Every finding on record at Pearl of Elk Grove, The

Based on interviews and records review, the facility failed to ensure high fall risk residents received adequate supervision and used assistive devices to prevent avoidable falls for two residents, and the facility failed to ensure nursing staff promptly reported resident accident resulting in injury to their immediate supervisor for one resident. These failures affected two (R1 and R2) of three residents reviewed for falls in a sample of 5. These failures resulted in R1 acquiring fractures of three toes on the right foot and R2 acquiring a head injury; contusion of right knee; and fracture of phalanx of right index finger.Findings include:1. R1 is an [AGE] year-old-female admitted to the facility on [DATE] with diagnosis including but not limited to Metabolic Encephalopathy; Chronic Respiratory Failure with Hypoxia; Chronic Obstructive Pulmonary Disease; Type 2 Diabetes Mellitus; Irritable Bowel Syndrome; Difficulty in Walking; Depression; Neuromuscular Dysfunction of Bladder; and Absolute Glaucoma.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 14 indicating intact cognition.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, shows functional limitation in R1's upper and lower extremities and sit-to-stand transfer to be performed with partial/moderate assistance where helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.Absent is fall care plan intervention prior to 6/29/2026 related to using gait belt during R1's transfers.Fall assessment dated [DATE] shows R1 is at high risk for falls.On 7/24/2026 at 12:33 PM Surveyor observed R1 sitting in the wheelchair, next to the bed with bedside table in front of her. R1 observed wearing right surgical shoe. R1 said, I fell when I was toileted on 6/21/2026, it happened around 11:30 AM - 11:40 AM. I was in the bathroom, V11 (Certified Nurse Assistant) was assisting me. V11 (CNA) had her hands underneath me and was pushing me up. They are always in so much rush. As V11 (CNA) was pushing me up, I hit the wall with both of my knees. I was in a lot of pain, and I remember my legs collapsing. I kneeled down to the floor with my right leg and bent my right foot toes. I wasn't even thinking about my toes at that time, my knees hurt from hitting the wall. I had no gait belt at any point during the attempted toilet transfer. V11 (CNA) grabbed me by my shoulders to put me back in the wheelchair. I noticed bleeding from my arm. That's how I got a skin tear on my left upper arm, I also broke three toes in my right foot as a result of the fall. The nurse came and asked me what happened after the fall, I don't remember the nurse's name, but I see them regularly.On 7/24/2026 at 12:43 PM V16 (Power of Attorney) said, I found out about the fall from R1. R1 texted me on 6/21/2026 to let me know what happened. I am R1's power of attorney but no one from the facility reached out to me on 6/21/2026. I know aids are supposed to use gait belt during R1's transfers. I was told that by R1's therapist. I see aids not using gait belt all the time though. I visit R1 frequently and rarely see aids using gait belt, even after R1's fall on 6/21/2026.On 7/24/2026 at 1:00 PM V17 (Physical Therapist) said, R1 had been in physical therapy throughout her stay in the facility. R1 gets therapy five days a week. R1's had her most recent session before the fall on 6/20/2026. On 6/20/2026, R1's transfer level was assessed at partial/moderate level, meaning R1 needs one person assist who's doing at least half of the work and gait belt. The gait belt has to be on during R1's transfers. Nursing staff are made aware of residents' transfer and other mobility needs by verbal reports and written notes.On 7/24/2026 at 3:02 PM V14 (Wound Care Nurse) said, When I assessed R1 on 6/22/2026, I noticed bandage on R1's left upper arm. I inquired about the wound, R1 said she went to the bathroom on 6/21/2026, and as she was falling, the CNA grabbed her upper arm. That's how R1 acquired the skin tear. Upon initial assessment the wound measured 2.3 cm x 1.1 cm x 0.1 cm. The wound is covered with foam dressing, and we recommended for R1 to long sleeves. The wound is consistently improving.On 7/25/2026 at 9:30 AM V15 (Restorative LPN/Fall Coordinator) said on 6/22/2026, I found out that R1 fell (on 6/21/2026). I brought V11 (Certified Nurse Assistant) to ask what happened. V11 (CNA) said that R1 was facing the wall in the bathroom, while holding onto the grab bar. There was wheelchair between V11 (CNA) and R1. R1 suddenly let go of the grab bar and kneeled with her right knee while bending her right foot toes. V11 (CNA) claimed she used a gait belt. V11 (CNA) did not explain how R1 acquired left upper arm skin tear. I asked why V11 (CNA) didn't report the fall right away, V11 (CNA) responded that she didn't think it was reportable incident because V11 (CNA) assisted R1 to the floor. The staff should have reported the incident to any available supervisor, whether the nurse or CNA, immediately after it happened. Once a fall is reported, fall protocols are followed, the resident is assessed and based on that, accurate orders are obtained. None of the fall protocols were followed on 6/21/2026 because no one was notified.On 7/25/2026 at 10:26 AM V11 (Certified Nurse Assistant) said on 6/21/2026, I took R1 to the bathroom. Usually, R1 can stand and can do everything by herself. That day, R1 stood up from her wheelchair and held on the grab bar. I pulled down R1's pants and brief and suddenly R1 lost her balance. I grabbed R1 and lowered her to the ground. I usually use a gait belt; the gait belt was on R1's waist, but R1 was in such a hurry that I did not grab the gait belt in time. V11 (CNA) unable to answer clarifying questions due to feeling sick, V11 (CNA) requested to finish the phone interview.On 7/25/2026 at 11:29 AM V19 (Agency Registered Nurse) said, I remember R1's fall but don't remember all the details. V11 (CNA) reported to me that R1's fell in a way that I didn't think it was a fall. V11 (CNA) said that R1 was about to fall while in the bathroom, but V11 (CNA) was able to hold on to R1 and R1 didn't fall. I went to assess R1, she appeared to be at the baseline. R1 had no obvious injury also, so what V11 (CNA) told me made sense at the time. I still reported it to the unit supervisor; I don't remember their name. I created risk management note. I don't remember the skin tear injury on R1's left shoulder.On 7/25/2026 at 11:39 AM V20 (Weekend Supervisor) said, I was a supervisor on duty on 6/21/2026. No incident was reported to me that day related to R1's fall or near fall. If I received a report of fall, I would help with assessment, notify another supervisor or Director of Nursing, and follow the fall protocol.On 7/25/2026 at 11:55 AM Surveyor attempted to interview V21 (Medical Doctor) via phone; no answer, voicemail left.On 7/25/2026 at 12:22 PM V3 (Director of Nursing) said, R1's fall occurred on 6/21/2026. On 6/22/2026, V15 (Restorative LPN/Fall Coordinator) was rounding, and it was reported by V11 (CNA) that R1 had an incident but V11 (CNA) wasn't sure if it was a fall. The incident was brought up to me and I determined it was a witnessed and interrupted fall. After that, nursing staff assessed R1 and initiated post-fall follow-up. We also notified V16 (Power of Attorney) and V21 (Medical Doctor). On 6/23/2026, R1 complained about increasing pain in her right foot. We performed in house x-ray that came back with suspicious fracture of the toes. At that point, we needed to obtain permission from V16 (Power of Attorney) to send R1 out for additional imaging. V16 (Power of Attorney) contacted us back on the morning of 6/24/2026 and R1 was sent out to the hospital for additional x-ray. The result of the hospital x-ray showed that R1 had three broken toes in her right foot. There was recommended pain management and a boot to stabilize the toes. I don't remember R1 having skin tear on her left upper arm. I completed an internal investigation of R1's fall. The result of the investigation was that R1 experienced weakness, her knees buckled, right knee touched the floor and toes of her right foot bent. V11 (CNA) said she used a gait belt during R1's toilet transfer. V11 (CNA) didn't think this was a fall incident because R1 didn't touch the floor with her buttock. I provided V11 (CNA) with in-service.Progress note dated 6/21/2026 written by V19 (Agency Registered Nurse) reads in part, CNA reported loss of balance of resident during transfer from wheelchair to toilet. Observed small skin tear, no other visible injury noted. Resident denies pain and denies hitting her head. Vital signs WNL BP: 109/60 P: 69 R: 18 Temp: 98.0 SPO2: 94% room air.Wound assessment dated [DATE] written by V14 (Wound Care Nurse) reads in part, Skin Tear Type 2: Partial Flap Loss; Facility-acquired; identified on 6/22/2026. Size: 2.30 x 1.10 x 0.10 (L x W x D). Upper arm noted with dressing during wound /skin assessment. (R1) stated she sustained skin tear during care while she was toiled. She let go of her arm from the holding bar; CNA tried to prevent her from falling and grabbed her arm. Left upper arm dressing removed. Area cleansed with ns, pat dry, picture and measurements taken and documented in Wound Rounds. (R1) denies any pain. Foam dressing applied. (R1) encouraged to wear long sleeves since skin is very fragile and she is anticoagulants.Hospital Record dated 6/24/2026 reads in part, Reason for exam: lateral foot pain and pain of toes, post fall and foot injury. Findings: AP view of right foot and images of the right toes show acute impacted fractures of the right third and fourth and fifth metatarsal heads.2. R2 is an [AGE] year-old-female admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side; Malignant Neoplasm of Endometrium; Chronic Kidney Disease; Type 2 Diabetes Mellitus; Anxiety Disorder; Selective Mutism; Acute Kidney Failure; and Unspecified Psychosis Not Due to a Substance or Known Physiological Condition.According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 is rarely understood and indicates R2 has memory problems.According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section GG, R2 has an impairment in one of the lower extremities and needs partial/moderate assistance where helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort with a mobility needs.Absent is fall care plan intervention prior to 6/21/2026 related to anticipating and meeting R2's needs.Fall assessment dated [DATE] shows R2 is at high risk for falls.On 7/24/2026 at 9:55 AM Per record review, R2 discharged from the facility on 7/14/2026, not available for observations or interview during course of the survey. On 7/24/2026 at 1:59 PM V10 (Certified Nurse Assistant) said, On 6/5/2026, I was not assigned to R2, but I helped to get her off the floor after she fell. The incident happened between 3:00 PM and 4:30 PM. R2 was in the 300-unit lounge room, we usually place residents there who are at high risk for falls for close monitoring because the lounge room is right across from the nursing station. There are no staff assigned to monitor the lounge room. On that day, R2 moved herself away from the view, she was by the wall, when another resident's family member noticed R2 on the floor, and let the nursing staff know. I overheard them say that I was one of the first staff who went in there. R2 was lying on her back and her legs bent to the side and arms along her body. R2 was bleeding from her head. R2's wheelchair was few feet away. The wheelchair wheels weren't locked. As the nurse was assessing R2, I went to get a mechanical lift, we placed R2 in the wheelchair and took R2 to her room.On 7/24/2026 at 2:25 PM V12 (Registered Nurse) said, on 6/5/2026, R2 was in the lounge area, across from the nursing station, while a family member noticed R2 on the floor and told us right away. R2 spend most of her days in the lounge area. That day, R2 moved herself from the center of the room towards the wall, and she must have fallen there, R2's fall was unwitnessed. I think R2 was able to unlock the wheelchair wheels, we are not sure how R2 fell. R2 seemed fine upon initial assessment, but I notified the doctor and R2's family. R2 was not really bleeding, R2 had abrasion on her head as a result of the fall. R2 was sent out to the hospital shortly after the fall and returned the following day.On 7/25/2026 at 11:55 AM Surveyor attempted to interview V21 (Medical Doctor) via phone; no answer, voicemail left.On 7/25/2026 at 12:22 PM V3 (Director of Nursing) said, I was notified about R2's fall on the afternoon of 6/25/2026, nursing staff called me. R2 was found on the floor in the 300-unit's lounge room. R2 had visible bleeding to her head, so she was sent out to the hospital for further evaluation. As a result of the fall, R2 had laceration to the head that required at least three stitches. Also, R2 had broken finger but we are not sure if the finger fracture was due to the fall, because R2 had a band-aid on the finger before the incident. The conclusion of the internal fall investigation was that R2 did not call for assistance. R2 was able to make her needs known even though she was mute. R2 didn't talk but could gesture. We inquired if R2's wheelchair wheels were locked; I was told by nursing staff that the wheelchair wheels were locked when R2 was left in the lounge room. CNAs should monitor the lounge room every hour. There is no lounge room monitoring schedule, but CNAs should take turn every hour to check the lounge room, go in and make sure everything is ok.On 7/25/2026 at 1:48 PM V13 (Certified Nurse Assistant) said on 6/5/2026, R2 was assigned to me (3:00 PM - 11:00 PM). Upon beginning of my shift, R2 was in the lounge room, watching TV. Shortly after beginning my shift, I changed R2. I then brought R2 back to the lounge room, locked the wheels in the wheelchair, and left R2 there. We were busy that day. R2 was found on the floor later that afternoon. I think R2 was trying to stand up. We monitor the lounge room occasionally, but nobody is assigned to monitor the room constantly, we peak in as we walk by, the room is located right across from the nursing station.Progress note dated 6/5/2026 written by V12 (Registered Nurse) reads in part, Around 4:55PM, while visitor passing by lounge, saw (R2) lying on the floor & informed this nurse. Went to (R2) & observed (R2) lying on her left side. (R2) unable to give information of what happened. Noted abrasion on top of left side of head & pinkish color on left shoulder & abrasion to right knee. Not in pain @ this time. With adequate ROM to both upper & lower extremities. Wears gym shoes. Alert & oriented x1, non-verbal. Supervisor, ADON, (V21 Medical Doctor) & (emergency contact) informed of incident. (Emergency contact) here & aware of (R2) sending to ER.Hospital Record dated 6/5/2026 reads in part, (R2's) Discharge diagnosis: Fall; Head Injury; Contusion of right knee; Right hand pain; Fracture of phalanx of right index finger.The facility Fall Prevention and Management policy last revised 03/25/2026 reads in part, The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. FALL INTERVENTIONS: Universal Fall Precautions/Facility Fall Protocol will be implemented to all residents admitted to the facility regardless of risk scores: a. Universal Fall Precaution Interventions may not reflect on Fall Risk Care Plan as facility uses this as standard nursing practice/protocol to prevent falls and injuries; b. Indicators for required transfer assistance will be implemented to communicate and alert staff to promote and ensure safe transfers; c. Fall Focus Program will be implemented to ensure purposeful rounding addresses residents positioning, pain, personal needs, personal items within reach, perils/safety hazards, and peaceful environment upon admission and throughout resident's stay. High-Risk Precautions will be implemented to residents and patients whose scores on Resident/Family Notification Fall Risk screen shows high risk will be considered on this precaution: a. Universal Fall Precautions /Facility Fall Protocol will be implemented in addition to High-Risk Fall Precaution Interventions; b. Staff will remain with patient or resident when assisted to the bathroom; c. Interventions will depend on identified and assessed risk factors, including root cause/s every after each fall or when a pattern has been identified. Some of these interventions may include but not limited to: i. Assess need for appropriate assistive device for mobility and locomotion; ii. Meaningful and or scheduled rounds. iii. Keep hearing aids, glasses, dentures with residents or patients; iv. Pharmacy medication review and observing resident or patient for any potential medication side effects/drug interactions or fall related side effects; v. Assess need for toileting or incontinence care; vi. PT/OT eval and treat; vii. Restorative Program: Ambulation, Transfers, Bed Mobility viii. Room near nursing station; ix. High risk indicators maybe utilized by the facility and placed in visible areas decided by facility. PROCEDURE FOR POST-FALL MANAGEMENT a. Post Fall will be reported and investigated; b. Perform assessment to the cause of the fall and potential for injury. a. Perform physical assessment including: i. Head to toe assessment; ii. Vital Signs: Temperature, Pulse, Respiratory Rate, Pulse Ox, Blood Pressure, Pain; iii. Range of Motion; iv. Neurological assessment as indicated. b. Environmental/physical assessment to identify any environmental/physical risk factors; c. Notify provider and family/ or state representative; d. Document the fall event in EHR under Risk Management; e. Nurse with knowledge of the event will document pertinent facts in the medical record. Other staff will be interviewed and or a written witness statement will be completed.

