTED]. Record review of consultation report dated 11-9-11 at 2132 (9:32 PM) denotes Diagnosis: [REDACTED]. 1. Diabetes, uncontrolled 2. Pneumonia 3. Acute [MEDICAL CONDITION] Record review of hospital discharge summary report dated 11-14-11: The patient was evaluated and admitted with the impression of [MEDICAL CONDITIONS], pneumonia and acute [MEDICAL CONDITION]. Surgery was scheduled for excision of infected inclusion cyst on 11/14/11 but patient was discharged against medical advice on the 6th hospital day. Final Diagnosis: [REDACTED]. 1. [MEDICAL CONDITION] 2. Diabetes Mellitus Type II, Uncontrolled .

Based on interviews, record review, review of hospital records, and review of medical examiner's report, the facility failed to provide adequate monitoring for one resident (R1) in the sample of three residents receiving [MEDICAL TREATMENT]. R1 had an AV (Arteriovenous) Fistula that was used for [MEDICAL TREATMENT] and who had a history of [REDACTED]. The last evidence that facility staff had monitored R1's AV fistula site was dated [DATE]. The facility failed to have a [MEDICAL TREATMENT] policy for staff to follow when caring for residents , as well as, the facility failed to have a monitoring tool for staff to use when caring for [MEDICAL TREATMENT] residents. On [DATE] at 5:10am, R1 was found in bed bleeding from left shunt/fistula and laying in a puddle of blood. R1 was transferred to a local hospital where R1 was later intubated. R1 expired in the emergency room of this local hospital at 7:27am ( less than 2 hours after transfer from the nursing home). Review of the Medical Examiner's Autopsy report indicates that "R1's AV fistula showed a thrombus (blood clot)1.5cm in diameter with 0.3 cm erosion of the intima" (inside). R1's death is ascribed to "Hemorrhage due to erosion of AV fistula. Review of [MEDICAL TREATMENT] data (a part of R1's care plan) from Midwest kidney center under section A-3 indicates that a blood clot can be detected by checking the [MEDICAL TREATMENT] access at least twice daily and listen for certain sounds (called the thrill and bruit). The last evidence that was provided to surveyor indicated that the facility staff had not checked/monitored R1's AV fistula site since [DATE]. The Acting Administrator (E9), the Director of Nurses (E2) and Assistant Director of Nurses (E3) were notified [DATE] at approximately 1:14 pm regarding the Immediate Jeopardy. This was determined to have begun on [DATE] at approximately 5:20am, when R1 was found in bed bleeding from a left AV fistula and lying in a puddle of blood. Findings Include: 1. R1 is an [AGE] year old resident who was admitted to the facility originally on [DATE] with [DIAGNOSES REDACTED]. R1 who has a left Arteriovenous fistula through which she recieves [MEDICAL TREATMENT] 3 times a week (Tuesday, Thursday, and Saturday) at a local hospital [MEDICAL TREATMENT] unit. During phone interview Z1 (family of R1) stated, "I really don't think they (staff) check on R1 at night, they don't answer call lights" Upon further interview Z1 added, "That's not the 1st time R1 had bleeding from that shunt, but they've (facility staff) always been able to stop it. Z1 continued, "I guess this time they hadn't seen R1 all night, so when They saw R1 it was too late, R1 probably had been bleeding all night! Record review of nurses notes dated [DATE] at 5:10am documents the following "Upon passing medication R1 told E10 (nurse) that she was bleeding . E10 discovered a puddle of blood on sheets, R1 was bleeding from the left arm shunt. Pressure was applied, 911 was called" Documentation continues 5:30am Am "Ambulance came and took R1 to hospital. E10 could not be reached for interview, however there was no documentation on this day ([DATE]) prior to R1 being found bleeding at 5:10am. The last documentation for R1 was dated [DATE] (late entry) at 600am. As well, further review of R1's closed clinical record indicated there had been no documentation with regard to the condition of R1's Av fistula since [DATE]. R1 has a care plan that indicates that staff will monitor graft site for redness, swelling and pain every shift. also noted was a form titled "checking bloodflow in your access" that was included in R1's clinical record along with the care plan that staff is to follow. This form included instructions for staff including in part: "you should check the access twice a day to make sure it is open, Clotting is one of 3 main problems that can happen with access. To help prevent clotting, check access at least twice a day to be sure it is open----" There was no documentation that this is being done since [DATE]. Surveyor reviewed R1's clinical record again for monitoring of R1 access. Later this day ([DATE]) E2 was interviewed regarding staff monitoring of R1's access. E2 with surveyor reviewed R1's clinical record in search for documentation of staff monitoring R1's access since [DATE]. Finally