Based on observation, interview, and record review, the facility failed to follow the Acute Respiratory Infection Policy when V3 (Registered Nurse) failed to wear a mask during a facility wide COVID outbreak and the facility failed to follow the Enhanced Barrier Precaution Policy when V3 was not wearing a gown when applying pain patch (direct physical contact) on a resident with Enhanced Barrier Precautions. This failure has the capacity to affect 4 residents in a total sample of 31.Findings include:On 12-16-25 at 9:00 AM, while entering the facility, front desk receptionist informed the survey team about facility outbreak of COVID and advised the survey team to wear a mask. Surveyor observed masks and hand sanitizer station in the lobby. Surveyor observed most staff and all visitors wearing masks and sanitizing their hands appropriately. V2 also told survey team about COVID outbreak status.On 12-17-25 at 4:56 AM, V3 was observed passing medications to R45 without wearing a mask. At 5:15 AM, V3 was observed passing medications to R12 without a mask. At 5:18 AM, V3 was observed passing medications to R137 without a mask. At 5:27 PM, V3 was observed providing direct patient care (applying pain patch) to R44 (orders of Enhance Barrier Precautions/ EBP) without wearing a gown.On 12-17-25 at 5:34 AM, V3 (Registered Nurse) said the facility is currently on COVID outbreak status and staff are to wear masks and wash their hands to prevent the spread of infection. V3 said R44 is on EBP but V3 said he did not directly touch R44 and said he touched the pain patch that touched R44.On 12-18-25 at 10:24 AM, V17 (Infection Preventionist) said they saw V3 working and not wearing a mask. V17 said she immediately provided 1:1 education and in-serviced V3 on wearing a mask and hand hygiene before and after patient contact. V3 said all staff who have direct patient contact (touching the patient) should wear a gown and gloves to prevent the spread of infection.On 12-18-25 3:49 PM V2 (Director of Nursing) said facility is currently at COVID Outbreak Status (more than 3 cases) and isolated to unit 300. V2 said staff, residents, and visitors are highly encouraged to use mask. V2 said residents have the right to refuse and staff and family were educated on using masks. V2 said V17 (IP Nurse) witnessed V3 on the floor without wearing a mask and immediately in-serviced V3 and provided PPE training and coaching.Physician Order Summary documents: Enhanced Barrier Precaution due to: wounds, indwelling urinary catheter, CRAB every shift.Enhanced Barrier Precautions reviewed 6-25 documents: Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S.aureus and Multidrug Resistant Organisms (MDRO). EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: wound or indwelling medical devices, regardless of MDRO colonization status, Infection or colonization with an MDRO.Acute Respiratory Illness Policy dated 11-14-25 documents: The facility will recommend masking for all healthcare personnel and visitors during a facility wide outbreak.

Based on observation, interview, and record review, the facility failed to follow the Medication Storage Policy by failing to ensure medications are secured and by failing to ensure medications are labeled. This failure has the capacity to affect 20 residents reviewed for medications in a total sample of 31 and 1 cart of 7 reviewed for medication storage.Findings include: 1.On 12-17-25 at 4:56 AM, V3 (Registered Nurse) left the medication cart unlocked and unattended while passing R45's medication. At 5:15 AM, V3 left the medication cart unlocked and unattended while passing R12's medication. At 5:18 AM, V3 left the medication cart unlocked and unattended while passing R137's medication. On 12-17-25 at 5:34 AM, V3 (Registered Nurse) said the nurse is responsible for securing medication storage by locking the cart while passing medications. V3 said this prevent people from taking medications from the medication cart. On 12-18-25 at 3:49 PM, V2 (Director of Nursing) said all medication should be locked in medication cart to ensure only nurses have access to the medications. Medication Storage Policy reviewed 4-18-25 documents: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. 2.On 12-17-25 at 6:34 AM, surveyor and V4 (Registered Nurse) were reviewing medication cart (for team 2 & 3). Surveyor observed a medication cup with unlabeled 7 tablets. The medication cup said 250mg Vit C with no other way to identify these tablets. V4 examined the cup and immediately disposed of the tablets. On 12-17-25 at 6:34 AM, V4 said she did not use this medication cart during her shift. V4 said she was not able to identify these medications, and the medications should be labeled. V4 said she will dispose of these medications immediately. On 12-18-25 at 3:49 PM, V2 (Director of Nursing) said unsecured unlabeled medications are to be discarded. V2 said she was made aware of the unlabeled medications, and it was determined the agency nurse used house stock Vitamin C 250 mg and placed in the medication cup. V2 said the responsible nurse should have retrieved a labelled bottle and mark the open date. V2 said this cart has medications for 16 residents currently. Medication Storage Policy reviewed 4-18-25 documents: F. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart. 3. On 12/16/2025 at 10:08AM during unit rounds, a medicine cup with a total of 4 pills, an orange, a purple, a white and a red, in it was at R89's bedside table. On 12/16/2025 at 10:09AM, V12 (Registered Nurse) came in R89's room and stated that she was pulled for another resident and did not mean to leave the pills on R89's bedside table. R89 stated that V12 leaves R89's medications with her all the time. On 12/18/2025 at 12:45PM during interview with V2 (Director of Nursing), V2 stated that nurses are to stay with the resident for the duration of medication administration to ensure medications are completely taken by the resident. V2 stated that she is not aware of any resident in the facility that can self-administer their medications. Review of R89's Order Summary Report dated 12/28/2025 indicated admission date of 07/27/2024, and diagnoses of not limited to unspecified dementia, anxiety disorder and depression. It also indicated may leave at bedside for patient to self-administer only for PreserVision AREDS (Multiple Vitamins with Minerals) and TheraBreath Oral Rinse (Throat Liquid Mouthwashes). Review of facility's policy entitled Medication Administration reviewed 04/18/2025 indicated the following: Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: 17. Remain with the resident to ensure that the resident swallows the medication.

Based on interview and record review, the facility failed to initiate the Level II PASRR (Preadmission Screening and Resident Review) process for residents identified with mental illness. This deficient practice affected 3 residents (R133, R12, and R9) reviewed for PASRR within a total sample of 31 residents. 1 -R9 is a [AGE] year-old female, admission record documents initial admission date to the facility was on 6/19/2019 with diagnosis of, not limited to, Dementia unspecified severity with other behavioral disturbance, onset date 10/01/2022. Major depressive disorder single episode unspecified, onset date 7/22/2020. Unspecified psychosis not due to substance or known psychological condition, onset date 7/29/2020. Personal history of other mental behavioral disorders, onset date 10/01/2020. Depression unspecified, onset date 5/20/2024. R9's OBRA I- Initial Screening dated: 6/26/2019, reads: based upon all information and data available to me for this person there is a reasonable basis for suspecting DD or MI, no was marked. On 12/17/2025 at 10:18AM V7 (Social Service Coordinator) said: R9 did not have any other PASARR (Pre-admission Screening and Resident Review) evaluation since the initial admission date to the facility. On 12/18/2025 at 11:32AM V8 (Social Service Director) stated, R9 should have been re-evaluated after new psych diagnoses were added after R9s admission date. V8 (Social Service) states a PASRR Level 1 should have been submitted before re-admission to facility. During record review of R9s census list, R9 was discharged from the facility on 2/8/2020 and admitted to the facility on [DATE]. Record reviewed R9s census list documents R9 was discharged from the facility on 11/23/2022 and readmitted to the facility on [DATE]. On 12/18/2025 at 11:33AM, V7 stated a PASRR was not completed after R9 was re-admitted into the facility. V7 stated he missed the opportunity to send a referral to the appropriate state authority when R9 had a new evident psych diagnosis. 2 - R12 is a [AGE] year-old male, admission record documents initial admission date 12/01/2023, admission date 6/12/2025 with diagnosis of, not limited to Post Traumatic Stress Disorder onset date 1/3/2024, anxiety disorder onset date 12/1/2023, unspecified psychosis not due to a substance or known physiological condition onset date 1/3/2024, major depressive disorder recurrent mild onset date 1/3/2024, bipolar disorder current episode mixed unspecified onset date 8/1/2024. R12's order summary documents Cymbalta Capsule Delayed Release Particles 60mg (Duloxetine HCI) give 1 capsule by mouth two times a day for depression, order date 10/21/2025. Diazepam oral tablet 5 mg (Diazepam) give 1 tablet by mouth at bedtime for anxiety, order date 6/12/2025. Olanzapine oral tablet 5 mg (Olanzapine) give 1 tablet by mouth at bedtime for psychosis, order date 7/10/2025. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate) give 1 tablet by mouth at bedtime for psychosis, order date 7/10/2025. During record review of R12's Review of Notice of PASRR (Pre-admission Screening and Resident Review) Level I screen Outcome, Notice Date: August 25, 2023 indicated R12's PASRR Level I Determination: Refer for Level II Onsite. R12's Review of Notice of PASRR Level II screen Outcome, Notice Date: August 28, 2023 indicated R12s PASRR Determination: Level II-Excluded from PASRR- No Diagnosis- No LOC. R12's PASRR Outcome Explanation documents, you don't' require further Level II screening unless you experience a significant change in status that suggest you have a serious mental illness, intellectual disability (ID), or developmental disability. In that case, the nursing facility must submit an updated Level I screening form to Maximus. On 12/18/2025 at 11:34AM V7 (Social Service Coordinator) stated that was the only PASRR (Pre-admission Screening and Resident Review) they had for R12, notice date 8/28/2023 and they did not make a referral to the state designated authority after diagnosis of Post Traumatic Stress Disorder, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder recurrent mild, bipolar disorder current episode mixed unspecified were identified. V7 stated he should have made the referral but missed it. On 12/18/2026 at 11:34 AM, V7 and V8 (Social Service Director) stated they receive the PASARR from the hospital when a resident is newly admitted to the facility. V7 and V8 stated a psychiatric nurse practitioner comes to the facility on Thursdays to assess residents and that is how V7 and V8 identify residents with new evident or possible MD (Mental Disorders), ID (Intellectual Disabilities), or related condition after admission. V7 and V8 stated the social service department is responsible for making referrals to the appropriate state-designated authority when a resident is identified as having an evident or possible Mental Disorder (MD), Intellectual Disability (ID), or related condition. 3 - R133 is a 79 -year-old female admitted in the facility on 12/8/2017. R133 has diagnoses of, but no limited to vascular dementia, COPD, major depressive disorder, bipolar, insomnia, hypothyroidism, anxiety, unspecified psychosis, hypertension, emphysema, sarcopenia. On 12/17/2025 at 11:27 AM, a record review for R133 showed that a PASRR (Preadmission Screening and Resident Review) Level I pre-screening was completed on 12/7/2017. The screening indicated that, based on all available information and data, there was a reasonable basis to suspect the presence of a developmental disability (DD) or mental illness (MI). The review also revealed that R133 was later identified with new diagnoses. Bipolar disorder was added on 7/12/2018, and Unspecified psychosis was added on 5/8/2024. R133's current physician's order list indicated that R133 is on the following medications: Ativan Tablet, Buspirone HCl Oral Tablet and Duloxetine HCl Capsule. On 12/17/2025 at 2:10 PM, V7 was interviewed regarding the facility's process for screening residents. V7 stated that the interdisciplinary team discusses any new diagnoses during the daily morning meeting. V7 further explained that once a new diagnosis for mental illness is identified, a PASRR II is required to be rerun, and the Social Services Department is responsible for completing this process. When asked whether R133 had a PASRR Level II screening completed, V7 stated, we do not have one. On 12/18/2025 at 11:41 AM, V8 confirmed that R133's PASRR Level I initial screen dated 12/7/2017 was marked Yes, indicating a reasonable basis to suspect the presence of a developmental disability (DD) or mental illness (MI). When V8 was asked whether R133 had a PASRR Level II screening completed, V8 stated that if V7 indicated there was none, then no PASRR Level II screening existed. On 12/18 /2025 V2 (Director of Nursing) presented the facility's policy on admission criteria dated 11/18/2021 with the latest review date of 4/12/2025 states in the procedure: 9. All new admissions and readmissions are screened for mental disorders MD), intellectual disabilities (ID) or related disorder (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual may meet the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on interview and record review the facility failed to follow the Fall Prevention and Management Policy by not completing post fall assessment dated [DATE] after a fall incident. This failure affected 1 resident (R3) of 3 residents reviewed for falls in a total sample of 31.Findings include:On 12-17-25 at 12:49 PM, V14 (Restorative Nurse) said R3's Fall Event dated 3-16-25 documents In Progress and nothing is entered. V14 said this event occurred before V14 was the Restorative Nurse. V14 said she does not have knowledge of this incident. V14 said the nurse on duty is responsible for completing the Fall Event form.On 12-18-25 at 10:46 Am, V2 (Director of Nursing) said the nurse on duty was an agency nurse who didn't complete the Fall Event form and did not enter any new interventions. V2 said the fall team completed a soft copy Fall Event form however did not enter the form in computer because she was not the nurse on duty at that time. V2 said the team decided to continue the current interventions however the date was not changed.R3's Fall Event dated 3-16-25 is not completed.Fall Prevention and Management Policy revised 3-31-25 documents: 3. Procedure for Post Fall Management. A. Post Fall Observation will be completed. B. Perform assessment to the cause and fall of the potential for injury. C. Perform physical assessment including head to toe assessment, vital signs, range of motion, neurological assessment as indicated.

Based on observation, interview, and record review, the facility failed to follow its Call Light Policy by not ensuring the call light was placed within easy reach of a resident. This deficient practice affected one resident (R83) out of three residents reviewed for accommodation of needs, within a total sample of 31 residents.R83 is a [AGE] year-old-female re-admitted to the facility on [DATE]. R83's medical diagnoses include, but not limited to Secondary parkinsonism, Alzheimer's disease, type 2 diabetes, anxiety, bipolar, hypertension, gout, hyperlipidemia, hypothyroidism. On 12/16/2025 at 9:54 AM during room rounds, R83 was observed in bed awake and resting. R83's call light string was noted on top of the bedside table and not within R83's reach. V5 (Certified Nursing Assistant/CNA) entered the room and was asked why R83's call light was positioned out of her reach; the CNA stated, It's because she always plays with the call light. When the CNA was asked how R83 could request assistance if the call light cord was positioned out of reach, no response was provided. On 12/17/2025 at 9:04 AM, R83 was observed in bed eating breakfast. The call light cord was observed positioned away from the resident, with the end of the string noted on the floor. V5 (CNA) entered the room and stated that R83 likely threw the call light onto the floor. When asked whether R83 uses the call light to request assistance, the CNA responded, Yes. V5 was also asked why floor mats were present on both sides of the bed and stated they were in place to prevent injury in the event of a fall. On 12/18/2025 staff was interviewed regarding call light use. At 9:14 AM, V9 (Registered nurse/RN) stated that staff needs to make sure that call light should be within the resident's reach. V9 said, We must put them close to the resident so that they can use it. If it's far, they won't reach it, and if the resident is at risk for fall then they might fall. So frequent rounds are necessary to make sure they are within reach. At 9:20 AM, V10 (Licensed Practical Nurse/LPN) said that call light should always be placed where residents can reach them so they can call for assistance when they need help. V10 also stated that if it's far, and they cannot reach it then falls may happen. At 9:54 AM, V11 (CNA), said that it is very important to place the call light within reach because you don't want any falls or anything like that to happen. She also said, clip it so they can reach it.R83's care plan for Activities of Daily Living (ADLs), revised on 3/12/2025, indicated that R83 had an ADL self-care deficit, as evidenced by an unsteady gait related to physical limitations, cognitive impairment, functional decline, and dependence on staff for ADLs and transfers.R83's care plan on Falls with a revised date of 9/22/2023 states that, R83 is high risk for falls, impaired mobility, cognitive deficit, dx/condition, potential s/e of meds and d/t poor safety awareness, cognitively impaired, poor communication and, unable to repositioned self, needing assistance from staff for ADL and dependent with transfer. On 4/21/2023 an intervention was added to her Fall care plan, which was Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. R83's Call Light Ability Screen-V1 assessment, completed by a nurse and dated 8/10/2024, indicated the following outcome:1. Instruction - #2 Resident is able to follow instruction on how to use call light? YES #3 Resident able to return demonstration on how to use call light immediately after instructions given? YES2. Ability - Resident is able to use the call lightThe facility's Call light Policy and Procedure, provided by V2 and last reviewed dated 2/25/2025, stated the following: Intent - Facility aims to meet resident's needs as timely as possible. Call light system is utilized to alert staff of resident's needs.Guideline:1. A call light ability screen will be completed for each resident on admission and with a significant change to determine the ability to use the call light.2. Residents capable of using the call light appropriately will have their call light accessible at all times.3. Residents incapable of using the call light will have alternative means or assistive devices based on functional ability.

Based on interview and record review, the facility failed to initiate a new Pre-admission Screening and Resident Review (PASRR) Level I and Level II screenings for 1 (R31) of 3 residents reviewed for PASRR screening in the sample of 31. R31 is a [AGE] year-old-male, admission record documents initial admission date 9/5/2025, with diagnosis of, not limited to anxiety disorder onset date 5/4/2020, bipolar disorder 1/27/2020, major depressive disorder recurrent moderate onset date 3/7/2018, unspecified psychosis not due to a substance or known physiological condition onset date 8/18/2013, unspecified dementia onset date 10/15/2010.On 12/18/2025 at 10:18AM, V7 (Social Service Coordinator) and V8 (Social Service Director) stated there was no Pre-admission Screening and Resident Review (PASARR) completed for R31 prior to admission. Review of Notice of PASRR Pre-admission Screening and Resident Review) Level I screen Outcome, Notice Date: December 17, 2025PASRR Level I Determination: No Level II Required- No SMI/ID/RCOn 12/18/2025 at 11:34AM, V7 confirmed the PASRR was not completed prior to admission.On 12/18/2026 at 11:34 AM, V7 and V8 stated they received the PASARR from the hospital when a resident is newly admitted to the facility. V7 and V8 stated a psychiatric nurse practitioner comes to the facility on Thursdays to assess residents and that is how V7 and V8 identify residents with new evident or possible MD (Mental Disorder), ID (Intellectual Disabilities), or related condition after admission. V7 and V8 stated the social service department is responsible for making referrals to the appropriate state-designated authority when a resident is identified as having an evident or possible Mental Disorder (MD), Intellectual Disability (ID), or related condition. V2 (Director of Nursing) presented Policy titled: admission Criteria, dated: 4/12/2025 reads: Policy: admission Criteria, reviewed on 4/12/2025 documents procedure:9. All new admissions and readmission are screened for mental disorder (MD)intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID or RD.

Based on observation, interview, and record review, the facility failed to ensure common areas are free of accident hazards for one of three residents (R42) reviewed for accidents in a sample of 31. Findings include:On 12/16/2025 at 10:02AM during unit rounds, R42 was lying on bed with discoloration on left eyebrow area. R42 stated that R42 fell on [DATE] in the lounge area within the unit. R42 got up on his wheelchair, went with surveyor to the lounge area and showed the surveyor how he fell. R42 stated that R42 stood up from wheelchair to transfer to the regular chair by holding on the table in the middle of the room but the table was wobbly so R42 fell on his left side. R42 touched the table and the table was wobbling. R42 stated that the table was wobblier when R42 fell. On 12/16/2025 at 10:52AM during observation with V12 (Registered Nurse), V12 touched the table in the lounge area and was wobbling. On 12/16/2025 at 10:52AM during interview with V12, V12 stated that the wobbling table is not safe for anyone who would want to sit by it. On 12/18/2025 at 12:55PM, V12 stated that she did not check the table at the time R42 fell. V12 stated that she just visually checked the surroundings. V12 stated that she received a call from R42's wife asking if there was any broken furniture where R42 fell but she did not visually see any, so she said no. On 12/18/2025 at 1:00PM during interview with V18 (Housekeeping), V18 stated that whenever she cleans the table in the lounge area, the table in the middle of the room was wobbling, and she has informed maintenance about it. On 12/18/2025 at 1:10PM during interview with V19 (Maintenance Director), V19 stated that he was not aware that the table in the lounge area was wobbling until the morning of 12/16/2025. Review of R42's facility incident report dated 12/14/2025 indicated the following:Incident Description: R42 was observed on the floor sitting, trying to get into a chair in the lounge.Predisposing Environmental Factors: None of the Above is checked and Furniture is not checked. Review of R42's Order Summary Report dated 12/18/2025 indicated admission date of 12/06/2025, and diagnoses of not limited to unspecified fall, other abnormalities of gait and mobility, acquired absence of left leg below knee, acquired absence of right leg below knee, and abnormal posture. Review of facility's policy entitled Fall Prevention and Management last revised on 03/31/2025 indicated the following:Policy Statement: The facility is committed its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained.Procedures:3. Procedure for Post-Fall Managementd. Environmental/physical assessment to identify any environmental/physical risk factors.

Based on observation, interview, and record review, the facility failed to assist residents who needed help with toileting, grooming, eating, and transfers.This applies to 5 out of 5 residents (R1, R2, R6, R7, and R8) reviewed for activities of daily living. The findings include:1. On 7/29/2025 at 9:30 AM, R1 was in bed. R1 said he required staff assistance with his toileting hygiene because he was incontinent of bowel and had an indwelling urinary catheter. R1 said he filed a grievance concern on 7/25/2025 because he was not assisted with his request for incontinence care. R1 said he then developed skin irritation on his scrotal area and was uncomfortable. At 9:50 AM, V4 (Registered Nurse/RN) assessed R1's catheter and scrotal area. R1's catheter tubing had soiled residue present, was not secured properly and the catheter's port was directly rubbing on his right inner thigh area. R1 also had a gauze dressing on his scrotal area. V4 removed the dressing, and R1 had soiled dry residue and skin irritation on the area. V4 applied a new gauze dressing to R1's scrotal area without cleaning the area and provided no toileting hygiene care.On 7/29/2025 at 1:30 PM, V8 (Wound Nurse) said R1 scrotal irritation was dermatitis related to moisture. V8 said staff was to apply incontinence barrier cream to R1's scrotal area every shift and as needed.R1's care plan, initiated on 2/27/2025, said R1 had an ADL self-care performance deficit, including with personal hygiene and toileting. The care plan's interventions said The resident requires x1 staff assist with personal hygiene and toileting. R1's care plan also said he was at risk for skin impairment, and skin should be kept clean and dry.2. On 7/29/2025 at 9:25 AM, R2 was in bed. R2 said he had been calling for assistance with his morning daily care, including toileting and transferring. R2 said he tried his best to dress himself but was unable to pull his pants up. R2 said he was unsure who his assigned CNA (Certified Nurse Assistant) was because no one had responded to his care request. R2 said he required staff assistance with toileting and transfers because he was incontinent of bowel and required the use of a mechanical transferring lift. At 10:20 AM, V6 (CNA) responded to R2's request for assistance with his ADL care. V6 said she was assigned to R2's care since 6:30 AM but had not assisted him earlier with his ADL care request. V6 then assessed R2's incontinent brief. The brief was soiled with dried feces.R2's care plan initiated on 4/18/2025 said R2 had required extensive to total assistance with his ADLs because he had impaired mobility and was incontinent of bowel. The care plan's interventions said staff were to assist R2 with his ADLs, including dressing, transferring, mobility, and toileting hygiene needs. 3. On 7/29/2025 at 12:00 PM, R8 was sitting in the dining room trying to eat her lunch by herself. R8 was blind and cognitively impaired and was having difficulty eating. R8 used her fingers to try to eat her meal. R8 was served an unopened milk carton and puree food items (non-finger food item). R8's care plan initiated on 7/23/2024, said R8 had an ADL self-care performance deficit, including with eating. The care plan's interventions last updated on 10/10/2024, said Provide finger foods when the resident has difficulty using utensils and The resident requires supervision by staff for her eating needs.R8's ADL documentation report dated 7/29/2025 for eating said R8 required setup and supervision or touching assistance with her meals in the past 30 days. 4. On 7/29/2025 at 12:40 PM, R6 was in bed. R6 was severely cognitively impaired and unable to express his needs. R6's served lunch meal was on his bedside table, covered and untouched. V9 (Unit Manager) said she had difficulty understanding R6 and was unsure why he was not eating. V9 said R6 required staff assistance with eating. R6's care plan initiated on 6/10/2024, said R6 had an ADL self-care performance deficit. R6's ADL intervention for eating assistance last updated on 7/23/2024, said Resident can eat independently.R6's ADL documentation report dated 7/29/2025 for eating said R6 required assistance for his meals varied from independent, setup, supervision or touching assistance, partial to moderate, and substantial to maximal assistance in the past 30 days. 5. On 7/29/2025 at 12:25 PM, R7 was sitting in his wheelchair wearing a hospital gown. R7's beard was long and unkept. R7 said he was upset because he had difficulty receiving assistance with his morning care. R7's memory was impaired and was unable to provide further information regarding his ADL care needs. R7's care plan initiated on 3/14/2023, said R7 had an ADL self-care performance deficit. R7's ADL interventions for dressing and personal hygiene were last updated on 7/20/2024, and said he required assistance choosing clothing and needed setup assistance with hygiene care from staff. R7's care plan also said he had impaired mobility and cognition related to dementia.R7's ADL documentation report dated 7/30/2025 for ADL hygiene care said R7 required substantial to total staff assistance in the past 30 days. R7's ADL documentation did not include ADL care for dressing.R7's MDS (Minimum Data Set) dated 6/10/2025 said R7 was provided with substantial to maximal staff assistance with dressing and personal hygiene in the look-back period. On 7/29/2025 at 2:30 PM, V2 (Director of Nursing) said ADL care should be provided to residents as indicated in their plan of care. V2 said residents were assessed routinely for their mobility and level of function, and their ADL care plans were updated accordingly. V2 said staff were to assist residents with ADL care needs as requested. V2 also said for residents with impaired cognition, they should be assessed and provided with routine ADL care, at a minimum of every two hours. The facility's policy titled Supporting Activities of Daily Living, dated 3/18/2024 said Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.including appropriate support and assistance with: a. Hygiene (bathing, grooming, and oral care); b. Mobility (turning, re-positioning, transfers and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication.