after a few minutes search E2 stated, "Its none here ! Upon further interview E2 stated, "The monitoring of R1's access should be documented here (referring to nurses notes), but I guess if its not documented it's not being done! E2 added, "We don't have a [MEDICAL TREATMENT] monitoring tool for staff to use, but Im going to work on developing one now". Later this day E2 approached surveyor , handed surveyor a form and stated, "This will be the new monitoring tool that staff will be using for all [MEDICAL TREATMENT] residents". During daily status later this day E1 (administrator) was unable to provide surveyor with a [MEDICAL TREATMENT] policy for staff to follow when caring for [MEDICAL TREATMENT] residents in the facility. Review of hospital emergency room records on the day R1 was transferred ([DATE]) indicates that R1 arrived via 911 ambulance at approximately 5:53am bleeding from left [MEDICAL TREATMENT] shunt. At 6:35am, R1 who was unable to be stabilized went into [MEDICAL CONDITION] and was intubated. R1 expired at 7:27am (less than 2 hours after R1 arrived) Review of the Medical Examiner's Autopsy report indicates that "R1's AV fistula showed a thrombus (blood clot)1.5cm in diameter with 0.3 cm erosion of the intima" (inside). R1's death is ascribed to "Hemorrhage due to erosion of AV fistula. Z4 (nephrologist/ physician of R1) was interviewed via phone regarding R1's death diagnoses. Z4 stated, "When residents are on [MEDICAL TREATMENT] for a period of time, the constant needle sticks sometimes thin the wall of the fistula and cause it to erupt and bleeding, that's not uncommon". Upon further interview Z4 acknowledge that R1 had a history of [REDACTED].! Z4 added, "[MEDICAL TREATMENT] patient needs to be monitored more closely!! During interview with E2 and E3 it was confirmed that R1 had a history of [REDACTED]. The Acting Administrator (E9), the Director of Nurses (E2) and Assistant Director of Nurses (E3) were notified [DATE] at approximately 1:14 pm regarding the Immediate Jeopardy. This was determined to have begun on [DATE] at approximately 5:20am, when R1 was found in bed bleeding from a left AV fistula and lying in a puddle of blood. While the immediate Jeopardy was removed on [DATE] at 5:59pm, the facility remains out of compliance at severity level 2 to allow time to evaluate the effectiveness of staff in-services, and evaluate changes made to address identified deficiency. The facility took the following steps to remove the Immediate Jeopardy: 1. R1 is no longer in the facility. 2. The facility has developed new policies on Care of a [MEDICAL TREATMENT] Resident and [MEDICAL TREATMENT] access Site Assessment. A new [MEDICAL TREATMENT] Access site Assessment log has been developed and implemented. All residents who recieve [MEDICAL TREATMENT] have been assessed and their access sites are checked daily. Completion date [DATE] 3. On or before [DATE] an inservice will be held with appropriate Facility staff. Director of Nursing or her designee will conduct the inservice. The inservice will include: 1) a review of the requirements that each resident receive the necessary care to attain or maintain the highest practicable physical, mental, and psychosocial well- being in accordance with their comprehensive assessment and care plan, 2) a review of the Facility's Care of a [MEDICAL TREATMENT] Resident and Arteriovenous Graft/fistula Site Assessment Policies: and 4) a review of how to conduct an AV site assessment and documentation. 4. Director of nursing or designee will complete random audits of AV site assessments and documentation. Director of Nursing and/or her designee will monitor for overall compliance through her general supervision and reports from Charge nurses on staff compliance. Completion date [DATE] Based on interview and record review the facility failed to adequately assess 1 of 3 sampled residents (R4), after observing R4 fall to the floor while attempting to stand up from a wheelchair. This failure resulted in R4 being placed in the bed and 6 hours later complaining of pain and being assessed and sent to the hospital where R4 was admitted and treated for [REDACTED]. Findings include: According to Rx clinical record nursing notes dated [DATE] at 8:30pm R4 was observed sitting in the hallway in the wheelchair, with wheels locked. The note indicates that facility staff observed R4 attempting to stand, the note indicates that staff redirected R4 to sit down, and as staff approached R4 to assist with sitting back down R4 fell to the floor. The note indicates that staff observed R4 fall to the floor on her buttocks. The note indicates that R4 was assisted back to the wheelchair, and was asked if she had any pain or discomfort, and denotes R4 stated she just wanted to go to bed. Nursing note also indicates that nurses informed R4 family member. Nursing note [DATE] 10:00pm indicates that the physician returned