Based on interview and record review, the facility failed to protect a resident's (R4) right to be free from sexual abuse by a facility staff member. This failure resulted in R4 experiencing psycho-social harm from V13's (Certified Nursing Assistant/CNA) inappropriate sexual touching. The facility also failed to protect a resident's (R2) right to be free from physical abuse by another resident (R1). This applies to 2 of 6 residents (R2 and R4) reviewed for abuse. The findings include: 1. On 6/03/2025 at 10:00 AM, R4 said V13 (CNA) had sexually touched her private vaginal area with his gloved hand and fingers when rendering incontinence care on the early morning of 6/01/2025. R4 said she told V13 to stop touching her because he was causing her pain in her private area. R4 said V13 would take approximately thirty minutes when providing her incontinence care, which was unusual for her. R4 said V13 had done this to her three times prior when rendering incontinence care. R4 said the prior incidents had occurred in the past months after she no longer had a roommate. R4 said she had not reported the prior incidents because she was afraid but after the last incident on 6/01/2025, she decided to report it to her family because it was painful. R4 said she also did not want this to occur to other residents. R4 said she then decided on 6/02/2025 to be transferred to the hospital for a sexual assault exam. R4 said she was told her exam showed trauma and has decided to pursue criminal charges. On 6/04/2025 at 11:00 AM, R4 said V13's inappropriate sexual contact to her vaginal area made her feel sexually violated. R4 said she had been fearful that V13 would continue to care for her after the incidents. R4 said she now felt safe that V13 was no longer at the facility. On 6/02/2025 at 1:55 PM, V14 (R4's Family Member) said R4 called her on the evening of 6/01/2025 and reported V13 had touched her private area inappropriately when providing incontinence care on four different occasions including on 6/01/2025. V14 said she notified V1 (Administrator) immediately. On 6/02/2025 at 12:40 PM, V17 (Social Worker) said she conducted a well-being check on R4 after being informed of R4's reported incident. V17 said R4 was alert and reviewed her care plan. V17 said R4 had no behaviors or history of reporting abuse. On 6/04/2025 at 10:15 AM, V15 (Hospital Sexual Assault Nurse Examiner/SANE) said she interviewed, recorded a physical assessment, and collected samples from R4 after she went to the hospital for sexual assault treatment. V15 said R4 reported V13 had assaulted her on 6/01/2025 at 3 AM when changing her incontinence brief and had done this three times prior in the past months. V15 said R4 reported V13 touched her vaginal and rectal areas with his gloved fingers causing her discomfort and one time he spit saliva in his hand for lubrication. V15 said R4's vaginal exam showed positive uptake of specialized dye which indicates trauma of abrasions or tears. V15 said she also collected swab samples as part of R4's kit. On 6/04/2025 at 10:50 AM, V16 (Local Police Detective) said he had formally interviewed R4 on 6/02/2025. V16 said R4 wanted to proceed with criminal charges. V16 said the criminal investigation was active and could not provide additional information. On 6/04/2025 at 3:30 PM, V11 (Physician) said on 6/04/2025 he interviewed R4 about her reported incident. V11 said R4 was alert and coherent. V11 said R4's statement about being sexually touched inappropriately by a CNA during incontinence care was consistent. On 6/02/2025 at 5:00 PM, V13 (CNA) was interviewed over the phone. V13 denied R4's allegation. V13 said he on 6/01/2025 he had provided R4 incontinence care at 3 AM and 6 AM. V13 said he had provided care to R4 in the past and believed the last time was weeks prior to 6/01/2025 when she had a roommate. On 6/02/2025 at 11:30 AM, V1 (Administrator) said V14 (R4's Family Member) notified him of R4's sexual abuse allegation involving V13 (CNA) on 6/01/2025. V1 said the facility had initiated an investigation and notified all responsible parties including the local police and V11 (Physician). V1 said V13 was immediately suspended from the building. V1 said R4 had refused to be transferred to the hospital on 6/01/2025 but after talking to V12 (Nurse Practitioner/NP) on 6/02/2025 she agreed. V1 said the facility was reviewing R4's hospital records from 6/01/2025 and communicating with the local police. R4's care plan dated 6/04/2025 had a focus problem initiated on 9/24/2024 for being at risk for abuse and trauma. The care plan said R4 should be observed and monitored to mitigate potential abuse. R4's MDS (Minimal Data Sheet) assessment dated [DATE] showed R4 was cognitively intact. The assessment also said R4 was frequently incontinent of bowel and bladder needing partial to moderate assistance with her toileting hygiene. R4's progress note dated 6/02/2025 said Primary MD by phone about resident reported incident on Saturday night. MD ordered to send resident to hospital ER for evaluation of trauma. V12's (NP) progress note dated 6/02/2025 said RN requested patient be seen for alleged sexual abuse. Pt states that CNA touched her inappropriately Saturday night .Appears to be anxious about events .Provided emotional support. R4's hospital records dated 6/02/2025 said R4 was evaluated and treated for sexual assault. The records said R4 reported V13 touched her inappropriately in her private area with his finger on 6/01/2025 at approximately 3 AM during incontinence care. The record said R4 reported V13 had done this three times prior. The record said R4's vaginal physical exam showed there was positive uptake of toluidine blue dye in five areas. Census List report dated 6/03/2025 showed R4 last had a roommate on 4/21/2025. The facility's untitled document showing V13's (CNA) residents assignments showed after 4/21/2025 V13 was assigned R4 on 4/28/2025, 5/01/2025, 5/15/2025, 5/21/2025, 5/22/2025, and 5/31/2025 on the overnight shift (10:30 PM-6:30 AM). 2. On 5/31/2025 at 9:55 AM, R1 was being assisted with his care by V4 (CNA). R1 was not able to engage in the interview. V4 said R1 was confused and had aggressive behaviors towards others. V4 said R1 had been aggressive towards R2 on 2/19/2025 and 5/14/2025 in the dining room. V4 said R2 no longer resided in the memory care unit. On 5/31/2025 at 9:45 AM, R2 was in her room. V5 (Registered Nurse/RN) asked R2 about her incident involving R1 in her preferred language. V5 said R2 was confused and unable to recall the incident because of her dementia. On 5/31/2025 at 12:05 PM, V7 (Agency CNA) said on 2/19/2025 she was supervising the memory care unit's dining room. V7 said R2 was trying to leave the area when R1 stood and started hitting R2 on the face and head. V7 said she intervened and then R1 launched and swung at her but did not hit her. V7 said R1 was redirected to his room and placed on 1-on-1 supervision till he was transferred to the hospital. On 5/31/2025 at 11:40 AM, V9 (Licensed Practical Nurse/LPN) said on 5/14/2025 he heard arguing coming from the memory care unit's dining room. V9 said R2 was on the floor and R1 was over her swinging his hands at her. V9 said R1 hit the back of R2's head. V9 said he had difficulty redirecting R1 but was able to separate them. V9 said R1 was transferred to the hospital for his aggressive behavior. V9 said R2 quickly forgot about the incident because of her dementia. On 5/31/2025 at 12:10 PM, V1 (Administrator) said he investigated R1 and R2's incidents on 2/19/2025 and 5/14/2025. V1 said his abuse investigation process included obtaining witness statements from those present to identify the root cause of the incident. V1 said R1 was petitioned out and admitted for aggressive behavior after both incidents. V1 said both R1 and R2 had dementia and believed R2's loud noises triggered R1 to flare his arms. R2's care plan dated 5/31/2025 said she had impaired cognition and was confused related to her dementia. The care plan also said R2 was at risk for abuse and trauma. R2's progress note dated 2/19/2025 said At approximately 1215 pm, a physical altercation occurred between [R2] and [R1] in the dining room. Witnesses reported that the incident started when [R2] became upset because [R1] was in the way when attempting to leave the dining room. She began to yell at [R1] in her native language. This evoked a response from [R1], where he struck [R2] in the head. V7's Statement form dated 2/19/2025 said she observed R1 approaching R2 when she was trying to leave the dining room. The statement continued to say R1 then hit R2 in the head with an open hand approximately twice. R2's progress note dated 5/14/2025 said Resident was found on the floor in the dining area following an altercation with another resident, who was observed hovering over her. V9's Statement form dated 5/14/2025 said he observed R1 hovering over R2 while she was on the floor. The statement continued to say V9 attempted to move R1 but was resistive and started to slap R2 in the head. R1's care plan dated 5/31/2025 said he had impaired cognition and was confused related to his dementia and schizoaffective diagnosis. The care plan said I am confused and disoriented and may misinterpret interactions/situations I experience. Consequently, I may present with aggression when agitated or frustrated. R1's Petition for Involuntary Judicial admission dated 2/19/2025 said R1 required an emergency inpatient hospital admission because he presented physically aggressive with another resident. The resident is nonredirectable at this time. R1's Petition for Involuntary Judicial admission dated 5/14/2025 said R1 again required an emergency inpatient hospital admission because he presented physically aggressive with another resident. The resident is nonredirectable at this time. The facility's final investigation report for R1 and R2's incident on 2/19/2025 said After review of the incident, contact between residents appears to be an accident R1 was startled by R2 speaking and is best suited in a calm atmosphere away from startling moments. CNAs and nurses educated on techniques of de-escalation and signs to monitor for R1 to encourage a calm atmosphere for him in this setting. The facility's final investigation report for R1 and R2's incident on 5/14/2025 said At this time, it appears that the contact between R1 and R2 was accidental and unintentional. R1 is best suited in a different setting. The facility's policy titled Behavior Management Policy and Procedure dated 12/18/2024 said Purpose- To ensure a safe, respectful, and therapeutic environment by providing consistent guidelines for identifying, preventing, and managing challenging or disruptive behaviors in residents while preserving their dignity and rights. The facility's policy titled Abuse Prevention Training Program undated said The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention .I. PREVENTION & SCREENING .II. IDENTIFICATION AND INTERNAL REPORTING .III. PROTECTION .IV. INVESTIGATION .V. REPORTNG & RESPONSE .Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Willful, as used in this definition of abuse, means the individual must have acted deliberately .Physical Abuse includes hitting, slapping, pinching, kicking .Sexual Abuse is non-consensual sexual contact of any type with a resident Mental Abuse is also the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. This includes, but is not limited to, harassing a resident; mocking, insulting, or ridiculing; yelling or hovering over a resident, with the intent to intimate .Abuse is most likely to happen in situations that result in frustration, annoyance, and anger .To prevent these situations from turning into a possibly abusive situation, you must know the causes of why a resident gets agitated or aggressive .Some of those causes could be .Dementia .Sudden movements, startling noises .

Based on interview and record review, the facility failed to follow their abuse policy and immediately report an allegation of abuse to the abuse coordinator. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, and right below the knee amputation. On May 7, 2025, at 12:16 PM, V4 (CNA/Certified Nursing Assistant) said he was providing incontinence care to R1 on May 6, 2025. V4 said R1 told V4 during the previous shift, when V3 (CNA) was providing care to R1, V3 (CNA) told R1 to shut up multiple times. V4 said he told R1 to report this to his sister or a manager because it was verbal abuse, and staff should not talk to residents that way. V4 said he did not report the allegation to anyone because he doesn't know V3 and didn't know if V3 would do something to V4 for reporting him. On May 7, 2025, at 12:40 PM, V1 (Administrator) said his expectation is facility staff should immediately report any allegation of abuse to either V1 or V2 (DON/Director of Nursing). V1 said he is the abuse coordinator. V1 said V4 did not report an abuse allegation to V1 or V2 on May 6, 2025. V1 said V4 should have reported R1's allegation immediately. The facility's undated policy titled Abuse Prevention Training Program showed, Objective of Abuse Policy: The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention. The Abuse Prevention Program will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and Performance Improvement (QAPI) program . B. Internal Reporting: Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator . Any employee who knows or suspects that abuse has occurred and makes and makes an immediate report out of a legitimate concern shall not be penalized or reprimanded for making such report .

Based on observation, interview, and record review the facility failed to ensure medications were given at the correct time for 12 of 13 residents (R1, R2, R4-R13) reviewed for medications in the sample of 14. The findings include: 1. On 3/27/25 at 10:20 AM, V4 LPN (Licensed Practical Nurse) gave R4 the following medications: escitalopram, ezetimibe, ferrous sulfate, loratadine, potassium chloride, senna-s, vitamin D3, Coreg, Eliquis, levetiracetam, and sodium bicarbonate. R4's March 2025 MAR (Medication Administration Record) showed these medications were scheduled to be given at 9:00 AM. R4's Face Sheet dated 3/27/25 showed diagnoses including left sided hemiplegia and hemiparesis, cerebral infarction, type 2 diabetes mellitus, hypertension, long term use of anticoagulants, hyperlipidemia, unspecified convulsions, depression, hypokalemia, chronic kidney disease, dysarthria and anarthria. On 3/27/25 at 10:52 AM, V4 LPN gave R5 the following medications: loratadine, senna plus, and sodium chloride. R5's March 2025 MAR showed these medications were scheduled to be given at 9:00 AM. R5's March 2025 MAR showed diagnoses including ischemic cardiomyopathy, atherosclerosis of coronary artery bypass grafts, mild protein-calorie malnutrition, insomnia, heart failure, gastro-esophageal reflux disease, takotsubo syndrome, anemia, and chronic obstructive pulmonary disease. On 3/27/25 at 10:59 AM, V4 gave R2 the following medications: carbamazepine, oxybutynin, vitamin C, aspirin, metoprolol, enoxaparin, multivitamin, metoprolol, baclofen, and Florastor. R2's March 2025 MAR showed all these medications were scheduled to be given at 9:00 AM except the enoxaparin which was scheduled for 10:00 AM. The Face Sheet dated 3/27/25 for R2 showed diagnoses including multiple sclerosis, cellulitis, functional quadriplegia, paroxysmal atrial fibrillation, deep venous thrombosis, trigeminal neuralgia, hydronephrosis, calculus of ureter, hypertension, benign prostatic hyperplasia, neuromuscular dysfunction of the bladder, major depressive disorder, retention of urine, and obstructive sleep apnea. On 3/27/25 at 11:19 AM, V4 gave R6 the following medications: famotidine, isosorbide mononitrate, lisinopril, trelegy ellipta inhaler, Wellbutrin, Zyrtec, Eliquis, metformin HCL, ranolazine, and gabapentin. R6's March 2025 MAR showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R6 showed diagnoses including malignant neoplasm of lung, type 2 diabetes mellitus, chronic obstructive pulmonary disease, atherosclerotic heart disease, neuropathy, hyperlipidemia, hypertension, and depression. On 3/27/25 at 11:31 AM, V5 RN (Registered Nurse/ MDS Care Plan Coordinator) stated she came to assist V4 with the medication administration because the medications were late. On 3/27/25 at 11:34 AM, V4 LPN stated there is no way possible to get these (medications) done on time; not with 24 residents. V4 stated she was off for two days, came back and the medication cart was not stocked. V4 stated it takes time away from her medication administration to get the medications. V4 stated medications can be given one hour before and one hour after the time they are scheduled. On 3/27/25 at 11:39 AM, V4 gave R7 the following medications: MiraLAX, calcium with vitamin D, celecoxib, meclizine, buspirone, ferrous sulfate, preservision, senna plus, aspirin, cholecalciferol, Ellipta inhaler, and aspirin. R7's March 2025 MAR showed all these medications were due at 9:00 AM except aspirin which was due at 11:00 AM. The Face Sheet dated 3/27/25 for R7 showed diagnoses including chronic obstructive pulmonary disease, anxiety, peripheral vascular disease, hyperlipidemia, major depressive disorder, cerebral aneurysm, hypertension, gastro-esophageal reflux disease, osteoporosis, anemia, and vascular dementia. On 3/27/25 at 11:42 AM, V5 RN gave R8 preservision, multivitamin, senna plus, aspirin, loratadine, sodium chloride, and artificial tears eye drops. The March 2025 MAR for R8 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R8 showed diagnoses including pleural effusion, hyperlipidemia, atherosclerotic heart disease, myocardial infarction, personality disorder, delusional disorder, hypertension, monoplegia of lower limb, macular degeneration, transient ischemic attack, and dependence on supplemental oxygen. On 3/27/25 at 11:49 AM, V4 gave R9 duloxetine, gabapentin, and insulin glargine. The March 2025 MAR for R9 showed these were daily medications that were due at 9:00 AM. The Face Sheet dated 3/27/25 for R9 showed diagnoses including fibromyalgia, osteoarthritis, cervical disc degeneration, type 2 diabetes mellitus, hypertensive heart disease, anxiety, depression, gastro-esophageal reflux disease, and congestive heart failure. On 3/27/25 at 11:54 AM, V4 gave R10 the following medications: MiraLAX, aspirin, ferrous sulfate, and multivitamin. The March 2025 MAR for R10 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R10 showed diagnoses including chronic respiratory failure with hypoxia, encephalopathy, hypertensive heart disease, congestive heart failure, chronic atrial fibrillation, gastro-esophageal reflux disease, sleep apnea, and hyperkalemia. On 3/27/25 at 12:02 PM, V5 gave R11 the following medications: Aricept, aspirin, ferrous sulfate, ergocalciferol, docusate sodium, metoprolol, Tylenol, and voltaren external gel. The losartan was not available in the medication cart. V5 went to the medication dispensing machine, obtained the losartan, and gave R11 her dose of the medication at 12:17 PM. The March 2025 MAR for R11 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R11 showed diagnoses including hypertension, gastro-esophageal reflux disease, hydronephrosis, dementia, anemia, osteoporosis, hypo-osmolality, and hyponatremia. On 3/27/25 at 12:55 PM, V4 gave R12 the following medications: divalproex, allopurinol, Colestipol, furosemide, ferrous sulfate, loratadine, magnesium oxide, primidone, Tylenol, and spironolactone. The March 2025 MAR for R12 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R12 showed diagnoses including hypertensive heart and chronic kidney disease, gout, hypothyroidism, type 2 diabetes mellitus, essential tremor, other seizures, iron deficiency anemia, glaucoma, paroxysmal atrial fibrillation, congestive heart failure, hyperuricemia, mixed hyperlipidemia, osteoarthritis, and gastro-esophageal reflux disease. On 3/27/25 at 12:48 PM, V4 gave R13 the following medications: Chlorthalidone, Lisinopril, Bactrim DS, and senna. The March 2025 MAR for R13 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R13 showed diagnoses including palliative care, protein-calorie malnutrition, acute respiratory failure, pleural effusion, pneumonia, atherosclerosis of coronary artery bypass graft, dementia, hypertension, hyperlipidemia, and pressure ulcer. On 3/27/25 at 1:53 PM, V2 DON (Director of Nursing) stated if medications are ordered at 9:00 AM they can be given one hour before and one hour after that time. V2 stated that was the facility's standard. V2 stated V4 did not call for assistance giving medications. V5 was the nurse manager assigned to that area, so she asked V5 to help V4. V2 stated the providers were notified of the late medications. V2 stated the night shift nurses are supposed to restock the medication carts. The facility's Medication Administration policy (4/18/24) showed, check medication administration record prior to administering medication for the right medication, dose, route, patient, and time. The policy did not show a policy in place that medications can be given one hour before and one hour after the scheduled time. 2. On 3/27/25 at 2:19 PM, R1 stated he had one day (3/18/25) that he had an agency person trying to give him his morning medications at 3:00 PM. R1 stated he had dinner medications coming up and didn't want to be overdosed. R1 stated he brought it up at resident council yesterday (3/26/25). On 3/27/25 at 3:13 PM, V2 DON (Director of Nursing) stated V3 ADON (Assistant Director of Nursing) noticed the agency nurse on 3/18/25 giving medications late that day and sent someone to help him. The morning medications were being given late in the afternoon. V2 stated that is not the facility's policy. V2 stated the medications can be given 1 hour before, and 1 hour after the scheduled time. On 3/27/25 at 3:30 PM, V3 ADON stated on 3/18/25 she ran into the agency nurse in the hallway that was coming on for the PM shift. That nurse said she couldn't start her shift because the AM nurse was there still giving medications. V3 stated she had a nurse help the AM nurse with the medication pass. V3 stated he was still giving morning medications and it was after 3:00 PM. The Medication Administration Audit Report dated 3/18/25 for R1 showed the following medications were due at 9:00 AM and were given at 3:13 PM/3:14 PM: Systane Balance eye drops, calcium 600/Vitamin D, bumex, Breo Ellipta inhaler, vitamin D3, metoprolol, lidocaine external patch, docusate sodium, acetaminophen, apixaban, finasteride, multivitamin, Jardiance, gabapentin, and Insulin Aspart. The Face Sheet dated 3/27/25 for R1 showed diagnoses including chronic obstructive pulmonary disease, obstructive sleep apnea, type 2 diabetes mellitus, morbid obesity, erythema intertrigo, cellulitis, peripheral vascular disease, chronic kidney disease, atrial fibrillation, osteoarthritis, hypertension, hypokalemia, hyperlipidemia, and benign prostatic hyperplasia. The facility's Medication Administration policy (4/18/24) showed, check medication administration record prior to administering medication for the right medication, dose, route, patient, and time. The policy did not show a policy in place that medications can be given one hour before and one hour after the scheduled time.

Based on observation, interview, and record review the facility failed to ensure patient care equipment was maintained to ensure residents were able to get out of bed for 4 of 4 residents (R1,R2,R3,R6) reviewed for full body mechanical sling lifts in the sample of 4. The findings include: On 01/15/2025 at 9:10AM, the #2 full body mechanical sling lift inspection sticker showed inspection was performed October 2024 and is due for re-inspection January 2025. On the lift arm that supported the resident there was exposed wires and what looked like part of a broken cover. At 9:30AM, there was a sign on lift #2 that showed, OUT of ORDER. The #8 full body mechanical sling lift inspection sticker showed, Preventative Maintenance 05/31/19. On 01/15/2025 at 9:20AM, V3 Maintenance said, I have not received any reports from the Nursing Staff on the need for mechanical lift maintenance or repair. There is a portal in our computer system that generates a workorder, that would be the proper way to request maintenance. Usually staff just call me, leave a voice mail, email, or report directly to me, even leave me a note, all those options work well. On 01/15/2025 at 9:30AM, V3 Maintenance said, Lift #2 has an exposed load cell for the scale. There is a sharp areas exposed, it should be covered up. This equipment is used for people. This does not look pretty; it should be a priority for repair. Equipment used for people comes first. On 01/15/2025 at 9:46AM, R1 said, on 01/12/2025 it took three hours for the staff to find a full body mechanical sling lift to get me out of bed. I wanted to go to the activity room to play cards with my friends. By the time they found a lift, it was too late in the evening, so I just stayed in bed. We need more full body mechanical sling lifts in the facility. On 01/15/2025 at 10:20AM, R3 said, I do not always want to get up for meals, but it would be nice to get up for an activity occasionally. I was told they ordered a piece of equipment and are waiting for it to be delivered before they can get me out of bed. On 01/15/2025 at 10:35AM, R2 said, I do not find it hard to get out of bed when I make the request, it's getting staff to put me back to bed with the full body mechanical sling lift. Usually it is two people to transfer me with the lift .every so often the CNA will do it alo ., .well, we could use some more staff .not agency staff though. On 01/15/2025 at 10:36AM, R6 said, we need more full body mechanical sling lifts in the facility. On 01/15/2025 at 10:44AM, V6 LPN-Licensed Practical Nurse said, R1 is usually up in the evening. He is very active. There is a group of residents that play cards together every evening. They stay up late, usually going to bed sometime before 11:00PM. The facility's Work Order Policy reviewed 10/21/2024 shows, it shall be the responsibility of the staff to report and department supervisors to fill out and forward such work orders to the Maintenance Director.

Based on interview and record review, the facility failed to monitor for behaviors and report the side effects of a resident's anti-psychotic medication. This failure resulted in R4 continuing to receive Seroquel and experiencing a hospitalization , increased falls, and inability to participate in his rehab care. This applies to 1 out of 3 (R4) residents reviewed for psychotropics. The findings include: R4's EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE] with multiple diagnoses including a history of falls, metabolic encephalopathy, vascular dementia, depression, epilepsy, convulsions, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, urinary tract infections, and left femur fracture. R4's MDS (Minimum Data Set) dated 10/18/2024 showed he was severely cognitively impaired and receiving high-risk medications including antipsychotics, antidepressants, and anticonvulsants. R4's EMR showed he was transferred to the hospital on 11/10/2024 and did not return to the facility. On 12/31/2024 at 8:50 AM, V8 (R4's Wife) said she would visit R4 frequently at the facility and became worried because he started to become overly sedated as if drugged and having multiple falls. On 1/2/2025 at 9:00 AM, V14 (Registered Nurse/RN) said she had been R4's routine morning nurse during his stay at the facility. V14 said R4 was nice but would become agitated when his wife was not present. V14 said R4 was a high risk for falls and had to be redirected frequently. V14 said R4 was hospitalized because he was noted to be too sleepy. V14 said R4 was non-decisional and V8 (R4's Wife) was his representative and decision-maker. On 1/2/2025 at 10:20 AM, V12 (Geriatric Nurse Practitioner/NP) said she had assisted in managing R4's primary care at the facility. V12 said she did not prescribe R4's Seroquel medication but had decreased, held, and discontinued it because she was informed he was too sedated. V12 said R4's behavior was difficult to manage and difficult to find the right balance of treatment. V12 said ultimately V13 (R4's Psychiatric NP) should have been notified as the ordering prescriber for Seroquel. On 1/2/2025 at 11:00 AM, V13 (Psychiatric NP) said she was consulted to treat R4 for behavior of agitation related to his dementia and managing his Seroquel. V13 said she last saw R4 on 11/7/2024 and decreased his Seroquel after she was informed of his fall. V13 said the facility should have called her first to inform her of R4's side effects as practice for managing residents receiving psychotropics. V13 said R4 had a lot of adjustments in a short period of time, which made it harder to identify the right dose for him. V13 said this could have contributed to R4 becoming more unstable and lethargic. V13 said it was always better to be cautious when using antipsychotics and that's why she started to taper his Seroquel in November. V13 said she did not contact R4's wife but discussed her recommendations with the facility's nurses. V13 said R4 was showing signs of sundowning (increased confusion in the evening hours) and would have also benefited from nonpharmacological approaches such as sleep hygiene promotion practices, activities, and family visits in the evenings. R4's comprehensive care plan showed R4 had a focus problem for the use of Seroquel (antipsychotic) medication for Alzheimer's disease initiated and last updated on 6/6/2024. The focus problem included a goal for R4 to reduce the use of psychotropic medications and included the interventions of Monitor for side effects and effectiveness [every] SHIFT. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. R4's care plan did not show any resident-centered target behaviors or non-pharmacological approaches for the use of Seroquel. R4's Order Summary Report dated 1/2/2025 showed R4 was started on SEROquel Oral Tablet 25 MG [milligrams] Give 1 tablet by mouth two times a day for depression on 6/6/2024. R4's EMAR (Electronic Medication Administration Record) showed R4 received Seroquel 25 mg twice a day until 9/10/2024. The Report showed R4 was started on an additional dose of SEROquel Oral Tablet 25 MG Give 1 tablet by mouth at bedtime related to UNSPECIFIED DEMENTIA on 6/13/2024. R4's EMAR showed R4 received Seroquel 25 mg at bedtime as well until 8/14/2024. R4's Order Summary Report showed R4 was started on an additional as needed dose of SEROquel Oral Tablet 25 MG by mouth every 24 hours as needed for Behavioral disturbances on 7/29/2024. R4's EMAR showed R4 had the order active for Seroquel PRN (as needed) until 10/15/2024 (79 days). The EMAR showed R4 received Seroquel PRN on 8/1/2024, 8/14/2024, and 8/23/2024. R4's Order Summary Report then showed R4's Seroquel at bedtime was increased to 75 mg on 8/15/2024 with the order SEROquel Oral Tablet 25 MG give 3 tablet by mouth at bedtime related to UNSPECIFIED DEMENTIA. R4's Progress Note dated 9/11/2024 said, Informed [V12 (Geriatric Nurse Practitioner/NP)] patient is sleeping most of the time in the morning after breakfast fall asleep again .D/C Seroquel during the day and leave Seroquel at bedtime, hold if sedated. V13's Psychiatric Periodic Evaluation note dated 9/12/2024 said, Nursing staff reported that dosage of Seroquel during the day was discontinued due to excessive daytime sedation. The evaluation said R4 was to continue with Seroquel 25 mg every 24hrs PRN, Seroquel 75 mg at bedtime for agitation/Psychosis, and to monitor for changes in mood and behaviors. R4's Pharmacy Recommendation dated 9/16/2024 said there were recommendations for a GDR (gradual dose reduction) for SEROQUEL 75MG QHS and a need for stop date of 14 days for PRN order for Seroquel. The recommendation was declined by V13 (Psychiatric NP) because the Patient has had good response to treatment and requires this dose for condition stability. R4's EMAR showed R4 received Seroquel 75 mg at bedtime until 9/17/2024. R4's Progress Note dated 9/18/2024 said, Informed [V12 (Geriatric NP)] that patient during the day there are times that patient is just sleeping, doesn't want to participate in the therapy .order reduce seroquel 50mg at bedtime. V13's Psychiatric Periodic Evaluation note dated 9/19/2024 said, The patient was referred to us today due to worsening depression and a lack of motivation. According to nursing staff, the patient has displayed little motivation lately, dragging himself around and showing a disinterest in participating in any activities, indicating worsening depression. The patient was seen sitting around the nursing station, confused at baseline, and was unresponsive during our interaction. Nursing staff recently discontinued his daytime dose of Seroquel, and while the patient is now more alert, he suntil does not engage much which is unusual for him. The evaluation said R4 was started on another psychotropic medication of Bupropion 100mg daily (antidepressant). R4's NP Progress Note from V12 (Geriatric NP) dated 9/20/2024 said, Pt seen for somnolence HPI Pt has been more sleepy. Seroquel reduced. V13's Psychiatric Periodic Evaluation note dated 10/3/2024 said Declined GDR recommendation for Seroquel at bedtime due to risk for decompensation. R4's Progress Note dated 10/14/2024 said, Resident slipped and fell from wheelchair hitting his head on the floor. Resident sustained a cut on his right forehead .Dr on file was reached and ordered resident to be sent out to ER. R4's Progress Note dated 10/15/2024 said, Pt is admitted for altered mental status. R4's Order Summary Report showed R4 was restarted on 50 mg at bedtime on 10/17/2024 with the order SEROquel Oral Tablet 25 MG Give 2 tablet by mouth at bedtime for bipolar disorder. The Report then showed on 10/26/2024, R4 was started on SEROquel Oral Tablet 25 MG Give 1 tablet by mouth two times a day for behavioral disturbances. R4's Progress Note dated 10/17/2024 said, Upon admission, res appeared very sleepy not verbally responsive even with much verbal cuing from staff and paramedics. His eyelids were quivering and throat had visible swallowing reflex. After about 10 minutes with verbal prodding from staff to say something res said hello and opened his eyes. R4's Progress Note dated 10/26/2024 said, Called [V13 (Psychiatric NP)] for patient being restless and keep on standing. Patient is very unsteady to stand up. NP ordered for Seroquel 25mg bid. Informed wife. R4's Progress Note dated 10/27/2024 said, Change in Condition/s reported this CIC Evaluation are/were: Altered mental status .Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Functional Status Evaluation: General weakness .Primary Care Provider responded with the following feedback .Monitor him closely. R4's Progress Note dated 11/2/2024 said SEROquel Oral Tablet 25 MG Give 1 tablet by mouth two times a day for behavioral disturbances patient appears calm and relaxed poa stated not to give. R4's Progress Note dated 11/7/2024 said, Seen by [V13 (Psychiatric NP)] due to sleepy during the day. D/C seroquel on 9am dose. R4's EMAR showed R4 received Seroquel 25 mg twice a day until 11/7/2024, and received Seroquel 50 mg at bedtime until 11/9/2024. R4's Progress Note dated 11/10/2024 said R4 fell and was transferred to the hospital for an evaluation. R4's EMARs from August through November 2024 showed an order for monitoring the use of Anti-Psychotic Medication Use: Observe closely for significant side effects, sedation, drowsiness, dry mouth, constipation, blurred vision, extra pyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Enter the number of times side effect noted. (Requires progress note of physician notification for each occurrence) every shift for Monitoring. R4's EMARs showed no side effects were documented for R4. R4's EMARs from August through November 2024 showed an order for Monitor/Record if targeted behavior of Agitation occurs every shift for Monitoring indicate if behavior occurred by indication the number of times observed. R4's EMARs showed R4 had the behavior documented on 11/8/2024 and 11/9/2024. R4's Incidents By Incident Type fall report dated 1/2/2025 said R4 had a total of 20 fall incidents during his stay at the facility. The report showed R4's initial fall was on 6/9/2024 (after starting Seroquel). The report showed R4 also fell on [DATE], 6/14/2024, 6/28/2024, 7/2/2024, 7/6/2024, 7/23/2024, 8/2/2024, 8/19/2024, 8/26/2024, 8/31/2024, 10/5/2024, 10/7/2024, 10/10/2024, 10/11/2024, 10/14/2024, 10/27/2024, 11/2/2024, 11/5/2024, 11/8/2024, and 11/10/2024. V16's (R4's Neurologist) Progress Notes dated 8/29/2024, 9/24/2023, and 10/31/2024 said [reccommend] limit seroquel. The facility's policy titled Psychotropic Drug Use dated 6/11/2024 said, The purpose is to promote the safe and effective use of psychotropic medications that are used in lowest possible dose and time frame and have indication for the use that enhances the resident's quality of life .Initiating the Use of Psychotropic Medications .4. Every attempt will be made to utilize the lowest possible dose of the medication .7. If an order is obtained for a Psychotropic Medication, the resident, family or POA must be informed of the risks and benefits of the medication The care plan will be developed with input from the resident, family, legal representative and include participation from the IDT (Interdisciplinary Team). 3. The care plan will be developed initially upon the start of the medication and be reviewed at least quarterly or more often as the resident's condition dictates .Monitoring and Gradual Dose Reduction .The Psychiatrist/PCP will review the continued need for the medication and monitor for side effects .The Psychiatrist or ANP will also be notified and review changes in the resident's condition and behavior or any side of the medications. The facility's policy titled Behavior and Psychoactive Management Program dated 10/22/2024 said, It is the policy of the facility to provide care and services to promote our resident's quality of life. It is the philosophy of the facility that all resident behavior has meaning. Our facility will work diligently to minimize the use of psychoactive medications in its resident population .a. Program will ensure that staff are monitoring residents' behavior to establish patterns, determine intensity and frequency behavior is exhibited, and identify specific targeted behavior/s that can be distressing to the resident. b. The program will assess the need for psychoactive medication use. Care plans with residents and or resident's representatives will be scheduled as necessary via phone or in person to discuss behaviors, psychoactive drug order/s and treatment, and recommended plan of care .e. Evaluating the effectiveness of pharmacological and non-pharmacological interventions will be performed. f. Monitoring for any adverse side effects of medications .g. Care plan on focus problem will be developed with approaches to address and manage identified behaviors .Tapering and Gradual Dose Reduction a. Facility will attempt to achieve the lowest effective dose, to discontinue the medications that no longer benefit the resident, and to minimize exposer to increased risk of adverse consequences .iii. Daily behavior monitoring. iv. May schedule resident and family meetings as necessary.