the call and gave orders for 72 hour evaluation. Nursing noted [DATE] at 2:00am denotes that nurse was notified by certified nurse ' s aid that R4 was complaining of pain. The nurse indicates that upon examination of R4 pain was noted in the right hip. The nurse indicates that R4 was unable to perform active range of motion, and that R4 was unable to tolerate assist to stand, or passive range of motion. The note indicates that physician was called. Nursing note [DATE] at 2:20am indicates the physician was notified of R4 status and gave orders to transfer to the hospital emergency room for evaluation. Nursing note 3:25am indicates that R4 was medicated for pain and transferred out of the facility by ambulance to the hospital for evaluation. Nursing note 8:00am denotes that the facility was informed by R4 family member that R4 was being admitted to the hospital for right [MEDICAL CONDITION]. According to the facility ' s unusual occurrence report dated [DATE] 8:00pm indicates that R4 was involved in a witnessed fall observed by facility staff certified nurses aide, the report indicates that facility staff observed R4 attempting to stand, the report indicates that staff redirected R4 to sit down, and as staff approached R4 to assist with sitting back down R4 fell to the floor. The report indicates that staff observed R4 fall to the floor on her buttocks. The report that R4 was assisted back to her wheel chair with no complaints of pain or discomfort. The report also indicates that R4 family was notified and the physician was notified and gave orders for monitoring 72 hours. On the bottom of the report hand written notes that R4 complained of pain at 2:00am [DATE] and was sent to the hospital for evaluation and admitted for right [MEDICAL CONDITION]. On [DATE] 10:00am E10 (nurse), said that she was sitting at the nursing station on [DATE] at approximately 8:00pm and R4 was sitting in a wheelchair next to her room. E10 said that she heard either E11/E12 (certified nurse aid), tell R4 to sit down. E10 said next thing R4 stood up and fell to the floor. E10 said by time she stood up to see what happened, E10 said that E11/E12 grabbed R4 under both of arms and by the pants and assisted R4 back to the wheelchair. E10 said that she asked R4 if she was okay, and said that R4 only wanted to go to bed with no complaints. E10 said that she called the physician and left R4 sitting up in the wheelchair for about an hour, then took her to bed. E10 said that she paged the physician at 8:30pm and he returned the call at 10:00pm. E10 also said that she notified the family that R4 had a fall with no complaints at the time. E10 said that she didn ' t do else for R4 because she denied pain at the time. E10 said that she didn ' t assess R4 for injury or assess her range of motion. On [DATE] at 3:00pm E11 (certified nurses aide), said that on [DATE] R4 was sitting up in a wheelchair next to the door of her room. E11 said that R4 was attempting to stand; I tried to redirect her she fell to the floor on her buttocks. E11 said that E12 and herself stood R4 back up and sat her in her wheelchair. E11 said that R4 was asked if anything was wrong and R4 said no. E11 said that R4 fell on the right side of her buttocks. E11 said that when R4 was put to bed E12 assisted her, E11 said that R4 had no complaints of pain, E11 said she can ' t recall if R4 had any swelling when she was put to bed. E11 said that also worked the 11:00pm to 7:00am shift, and while making rounds at 2:00am on [DATE] R4 was noted with complaints of pain to the right hip area. On [DATE] at 3:20pm E12 (certified nurses aid), said that on [DATE] around 7:30pm she saw R4 on the floor, but didn ' t see R4 fall. E12 said that she assisted E10/E11 with picking R4 up from the floor, and putting her back into the wheelchair. E12 said that there was one person under each arm and the used her pants to lift R4 to her feet and place her in the wheel chair. E12 said after R4 was placed in the wheelchair she can ' t recall if she complained of pain. E12 said that after R4 was sitting in the wheelchair she and E11 transferred R4 to the bed but don ' t recall R4 complaining of pain at that time, and E12 said that she can ' t recall observing any swelling or redness along R4 ' s right hip area. E12 also said that she can ' t recall E10 looking at or assessing R4 after the fall. E12 said that she last saw R4 at around 10:00pm and she was sleep in the bed. On [DATE] at 4:20pm E2 (director of nursing), said that after resident are involved in a fall incident she expects her nurses to examine the resident for injuries, and if there are injuries to assess, and treat with first aide if required. E2 said that after assessing the residents the nurse should notify the physician of the findings and of the incident. E2 said that if the physician fails to call back within 30 minutes the nurses should call the medical director. E2 said the nurse ' s assessment should include head to toe exam, looking for wounds, bruising, swelling redness or dislocations. E2 said that the nurses should also assess for range of motion, along with a full set of vital signs. E2 said that she would expect the nurses to document their findings in the resident ' s clinical record. E2 said that just asking a resident if she is okay is not acceptable. According to the facility ' s policy regarding accidents/incidents/unusual occurrences indicates that after a resident is found after a fall incident the resident is not to be moved until the nurse has assessed the resident. The policy indicates that the nurse assessment will be completed using nursing judgment concerning the data elements to be collected based on the resident, type and severity of the occurrence. The policy also indicates that documentation will support the assessment, findings and action taken. According to the policy what to do asses after a fall, denotes in the event a resident has a fall the nursing staff is to assess the resident and provide for emergency care as needed. The procedure denotes to ask the resident if they have pain assess the resident prior to moving them. Get base vital and neuro signs. Assess for any changes in range of motion. Assess the resident using the following guideline. Observe for bruises, lacerations, skin tears, and abrasions. Note if there is any pain or deformity in the extremities, particularly the hip, arm, leg, or lumbar sacral spine. Assess the blood pressure lying down, and sitting down. According to the hospital records dated [DATE] radiology report findings include an oblique [MEDICAL CONDITION] femur with sperolateral displacement. [DATE] R4 under went the partial right hip replacement surgery.

Based on interview and record review the facility neglected to follow their policy and adequately assess 1 of 3 sampled residents (R4) after a witnessed fall incident. This failure resulted in R4 attempting to stand up from a wheelchair and falling to the floor at 8:30pm on 9/28/10, R4 was placed back in the wheelchair and sat in the hallway. R4 was eventually placed in the bed and at 2:00am 9/29/10 R4 complained of pain and was assessed to have pain at the right hip area and loss of range of motion of the right hip. R4 was transferred to the hospital for evaluation and admitted and treated for [REDACTED]. Findings include: According to Rx clinical record nursing notes dated 9/28/10 at 8:30pm R4 was observed sitting in the hallway in the wheelchair, with wheels locked. The note indicates that facility staff observed R4 attempting to stand, the note indicates that staff redirected R4 to sit down, and as staff approached R4 to assist with sitting back down R4 fell to the floor. The note indicates that staff observed R4 fall to the floor on her buttocks. The note indicates that R4 was assisted back to the wheelchair, and was asked if she had any pain or discomfort, and denotes R4 stated she just wanted to go to bed. Nursing note also indicates that nurses informed R4 family member. Nursing note 9/28/10 10:00pm indicates that the physician returned the call and gave orders for 72 hour evaluation. Nursing noted 9/29/10 at 2:00am denotes that nurse was notified by certified nurse ' s aid that R4 was complaining of pain. The nurse indicates that upon examination of R4 pain was noted in the right hip. The nurse indicates that R4 was unable to perform active range of motion, and that R4 was unable to tolerate assist to stand, or passive range of motion. The note indicates that physician was called. Nursing note 9/29/10 at 2:20am indicates the physician was notified of R4 status and gave orders to transfer to the hospital emergency room for evaluation. Nursing note 3:25am indicates that R4 was medicated for pain and transferred out of the facility by ambulance to the hospital for evaluation. Nursing note 8:00am denotes that the facility was informed by R4 family member that R4 was being admitted to the hospital for right [MEDICAL CONDITION]. According to the facility ' s unusual occurrence report dated 9/28/10 8:00pm indicates that R4 was involved in a witnessed fall observed by facility staff certified nurses aide, the report indicates that facility staff observed R4 attempting to stand, the report indicates that staff redirected R4 to sit down, and as staff approached R4 to assist with sitting back down R4 fell to the floor. The report indicates that staff observed R4 fall to the floor on her buttocks. The report that R4 was assisted back to her wheel chair with no complaints of pain or discomfort. The report also indicates that R4 family was notified and the physician was notified and gave orders for monitoring 72 hours. On the bottom of the report hand written notes that R4 complained of pain at 2:00am 9/29/10 and was sent to the hospital for evaluation and admitted for right [MEDICAL CONDITION]. On 10/26/10 