Based on interview and record review the facility failed to resolve resident grievances for 5 of 6 residents (R1, R3, R4, R5 R6) reviewed for grievances in the sample of 6. The findings include: On 12/17/24 at 9:55 AM, R1 stated he has seen R2 standing at the lunch time steam cart in the hall. R1 said R2 continually touches the trays and removes plate lids with his bare hands. R1 said it is unsanitary and spreads germs. R1 said it has been discussed at group meetings when staff members are present. Nothing is being done about it. On 12/17/24 at 12:37 PM, R4 stated she has seen R2 pick food off resident trays and hovers over the steam carts to find his tray. R4 said she has seen R2 pick food off used trays and then touch fresh food trays. R4 said R2 touches the warming covers with his dirty hands. R4 said it was discussed at the last food focus meeting and staff know about the issue. R4 said no one is doing anything about it. On 12/17/24 at 11:21 AM, V3 (Registered Nurse) said R2 does touch the food trays at mealtimes. R2 is alert and has OCD (obsessive compulsive disorder). Timing is important to him. If his tray is not delivered to his room at the same time each meal, R2 will go to the steam cart and look for it. He touches trays and tickets to find his own. R2 picks up warming lids to see if the trays have been eaten or not. On 12/17/24 at 11:42 AM, V5 (Registered Nurse) said R2 can independently walk up and down the halls. V5 stated he was aware of R2 looking at the food trays in the past but thought that concern had been corrected. V5 said R2 does carry his used tray back to the hall steam cart after he is done eating. On 12/17/24 at 12:17 PM, V6 (Social Service Director) stated he heard R1 and R2 arguing outside his door about one week ago. V6 said R1 was telling R2 to stop touching food trays. V6 said he interviewed both residents and determined the issue had been brought up by several residents at past food focus meetings. On 12/17/24 at 1:35 PM, V7 (Food Service Manager) stated residents have been complaining at food focus meetings regarding R2 picking at food on the steam carts. Residents said he touches the trays and snack items. V7 said R1, R3, R4, R5 and R6 were the residents that had witnessed R2 and voiced their concerns. V7 said they are all alert and oriented with no memory issues. V7 said she reported the complaints to the DON (Director of Nurses) but was not sure how it was followed up. R1, R3, R4, R5 and R6's facility assessments showed no cognitive impairment. The food focus meeting notes dated 12/11/24 (six days ago) showed R2 still messing with the food trays and interfering with staff passing the trays. The notes showed R2 takes snacks, sandwiches, and checks the food trays himself. On 12/17/24 at 2:20 PM, V2 (Director of Nurses) stated residents are not allowed to pass food trays and should not be anywhere near the steam carts. There is the potential for germs to be spread or residents get the wrong food tray. V2 said she was told by V7 about the complaints at past food focus meetings. V2 said she did speak with R2 about the concerns but unfortunately did not document the follow up or resolution anywhere. The facility's Grievance Program policy last review dated 5/15/24 states: 7. b. The grievance will be logged on the facility grievance log .h. All facility grievance investigations will be initiated as soon as possible after the grievance is filed. Completed and timely follow up will be conducted by the department supervisor, the Grievance Office and/or the Administrator.

Based on observation, interview, and record review, the facility failed to provide a sufficient amount of nursing staff/providers to notify family of change in condition, provide grooming needs, and distribute meals in a timely manner. This applies to 7 of 11 residents (R2-R8) reviewed for nursing care. Findings include: 1.R3's Electronic Medical Records (EMR) showed R3's diagnoses include paraplegia, congenital hydrocephalus, heart failure, and palliative care. R3's Minimum Data Set (MDS) dated [DATE] showed R3 was cognitively moderately impaired and dependent on one to two staff assistants for daily care activities. During the observation on 11/02/2024 at 1:35 PM, R3 was in bed sleeping with noisy breathing, and the meal tray was by his bedside untouched. V15 (Agency- Certified Nursing Assistant) said he didn't know about R3. Since morning, he has had noisy breathing and didn't even eat breakfast. V15 said V6(Agency Registered Nurse) is aware of R3's condition. Around 1:45 PM, R6 said he had been having the issues since morning, and when the writer asked R6 whether the family and provider knew about the change in conditions of R3, V6 said she did not get a chance and would notify as soon as she could. On 11/04/2024 at 10:54 AM, V18 (R3's family member) said care and Staffing are a big concern in the facility since the new management took over, and around 2:40 PM on 11/02/2024 a nurse from the facility called her to say that R3 was choking, and he will be placed on thin consistency diet. V18 said around 3:36 PM, someone called her and said R3 had passed away. V18 said she is very upset about the way they care for residents. V18 said that doesn't happen right away and why they took so long to call her. On 11/04/2024 at 1:45 PM, V19(RN-Hospice) said he and the Certified Nursing assistant last saw R3 on 10/28/2024, and he was minimally verbally responsive and appeared to be comfortable. V19 said the hospice received the call regarding his change in condition around 2:27 PM. Usually, the facility notifies the hospice as soon as the changes are identified so that the hospice can send some to the resident to make him comfortable. On 11/04/2024 at 2:30 PM, V2(Director of Nursing) said any change in conditions should be notified to family, physician, and hospice as applicable as soon as a change is identified. On 11/05/2024 at 10:30 AM, V7(Agency- Licensed Practical Nurse) and V8 (Registered Nurse) said any change in resident conditions is notified to the appropriate parties as soon as it occurs. The facility policy titled Change in Condition (revised dated 12/18/2023) states that regardless of the resident's current mental, medical, and physical conditions, a nurse will inform the resident representative/guardian of any changes in any incident, including medical or nursing treatment. 2. R2's EMR showed R2's diagnoses include morbid obesity, acute kidney failure, h/o fracture osteo arthritis, bipolar, anxiety, and mood disorder. R2's MDS dated [DATE] showed that R2 was cognitively intact and required one to two extensive assists for most of his daily activities. On 11/02/2024 at 2:00 PM, two urinals with urine were in R2's drawer. R2 said one urinal had urine before breakfast, and the second one had urine after lunchtime. R2 had quarter inch-long right-hand fingers with blackish dirt under the nails and said that staff only cut his nails once, they do not care. 3. R4's EMR showed R4 had diagnoses including hypertensive heart disease, acute kidney disease, palliative care, dementia, and cerebrovascular disease. R4's MDS dated [DATE] showed R4 is cognitively moderately intact and requires one to two staff assistance for most daily care activities. On 11/02/2024 at noon, observed R4 with more than a quarter inch-long nails on both hands, with sharp edges and brownish dirt under the nails. R4 said no one cuts her nails. 4. R8's EMR showed R8 had diagnoses including chronic respiratory failure, atrial fibrillation, and heart failure. R8's MDS dated [DATE] showed R8's cognitive abilities were severely impaired and required one to two staff assistance for activities of daily living. On 11/02/2024 around 1:00 PM, R8 was minimally interviewable and had more than a quarter-inch nails with blackish/brownish discoloration under fingernails with right index fingernails broken with a wrapped dirty band aid. When the writer asked whether it was painful, R3 said yes and wanted the writer to change her dirty band, Aide. The writer. Reported to V7(Agency Licensed Practical Nurse). On 11/05/2024, around 10:00 AM, R8 still had the wrapped falling off band aide, and no nail care was provided. 5. R5's EMR showed R5 had diagnoses including fibromyalgia, osteoarthritis, abnormal aortic aneurism, and atrial fibrillation. R5's MDS dated [DATE] showed R5 is cognitively intact. A random meal lunch tray temperature on 11/02/2024 at 1:00 PM showed the temperature of sweet potato at 92 degrees Fahrenheit and beans at 97 degrees Fahrenheit. On 11/04/2024 at 1:30 PM, R5 said food trays were not served in a timely manner, and it was always cold. 6. R6's EMR showed R6 had diagnoses including Type 2 diabetes, kidney diseases, anxiety disorder, and dementia. R5's MDS dated [DATE] showed R6 is cognitively moderately intact. The random meal lunch tray temperature on 11/02/2024 at 12:58 PM showed the temperature of sweet potato at 94 degrees Fahrenheit and beans at 87 degrees Fahrenheit. On 11/02/2024 at noon, R6 said food trays are usually given late, and the food is cold. 7. R7's EMR showed R7 had diagnoses including Parkinson's disease, Type 2 diabetes, osteoarthritis, and agitation. R7's MDS dated [DATE] showed that R7 is cognitively intact and requires one to two assistances for most activities of daily living. The random meal lunch tray on 11/02/2024 at 12:55 PM showed a sweet potato temperature of 94 degrees Fahrenheit and beans at 88 degrees Fahrenheit. On 11/02/2024 at 12:05 PM, R7 said food is usually cold and given late. R7 said they have different staff each time and don't have enough help. On 11/02/2024, during lunchtime, V13-V15(Agency- Certified Nursing Assistants) delivered meal trays and said they were doing it as fast as possible. On 11/02/2024 at 12:30 PM and 11/04/2024 at 1:15 PM, V5(Cook) and V3(Food Service Director) said meal trays are sent with hot plates, sit in the unit for a while and are not distributed to all residents on time. V3 said several times she addressed the concerns about cold food with management before the new administrator started, and it continues to be the problem. The review of the facility staffing schedule showed that over the weekend on 11/02/2024 and 11/03/2024, an average of 45 percent of staff was working from the Agency. The review of resident council meeting minutes from August 2024 to the present showed residents complaining about Agency staff's slow response time for their care. On 11/05/2024, around 10:30 PM, V2(Director of Nursing) said the facility management knew the issue. They placed many agency staff on Do Not Rehire (DNR), and the facility ran out of providers. V2 said the facility has a new Administrator and will work with human resources to place regular staff and provide the right training. The facility policy titled 'Staffing) dated 09/01/2024, in part, stated the facility provides sufficient staff members with the skills and competency necessary to provide care and services for all residents per resident care plans and facility assessments.

Based on the observation, interview, and record review, the facility failed to notify the family, physician, and hospice provider in a timely manner about the change of conditions for a resident. This applies to 1 of 1 resident (R3) who was reviewed for significant change in condition in a sample of 12. Findings include: During the observation on 11/02/2024 at 1:35 PM, R3 was in bed sleeping with noisy breathing, and the meal tray was by his bedside untouched. V15 (Agency- -Certified Nursing Assistant) said he is from the agency and does not know about R3. V15 said that since morning, he has had noisy breathing sounds and hasn't even eaten breakfast. V15 said that V6(Agency Registered Nurse) knows R3's condition. Around 1:45 PM, R6 said they did not feed him to avoid R3 from aspirating on food. When the writer asked R6 whether the family and provider knew about the change in conditions of R3, V6 said she did not get a chance and would notify them soon. On 11/04/2024 at 10:54 AM, V18 (R3's family member) said care and staffing are a big concern in the facility since the new management took over, and around 2:40 PM on 11/02/2024, a nurse from the facility called her to say that R3 was choking, and he will be placed on thin consistency diet. V18 said around 3:36 PM, someone called her and said R3 had passed away. V18 said she is very upset about the way they care for residents. V18 said that it didn't happen right away and asked why they took so long to call her. On 11/04/2024 at 1:45 PM, V19(RN-Hospice) said that the hospice received the call regarding his change in condition around 2:27 PM. Usually, the facility notifies the hospice as soon as the changes are identified so that the hospice can send som to the resident to make him comfortable. R3's Electronic R3'scal Records (EMR) showed R3's diagnoses include paraplegia, congenital hydrocephalus, heart failure, and palliative care. R3's Minimum DatR3'st (MDS) dated [DATE] showed R3 was cognitively moderately impaired and dependent on one to two staff assistants for daily care activities. On 11/04/2024 at 2:30 PM, V2(Director of Nursing) said any change in condition, should be notified to family, physician, and hospice as applicable as soon as a change is identified. On 11/05/2024 at 10:30 AM, V7(Agency- Licensed Practical Nurse) and V8 (Registered Nurse) said any change in resident conditions is notified to the appropriate parties as soon as it occurs. The facility's policy, Change in Condition, revised on 12/18/2023, states that regardless of the resident's current medical and physical conditions, a nurse will inform the resident representative/guardian of any changes in any incident, including medical care or nursing treatment.

Based on observation, interview, and record review, the facility failed to provide nail care for residents' dependent on staff. This applies to 3 of 8 residents (R2, R4, and R8) reviewed for Activities of Daily Living (ADL) care in a sample of 12. The findings include: 1. R2's EMR showed R2's diagnoses include morbid obesity, acute kidney failure, h/o fracture, osteoarthritis, bipolar, anxiety, and mood disorder. R2's Minimum Data Set (MDS) dated [DATE] showed that R2 was cognitively intact and required one to two extensive assists for most of his daily activities. R2 had quarter inch-long right-hand fingers with blackish dirt under the nails and said that only once the staff cut his nails and they don't care. 2. On 11/02/2024 at noon, observed R4 with about an inch-long nails on both hands, with sharp edges and brownish dirt under the nails. R4 said no one cuts her nails. R4's EMR showed R4 had diagnoses including hypertensive heart disease, acute kidney disease, palliative care, dementia, and cerebrovascular disease. R4's MDS dated [DATE] showed R4 is cognitively moderately intact and requires one to two staff assistance for most daily care activities. 3. On 11/02/2024 around 1:00 PM, R8 was minimally interviewable and had an inch long nail with blackish/brownish discoloration under fingernails with right index fingernails broken with a wrapped dirty band-aid. When the writer asked whether it was painful, R3 said yes and wanted the writer to change her dirty band aid. The writer reported to V7(Agency Licensed Practical Nurse). On 11/05/2024, around 10:00 AM, R8 still had the wrapped falling off band aide, and no nail care was provided. R8's EMR showed R8 had diagnoses including chronic respiratory failure, atrial fibrillation, and heart failure. R8's MDS dated [DATE] showed R8's cognitive abilities were severely impaired and required one to two staff assistance for activities of daily living. On 11/05/2024 at 10:00 AM, V7(Agency-Licensed Practical Nurse) and V8 (Registered Nurse) said that usually, Certified Nursing assistants do the nail care. V7 and V8 said the residents' nails should be short to prevent them from getting dirty and reduce the risk of infection. On 11/05/2024 at 10:30 AM, V2(Director of Nursing) said CNAs are responsible for cutting the residents' nails. V2 said nail care was done as needed, typically on shower days. V2 said nails should be cut short to prevent scratching, inadvertently hurting themselves, and could also accumulate dirt under them. The facility's policy, Activities of Daily Living, revised 05/22/2024, in part states that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure food was served at palatable temperatures. This applies to 3 of 5 residents (R5-R7) reviewed for meal service. Finding includes: Observation of the lunch meal on 11/02/2024 between 12:10 PM and 1:15 PM at the 100 halls, where the residents were served meals to rooms. A random temperature check of R5, R6, and R7 trays showed that sweet potatoes and beans delivered to residents were below 100 degrees Fahrenheit. On 11/04/2024 at 1:15 PM, V3 (Food Service Director) said the temperature of the meal tray should not be going below 135 degrees Fahrenheit. V3 said she addressed the concerns about cold food due to staff distributing it on time with management several times before the new administrator started, and it continues to be a problem. On 11/02/2024, between 12:15 PM and 1:00 PM, V5(Cook) recorded the temperature of random residents' meal trays and said that during lunchtime meal trays are sent with hot plates, but they sit on the unit for a while and are not distributed to all the residents quickly enough. On 11/02/2024 at 12:30 PM and 11/04/2024, V13-V14(Agency Certified Nursing Assistants) delivered meal trays at 100 Hall and said they were doing it as fast as they could. 1. R5's EMR showed R5 had diagnoses including fibromyalgia, osteoarthritis, abnormal aortic aneurism, and atrial fibrillation. R5's MDS dated [DATE] showed R5 is cognitively intact. A random meal lunch tray temperature on 11/02/2024 at 1:00 PM showed the temperature of sweet potato at 92 degrees Fahrenheit and beans at 97 degrees Fahrenheit. On 11/04/2024 at 1:30 PM, R5 said food trays were not served in a timely manner, and it was always cold. 2. R6's EMR showed R6 had diagnoses including Type 2 diabetes, kidney diseases, anxiety disorder, and dementia. R6's MDS dated [DATE] showed R6 is cognitively moderately intact. The random meal lunch tray temperature on 11/02/2024 at 12:58 PM showed the temperature of sweet potato at 94 degrees Fahrenheit and beans at 87 degrees Fahrenheit. On 11/02/2024 at noon, R6 said food trays are usually given late, and the food is cold. 3. R7's EMR showed R7 had diagnoses including Parkinson's disease, Type 2 diabetes, osteoarthritis, and agitation. R7's MDS dated [DATE] showed that R7 is cognitively intact and requires one to two assistances for most activities of daily living. The random meal lunch tray on 11/02/2024 at 12:55 PM showed a sweet potato temperature of 94 degrees Fahrenheit and beans at 88 degrees Fahrenheit. On 11/02/2024 at 12:05 PM, R7 said food is usually cold and given late. R7 said they have different staff each time and don't have enough help. On 11/05/2024 at 10:30 AM, V1(Administrator) and V2 (Director of Nursing) said residents are expected to get food at a palatable temperature. The facility policy titled Food Temperature with no date in part showed food will be held at 135 degrees or above before serving to maintain food safety.

Based on observation, interview, and record review the facility failed to implement a fluid restriction for a resident with congestive heart failure (CHF) and failed to do daily weights for residents with CHF. This applies to 3 of 29 residents (R6, R13, and R82) reviewed for quality of care in the sample of 29. The findings include: 1. R6's Face Sheet printed on 10/22/24 showed R6 had a diagnosis of CHF. R6's Order Summary report showed an order for a fluid restriction of 2-2.5 liters per day. The order had a start date of 10/10/24. On 10/22/24 at 10:27 AM, V2 (Director of Nursing) said R6 was on a fluid restriction for CHF. On 10/22/24 at 11:15 AM, R6 said she was not aware if she was on a fluid restriction. On 10/21/24 at 12:18 PM, on R6's bedside table was a large disposable foam cup, two plastic cups, a dietary supplement drink (in its original container), and a container of milk. The large disposable foam cup appeared to be full. One plastic cup was half full. The other plastic cup was three quarters full. The dietary supplement drink appeared full. The container of milk was unopened. On 10/22/24 at 8:45 AM, behind the nurses station was a sign that indicated what residents were on a fluid restriction. The sign did not indicate R6 was on a fluid restriction. On 10/22/24 at 09:43 AM, V4 (Dietary Manager) said if a resident had an order for fluid restriction the nursing staff would notify dietary. The fluid restriction will be placed on the resident's meal ticket. V4 added the kitchen will not send any fluids for a resident on a fluid restriction. V4 said there are fluid stations on each hallway and the nursing staff will be responsible for providing the fluids. On 10/22/24 at 1:02 PM, R6's tray from the kitchen had a cup of juice and coffee on it. The meal ticket on the tray did not indicate R6 was on a fluid restriction. On 10/22/24 at 10:01 AM, V9 (Certified Nursing Assistant - CNA) said she was taking care of R6. V9 said if a resident is on a fluid restriction the nurses will verbally let the CNAs know and it will be on the meal ticket. V9 said R6 was not on a fluid restriction. 2. R82's Face Sheet printed on 10/21/24 showed R82 was diagnosed with heart failure. R82's Order Summary Report printed on 10/21/24 showed an order for daily weights starting on 7/15/24. R82's Medication Administration Record (MAR) for October showed R82 was to be weighed daily. On the MAR there was a, X documented and no numerical number recorded for the weights. R82's Weights and Vitals Summary for 10/1/24 - 10/21/24 had no recorded dates for 10/1/24, 10/2/24, 10/3/24, 10/4/24, 10/7/24, 10/8/14, 10/11/24, 10/12/24, 10/13/24, 10/15/24, 10/17/24, 10/18/24, and 10/19/24 (missing weights for 13 out of 20 days). 3. R13's Face Sheet printed on 10/21/24 showed R13 was diagnosed with CHF. R13's Order Summary Report printed on 10/21/24 showed an order for daily weights starting on 6/3/24. R13's MAR for October and Weights and Vitals Summary for 10/1/24 - 10/21/24 showed missing weights on 10/3/24, 10/5/24, 10/11/24, 10/13/24, and 10/16/24 (missing weights for 5 out of 20 days). On 10/22/24 at 10:27 AM, V2 said for residents with CHF weights are done to monitor for fluid retention. V2 added that weights are recorded on the MAR and Weights and Vitals Summary.

Based on interview and record review, the facility failed to follow their policy to conduct a thorough investigation of a sexual abuse allegation. This failure resulted in immediate jeopardy when V3 (CNA-Certified Nursing Assistant) reported to V1 (Administrator) that she observed R2 exposing his genitals to R1 and attempting to insert his penis into R1's mouth. The facility unsubstantiated sexual abuse without interviewing all possible witnesses. The immediate jeopardy began on September 10, 2024 when the facility failed to thoroughly investigate an allegation of sexual abuse. V1 (Administrator) was notified of the Immediate Jeopardy on September 24, 2024 at 11:44 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on September 25, 2024 at 1:48 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. This failure has the potential to affect all 148 residents residing in the facility. The findings include: The Facility Data Sheet dated September 19, 2024 shows the facility census as 148 residents. On September 18, 2024 at 1:39 PM, and on September 23, 2024 at 2:09 PM, V3 (CNA) said on September 10, 2024 she was walking up and down the corridor, picking up dinner trays. V3 noticed R2 was out of his room. V3 said she approached R1's room and the privacy curtain was closed. V3 said she was surprised by this because the staff never leave R1's privacy curtain closed when they are not in the room because R1 is a high fall risk and requires frequent observation. V3 said she went to pull the privacy curtain back and found R2 standing at R1's bedside with one knee on R1's bed. R2's khaki shorts and belt were down around R2's ankles. V3 could see R2's bare buttocks. V3 continued to say R2 had one hand behind R1's head, and his other hand on his penis, and was trying to put his penis in R1's mouth. V3 said she screamed What are you doing? very loudly and R2 let go of R1 and started to walk back to his room, which was located next to R1's room, with his pants around his ankles. V3 said as R2 shuffled back to his room, his pants remained around his ankles and his belt buckle was clattering on the floor and could be heard as he walked. V3 continued to say she reported the same information to V1 (Administrator) on September 10, 2024. The facility's final report to IDPH (Illinois Department of Public Health) dated September 17, 2024 shows, reported R1 and R2 were in a room. R2 appeared partially undressed. Separated immediately. Abuse cannot be substantiated based on information and facts gathered . On September 19, 2024 at 12:40 PM, V1 (Administrator) said interviews of staff members were done on September 16, 2024, six days after the alleged sexual abuse. V1 said the facility's abuse policy shows interviews with possible witnesses should be conducted as soon as possible. V1 continued to say as soon as possible means the staff should be interviewed right away. V1 also said it did not appear the staff that were present in the facility on September 10, 2024 were interviewed as part of the investigation. V1 said, Interviews with residents and staff were done on September 16, 2024. Maybe we were so overwhelmed about what happened that we didn't interview the people that worked that day. V1 continued to say the allegation of sexual abuse was unsubstantiated based on the facility's investigation. Facility documentation shows V2 (DON-Director of Nursing) obtained statements from V3 (CNA) and V10 (LPN) on September 10, 2024. The statements are typed statements. V3 and V10 did not sign their typed statements. The facility does not have documentation to show any other staff provided statements on September 10, 2024. The staffing schedules for September 10, 2024 were reviewed with V1 (Administrator) and compared to the staff statements obtained on September 16, 2024, for the sexual abuse investigation. None of the staff statements obtained on September 16, 2024 were signed by the staff member being interviewed. The staffing schedules show the following staff were present in the facility on September 10, 2024 between 2:30 PM and 10:30 PM, during the alleged sexual abuse. the facility does not have documentation to show the following staff were asked to provide statements during the abuse investigation, including: CNAs: V15, V16, V17, V18, V19, V20, V21, V22, V23, V23, V25, V26 LPNs (Licensed Practical Nurses): V28, V29 RNs (Registered Nurses): V27, V30, V31 On September 23, 2024 at 2:09 PM, V32 (CNA) said she had worked the day shift on September 10, 2024 from 6:30 AM to 2:30 PM. V32 said she was assigned to the unit where R2 resided, and he had walked down the hall towards her to ask for a cup of ice. V32 said R2 was wearing khaki shorts and a belt. V32 said she did not see R2's shorts falling down at any time during her shift, and R2's shorts were not falling down while he was walking down the hall to ask for a cup of ice. V32 said, as of September 23, 2024, she had not been interviewed regarding R2, including asking what clothes he was wearing that day or if she had seen any type of wardrobe malfunction on September 10, 2024. The EMR (Electronic Medical Record) shows R1 is a [AGE] year old female resident admitted to the facility on [DATE]. R1 has multiple diagnoses including, pelvis fracture, falls, gastrostomy tube, dysphagia, reduced mobility, spinal stenosis, dementia, schizophrenia, generalized anxiety disorder, and fracture of the fifth lumbar vertebra and sacrum. R1's MDS (Minimum Data Set) dated July 30, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, is dependent on facility staff for bed mobility and transfers between surfaces, and requires substantial/maximal assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. The EMR shows R2 is a [AGE] year old male resident, admitted to the facility on [DATE]. R2 has multiple diagnoses including, Parkinson's Disease, dementia with behaviors, anxiety, falls, psychotic disorder with delusions, insomnia, and depression. R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, supervision with oral hygiene, partial/moderate assistance with personal hygiene, bed mobility, and transfers between surfaces, substantial/maximal assistance with toilet hygiene, showers, and lower body dressing, and is occasionally incontinent of bowel and bladder. The facility's Abuse Prevention Program - Policy, effective November 22, 2017 shows: IV. Investigation: As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: All persons who reported the suspicion, allegation or incident, the alleged victim (if the victim is unable to be interviewed, this shall be documented), the alleged perpetrator (if the alleged perpetrator is a resident who cannot be interviewed, this shall be documented), any witnesses or potential witnesses to the alleged occurrence or incident, any staff having contact with the resident during the period of the alleged incidents, roommates, other residents, family or visitors. The facility's Abuse Prevention Program - Toolkit, reviewed 09/05/2024 shows: Investigation Procedures: Regardless of the specific nature of the allegation (physical, sexual, verbal/mental abuse, theft, neglect, unreasonable confinement/involuntary seclusion or exploitation), the investigation shall consist of: Interview of the person(s) reporting the incident, interview of the alleged victim, if interviewable, interview of the alleged perpetrator, interview of the witnesses to the incident, if any, which includes visitors to the facility, interview of staff members having contact with the alleged victim and alleged perpetrator during the period of the alleged incident. Interview Process: Determine if written statements will be taken of the interviewee. If statements are taken, ensure that the statement is factual and not conclusory (i.e., no assumptions, only facts observed or known to the interviewee). Whether handwritten or typed, the statement must be signed and dated. If the interviewee refuses to sign, the interviewer should document that fact on the statement and sign and date the statement themselves. To the extent possible, all interviews should be conducted with another person present for the interview. The facility presented an abatement plan to remove the immediacy on September 24, 2024 at 5:15 PM. The survey team was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented an abatement plan to remove the immediacy on September 25, 2024 at 1:48 PM and the survey team accepted the abatement plan on September 25, 2024 at 2:33 PM. The Immediate Jeopardy that began on September 10, 2024, at approximately 6:00 PM was removed on September 25, 2024 at 1:48 PM when the facility took the following actions to remove the immediacy: V3 was immediately interviewed regarding the allegation. All staff that were on the schedule on September 10, 2024, the day of the allegation were reinterviewed on September 19, 2024. Law Enforcement report was made on September 10, 2024, Case #EGP24-018160 Facility staff assessed all residents in house with possible similar challenging behaviors to ensure that the safety of individuals is met at all times on September 24, 2024. Facility has reviewed the policy and procedure on investigating abuse allegations on September 24, 2024. Facility completed education with V1 (Administrator) regarding investigating abuse allegations on September 24, 2024 by consultant, [NAME] President of Operations. Facility completed education with V2 (DON) regarding investigating abuse allegations on September 24, 2024 consultant, [NAME] President of Operations. Facility completed education with V12 (Director of Clinical Services) regarding investigating abuse allegations on September 24, 2024, with V11 (CNO-Chief Nursing Officer). Facility completed education with clinical staff regarding investigating abuse allegations on September 17, 2024. Facility created an audit tool to measure thorough investigations of all abuse allegations. Facility Administrator and/or designee will monitor all abuse allegations for appropriateness to include ensuring all possible witnesses or potential witnesses to abuse allegations are interviewed. QA (Quality Assurance) plans to monitor facility performance to make sure that the corrective actions are achieved and permanent: Administrator and/or designee will review audits weekly to ensure compliance with the measures put in place to address thorough investigation of all abuse allegations for four weeks. AD HOC QAPI (Quality Assurance Performance Improvement) was initiated on September 18, 2024 to discuss with QA Committee and Medical Director, Plan of Removal and to ensure that all corrective actions and safety measures are consistently implemented. Ad HOC QAPI was completed and implemented on September 24, 2024.