10:00am E10 (nurse), said that she was sitting at the nursing station on 9/28/10 at approximately 8:00pm and R4 was sitting in a wheelchair next to her room. E10 said that she heard either E11/E12 (certified nurse aid), tell R4 to sit down. E10 said next thing R4 stood up and fell to the floor. E10 said by time she stood up to see what happened, E10 said that E11/E12 grabbed R4 under both of arms and by the pants and assisted R4 back to the wheelchair. E10 said that she asked R4 if she was okay, and said that R4 only wanted to go to bed with no complaints. E10 said that she called the physician and left R4 sitting up in the wheelchair for about an hour, then took her to bed. E10 said that she paged the physician at 8:30pm and he returned the call at 10:00pm. E10 also said that she notified the family that R4 had a fall with no complaints at the time. E10 said that she didn ' t do else for R4 because she denied pain at the time. E10 said that she didn ' t assess R4 for injury or assess her range of motion. On 10/26/10 at 3:00pm E11 (certified nurses aide), said that on 9/28/10 R4 was sitting up in a wheelchair next to the door of her room. E11 said that R4 was attempting to stand; I tried to redirect her she fell to the floor on her buttocks. E11 said that E12 and herself stood R4 back up and sat her in her wheelchair. E11 said that R4 was asked if anything was wrong and R4 said no. E11 said that R4 fell on the right side of her buttocks. E11 said that when R4 was put to bed E12 assisted her, E11 said that R4 had no complaints of pain, E11 said she can ' t recall if R4 had any swelling when she was put to bed. E11 said that also worked the 11:00pm to 7:00am shift, and while making rounds at 2:00am on 9/29/10 R4 was noted with complaints of pain to the right hip area. On 10/26/10 at 3:20pm E12 (certified nurses aid), said that on 9/28/10 around 7:30pm she saw R4 on the floor, but didn ' t see R4 fall. E12 said that she assisted E10/E11 with picking R4 up from the floor, and putting her back into the wheelchair. E12 said that there was one person under each arm and the used her pants to lift R4 to her feet and place her in the wheel chair. E12 said after R4 was placed in the wheelchair she can ' t recall if she complained of pain. E12 said that after R4 was sitting in the wheelchair she and E11 transferred R4 to the bed but don ' t recall R4 complaining of pain at that time, and E12 said that she can ' t recall observing any swelling or redness along R4 ' s right hip area. E12 also said that she can ' t recall E10 looking at or assessing R4 after the fall. E12 said that she last saw R4 at around 10:00pm and she was sleep in the bed. On 10/26/10 at 4:20pm E2 (director of nursing), said that after resident are involved in a fall incident she expects her nurses to examine the resident for injuries, and if there are injuries to assess, and treat with first aide if required. E2 said that after assessing the residents the nurse should notify the physician of the findings and of the incident. E2 said that if the physician fails to call back within 30 minutes the nurses should call the medical director. E2 said the nurse ' s assessment should include head to toe exam, looking for wounds, bruising, swelling redness or dislocations. E2 said that the nurses should also assess for range of motion, along with a full set of vital signs. E2 said that she would expect the nurses to document their findings in the resident ' s clinical record. E2 said that just asking a resident if she is okay is not acceptable. According to the facility ' s policy regarding accidents/incidents/unusual occurrences indicates that after a resident is found after a fall incident the resident is not to be moved until the nurse has assessed the resident. The policy indicates that the nurse assessment will be completed using nursing judgment concerning the data elements to be collected based on the resident, type and severity of the occurrence. The policy also indicates that documentation will support the assessment, findings and action taken. According to the policy what to do asses after a fall, denotes in the event a resident has a fall the nursing staff is to assess the resident and provide for emergency care as needed. The procedure denotes to ask the resident if they have pain assess the resident prior to moving them. Get base vital and neuro signs. Assess for any changes in range of motion. Assess the resident using the following guideline. Observe for bruises, lacerations, skin tears, and abrasions. Note if there is any pain or deformity in the extremities, particularly the hip, arm, leg, or lumbar sacral spine. Assess the blood pressure lying down, and sitting down. According to the hospital records dated 9/29/10 radiology report findings include an oblique [MEDICAL CONDITION] femur with sperolateral displacement. 10/1/10 R4 under went the partial right hip replacement surgery.