Based on interview and record review, the facility failed to protect a resident's right to be free from sexual abuse by a resident with known sexual behaviors and public displays of affection. This failure resulted in R2, a [AGE] year old male resident exposing his genitals to R1, a [AGE] year old female resident and attempting to insert his penis into R1's mouth. R1 has severe cognitive impairment and is unable to consent to sexual relations. This failure resulted in immediate jeopardy when the facility lacked interventions and processes to protect female residents from a resident with known sexual behaviors. The immediate jeopardy began on August 6, 2024 when R2 was moved from a secure Dementia Unit after allegedly kissing and hugging R3. R2's new room was located directly next to R1. No interventions were put in place to ensure other female residents were protected from R2 after moving R2's room. V1 (Administrator) was notified of the Immediate Jeopardy on September 24, 2024 at 11:44 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on September 25, 2024 at 1:48 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. This applies to 1 of 5 residents (R1) reviewed for resident-to-resident sexual assault in the sample of 5. The findings include: On September 18, 2024 at 1:39 PM, and on September 23, 2024 at 2:09 PM, V3 (CNA-Certified Nursing Assistant) said on September 10, 2024 she was walking up and down the corridor, picking up dinner trays. V3 noticed R2 was out of his room. V3 said she approached R1's room and the privacy curtain was closed. V3 said she was surprised by this because the staff never leave R1's privacy curtain closed when they are not in the room because R1 is a high fall risk and requires frequent observation. V3 said she went to pull the privacy curtain back and found R2 standing at R1's bedside with one knee on R1's bed. R2's khaki shorts and belt were down around R2's ankles. V3 could see R2's bare buttocks. V3 continued to say R2 had one hand behind R1's head, and his other hand on his penis, and was trying to put his penis in R1's mouth. V3 said she screamed What are you doing? very loudly and R2 let go of R1 and started to walk back to his room, which was located next to R1's room, with his pants around his ankles. V3 said as R2 shuffled back to his room, his pants remained around his ankles and his belt buckle was clattering on the floor and could be heard as he walked. V3 continued to say she reported the same information to V1 (Administrator) on September 10, 2024. The local police department's report dated September 10, 2024 shows V3 (CNA) provided the same statement to the responding police officer. The EMR (Electronic Medical Record) shows R1 is a [AGE] year old female resident admitted to the facility on [DATE]. R1 has multiple diagnoses including, pelvis fracture, falls, gastrostomy tube, dysphagia, reduced mobility, spinal stenosis, dementia, schizophrenia, generalized anxiety disorder, and fracture of the fifth lumbar vertebra and sacrum. R1's MDS (Minimum Data Set) dated July 30, 2024 shows R1 has severe cognitive impairment, requires setup assistance with eating, is dependent on facility staff for bed mobility and transfers between surfaces, and requires substantial/maximal assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. On September 19, 2024 at 8:41 AM, R1 was sitting at the nurse's station playing a card game with staff and was not able to be interviewed at that time due to the lack of privacy. On September 19, 2024 at 11:30 AM, R1 was sitting at the nurse's station in a wheelchair, sleeping. On September 19, 2024 at 1:38 PM, R1 was lying in bed in her room. R1 was not able to answer questions regarding the incident due to her cognitive status. On September 23, 2024 at 10:21 AM, V8 (Physician) said, [R1] has very advanced dementia. She cannot consent to sex. You cannot even hold a meaningful conversation with her. The EMR shows R2 is a [AGE] year old male resident, admitted to the facility on [DATE]. R2 has multiple diagnoses including, Parkinson's Disease, dementia with behaviors, anxiety, falls, psychotic disorder with delusions, insomnia, and depression. R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, supervision with oral hygiene, partial/moderate assistance with personal hygiene, bed mobility, and transfers between surfaces, substantial/maximal assistance with toilet hygiene, showers, and lower body dressing, and is occasionally incontinent of bowel and bladder. R2's care plan initiated May 9, 2024 shows, [R2] exhibits inappropriate or overly friendly behavioral symptoms including touching staff members and himself while receiving care and making unwanted contact (hugging) and gestures (blowing kisses towards others. He has also entered the rooms of other residents. He lacks insight, reasoning and judgement related to his medical needs. He responds to staff redirection. Multiple interventions initiated May 9, 2024 include, Communicate assertively that resident exercise control over impulses and behavior, intervene and re-direct when any inappropriate behavior is observed, refer for psychiatric evaluation and utilize psychoactive medications as warranted, remind resident to refrain from hostile remarks and inappropriate touching. The facility does not have documentation to show new interventions were initiated until September 17, 2024. On September 19, 2024 at 8:45 AM, R2 was sitting in his room. V4 (RN-Registered Nurse) was present in the room and a one-to-one sitter was sitting at a table outside of R2's room. V4 said R2 is able to walk without assistance or an assistive device. V4 continued to say a one-to-one sitter was present because R2 kept going in and out of other resident's rooms, and because R2 had inappropriate sexual behaviors. V4 left the room and the interview with R2 continued. R2 said he has had Parkinson's disease since 2011. R2 did not have a noticeable tremor when doing purposeful movements during the interview, including reaching for cups of water and juice on his bedside table, drinking, or when walking in his room. R2 did have a quiet vocal tone, and occasionally stuttered. R2 said he was hospitalized in June 2023 at a psychiatric hospital for mental problems. R2 continued to say one of the medications he takes causes excessive behaviors such as gambling, sexual feelings, and the need to masturbate. R2 spelled out the name of the medication as pramipexole. R2 said he frequently has hallucinations. R2 continued to say on September 10, 2024, he was in his room and his room was feeling, Too tiny, too closed in. That bothers me and makes me anxious. I know I am supposed to just suck it up, but sometimes I cannot. I went in [R1's] room and she was lying in bed. I sat on the end of her bed, right next to the board on the end of the bed (resident motions to footboard on his own bed). [R1] was intensely screaming and I wanted to help her. I thought maybe we could chit chat. She asked me if I was the cook, so I knew she didn't have it all upstairs, if you know what I mean. R2 continued to say his pants were falling down due to being uneven because his sister had not sewn his pants correctly. R2 said his pants were falling off and his penis was exposed. The EMR shows multiple documentations regarding R2 including: May 9, 2024 at 4:14 PM, [R2] received a scheduled shower after lunch. CNA reported inappropriate behavior that happened during assisting resident. CNA reported resident touched her lower back. CNA turned and asked him to remove his hand. Resident removed his hand. Resident turned and touched his front perineal area along with masturbation. May 17, 2024 at 1:30 PM, [R2] was observed taking pictures of residents in shared areas and was told to refrain from doing so in the future. The facility's final report to IDPH (Illinois Department of Public Health), received on August 10, 2024 shows on August 5, 2024, [R3] reported that a male resident (R2) made her feel uncomfortable by giving her a hug and a kiss on the cheek because she is married. On August 6, 2024 at 8:42 AM, V13 (NP) documented, [AGE] year old male at [facility] being seen today for hypersexual behaviors. Patient attempting to kiss other residents. He stated he has his reasons why he was doing so. He would not disclose to me. On August 6, 2024 at 5:20 PM, V7 (SSC-Social Service Coordinator) documented, Writer met with [R2] on nursing unit to discuss room change. Writer explained to patient that he is more appropriately placed on a different nursing unit as he does not directly benefit from the style of dementia-focused activities . He strongly feels that his (self-described) inappropriate behavior on Monday evening is the result of a change to his [pramipexole] dosage. Discussed with guardian and per her request, patient's sister (V33). [V33] recounted patient's history of hypersexual behaviors and expressed understanding as to why relocation may be beneficial for resident. Guardian is also agreeable to room change. Patient ultimately consent to the room change and nursing staff began assisting with relocation to [room close to R1]. On September 16, 2024, V2 (DON) documented a late entry effective September 10, 2024 at 5:15 PM. V2 documented, Received report that resident was observed in another resident's room and appeared partially exposed. On September 11, 2024 at 6:40 AM, V8 (Physician) documented, I was paged by the DON that yesterday [R2] had an episode of hypersexual behaviors. It was reported that yesterday he was found by the CNA in a female resident's room and partially undressed exposing his genitalia to her. The other resident did not come in contact with him, she was sitting on the edge of her bed, according to social services report. In regard to witness's report that patient was partially unclothed, patient notes that he was wearing a pair of shorts which are uneven and have a tendency to sag down but denies any other activities taking place.Patient was seen and examined today. When asked about the incident patient states he was probably behaving inappropriately due to his Parkinson's medications. Patient denies any hypersexual behavior in the past. He ambulates around the facility without an assistive device. A&P (Assessment and Plan): Hypersexual behaviors - discussed in detail with the DON, social services, CNA, and the patient. Refer to psychiatry for psychosis. Refer to neurology for possible change in Parkinson's medications due to possible side effect of hypersexual behaviors, 1-to-1 babysitter advised until further notice. Patient's room changed - advised no shared rooms with other residents. The facility's final report to IDPH (Illinois Department of Public Health) dated September 17, 2024 shows, reported R1 and R2 were in a room. R2 appeared partially undressed. Separated immediately. Abuse cannot be substantiated based on information and facts gathered . On September 19, 2024 at 10:39 AM, V2 (DON-Director of Nursing) said, [V10] (LPN-Licensed Practical Nurse) reported that [R2] was in [R1's] room, which were next to each other. [V3] (CNA) had cared for [R2] all day. They observed [R2] at the bedside of [R1] and [R2's] pants were sagging down. [V3] reported [R2] had his hand on his penis, and his other hand was behind [R1's] head. [R2's] room was moved on August 6, 2024. He was in the Dementia Unit, so he was moved to separate him from [R3]. It was reported he attempted to hug and kiss [R3]. We had psych see him and we made some changes to his pramipexole medication. We were hoping the medication adjustment would help. V2 could not say what other interventions were put in place to protect female residents from R2 after he was moved from the Dementia Unit on August 6, 2024. On September 23, 2024 at 2:09 PM, V32 (CNA) said she had worked the day shift on September 10, 2024 from 6:30 AM to 2:30 PM. V32 said she was assigned to the unit where R2 resided, and he had walked down the hall towards her to ask for a cup of ice. V32 said R2 was wearing khaki pants and a belt. V32 said she did not see R2's pants falling down at any time during her shift, and R2's pants were not falling down while he was walking down the hall to ask for a cup of ice. On September 19, 2024 at 3:42 PM, V9 (Psych NP-Nurse Practitioner) said, I see [R2] at least once a month. The nurses called me at home, and it seemed like his sexual behaviors escalated so I put him on Paxil to lower his libido. We are giving him the medication to make him not want to have sex as much and for his anxiety and his mood. I am not sure he is a good candidate to be in that facility. I don't think he was a good candidate to be in a room near a cognitively impaired female resident who cannot give consent. On September 23, 2024 at 11:30 AM, V7 (SSC) said, During a meeting with [V33] (Sister of R2) on August 6, 2024, [V33] said [R2] has a history of misinterpreting signs from women as being flirtatious or inviting. He made inappropriate gestures to women, and this extended to family members. [R2] made sexual comments to his sister-in-law. It was known that hypersexuality was part of his situation. He was referred to psych after the sister said that, and the staff were made aware of the potential behaviors and to be aware. The facility does not have documentation to show interventions were put in place regarding R2's sexual behaviors after the kissing/hugging allegation on August 6, 2024 or with R2's room change to a new unit to protect female residents. The facility's Abuse Prevention Program - Policy, effective November 22, 2017 shows, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms.Definitions: Sexual abuse is non-consensual sexual contact of any type with a resident. The facility presented an abatement plan to remove the immediacy on September 24, 2024 at 5:15 PM. The survey team was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented an abatement plan to remove the immediacy on September 25, 2024 at 1:48 PM and the survey team accepted the abatement plan on September 25, 2024 at 2:33 PM. The Immediate Jeopardy that began on September 10, 2024, at approximately 6:00 PM was removed on September 25, 2024 at 1:48 PM when the facility took the following actions to remove the immediacy: Social Service Director conducted an audit of all residents with hypersexual behaviors on September 24, 2024. No other male resident was identified during the audit. All female residents were assessed for potential sexual abuse by Social Service Director on September 24, 2024. Care plan review was initiated and completed by September 24, 2024. Policy was developed by Regional Social Service Consultant to address hypersexual behaviors that are not easily redirectable. Facility initiated in-services on facility's abuse program and policies to all shifts immediately after the incident and is on-going. All agency staff will receive the same training before the start of the shift. All staff who are not available at this time due to vacation or leave of absence will also receive with the same training prior to start of shift upon return to work. In-services were provided and are being provided by Administrator, DON, and or Social Service and clinical supervisor. Facility Administrator and Social Service developed a process to ensure facility staff caring for a resident with the potential for abusing other residents are educated on specific interventions to prevent abuse and protect all residents. Facility Administrator, DON and Social Service provided in-services on all shifts on the following topics: Facility interventions and processes to ensure every effort will be taken to protect female residents from a resident with known sexual behavior. All direct patient care staff were educated specifically on interventions for R2 to prevent abuse and protect all residents. Management of Sexual Behavior policy. Quality Assurance (QA) plans to monitor facility performance to make sure that the corrective actions are achieved and permanent: Administrator developed and utilized a QA tool to ensure that specific interventions for R2 are implemented by direct patient care staff as noted. This audit will be conducted twice weekly for four weeks. All residents that are high risk for sexual abuse will be observed twice weekly to ensure that they are free from abuse and remains safe while residing in the facility. Administrator will randomly select five residents twice weekly and observations to be completed for four weeks. ADHOC QAPI (Quality Assurance Performance Improvement) was initiated on September 18, 2024, and completed on September 24, 2024 to discuss with QA Committee and Medical Director, Plan of Removal and ensure that all corrective actions and safety measures are consistently implemented.

Based on record review and interview, the facility failed to ensure two staff assisted a dependent resident while providing incontinent care. This failure resulted in R2 falling from the bed to the floor, sustaining a left eye laceration along her hairline. This applies to 1 of 4 residents (R2) reviewed for falls and accidents in a sample of 9. Findings include: V3's (Registered Nurse) witness statement dated 06/23/2024 showed R2 falling on the floor while V4 (Certified Nursing Assistant) was providing incontinent care. R1's Minimum Data Set, dated dated dated [DATE] showed R2 was dependent on most of the activities of daily living, including toileting, hygiene, and rolling left to right, and required two or more assistance to provide incontinent care. The hospital emergency physician progress notes on 06/23/2024 showed R2 fell out of bed with multiple lacerations to the head; CT (Computed Tomography) of the head revealed subdural hematoma, and R2 was admitted for further management to ICU (Intensive Care Unit) V4's incident witness statement dated 06/23/2024 showed he was changing R2 and rolling her to her side. V4 thought R2 attempted to grab the tray or table for stability, which slid away, and R2 lost her balance and fell . A review of the post-fall huddle worksheet showed one Certified Nursing Assistant (V4) was changing R2, and R2 was on her side and left the left side of her bed; the resident appeared to have hit her head on the table and had two lacerations, one on the hair line and other one was on the left eyebrow. On 07/10/2024 at 11:05 AM, V4 (Certified Nursing Assistant) said that on the day of the incident, R2 was soiled, and everyone was busy. V4 said she thought she could help R2 by herself; however, dependent residents need two staff members' assistance, and if she had taken the help of another staff member, she could have probably prevented the fall. On 07/09/2024 at 3:00 PM, V12 (Physical Therapist) said dependent residents should always have at least two staff members assist with bed mobility and incontinent care to prevent falls and injuries. On 07/09/2024 at 12/12/2023 at 11:22 AM, R2 was in bed and was not interviewable. A review of the face sheet showed that R1 was a [AGE] year-old initially admitted on [DATE] with diagnoses including polyarthritis, fall, long-term use of blood thinner, contusion (discoloration) of the left upper arm, heart diseases with a pacemaker, type 2 diabetes, and chronic kidney disease. On 07/09/2024 between 2:38 PM and 3:00 PM, V5 and V6 (Registered Nurses) and V11 (Certified Nursing Assistant) said dependent or bedbound residents' care should be provided with two assists. V11 said R2 always required two assists for incontinent care and mobility. V11 said when he came to work on the morning of the R2's incident and transferred to the hospital, some staff told him that R2 had a fall while changing with one assist while R2 was holding the bedside table, which slid, and R2 lost her balance and rolled down to floor from the bed. On 07/09/2024 at 2:00 PM, V1 (Administrator) said she thought R2 was with one assist for incontinent care and bed mobility but realized R2 was with two assists after reviewing R2's MDS (Minimum Data Set) documents. She said a dependent resident should have two assistants for activities of daily living care to prevent accidents. V1 said the facility follows universal fall prevention precautions. V1 said R2's fall incidents with injuries were reported to IDPH. A review of the facility's fall prevention and management policy, dated October 2021, showed, in part, that all residents and patients considered at risk for falling regardless of fall risk score. Universal fall precaution (Facility protocol) interventions will be implemented to all. High-risk residents for falls will receive individualized intervention as appropriate to risk factors.

Based on observation, interview, and record review the facility failed to monitor a resident's weight, assess the resident's nutritional status, and assist the resident with eating to prevent significant weight loss. This failure resulted in R1 experiencing a weight loss of 11.5% in one month. This applies to 1 out of 3 residents (R11) reviewed for nutrition. The finding includes: R11's EMR (Electronic Medical Record) showed an admitted [DATE] with multiple diagnoses including metabolic encephalopathy, facial weakness, pneumonia, acute kidney failure, dysphagia, vitamin B12 deficiency anemia, assistance with personal care, pressure ulcer, delirium, dementia, and depression. R11's MDS (Minimum Data Set) dated 5/15/2024 showed R11 was cognitively impaired and required moderate assistance with eating. On 6/12/2024 at 12:34 PM, R11 was in bed sleeping, he appeared thin with dry skin. Then at 1:40 PM R11 was awake and said he was hungry. R11 started to fidget and lean on his right side trying to reach for a cup of water on his bedside table. V27 (Registered Nurse/RN) was alerted and came to assess R11. R11 yelled, I need food, I did not eat. Then V28 (Certified Nurse Assistant/CNA) said R11 had refused breakfast and lunch, and he had been pocketing and spitting his food earlier in the week. Then at 1:50 PM V28 brought R11 two cups of nutritional supplement drinks and proceeded to assist R11. R11 was shaky and sipped one entire cup and did not want to let go of the cup; then V28 continued to assist R11 with the second cup. V27 (RN) said R11 appeared hungry, and staff should have gotten R11 something else if he had refused his meal. On 6/13/2024 at 9:08 AM, V28 (CNA) said she was familiar with R11 and for approximately a week he had been taking a few bites and then spitting them out and his oral intake would vary every meal. V28 said she had been offering R11 different foods and giving nutritional supplement drinks. R11's nutrition care plan was reviewed on 6/12/2024 and showed R11 was overweight. The care plan was updated on 4/29/2024 and showed Current weight shows 3 lb increase in 1 month. The care plan included an intervention to assist at meals as needed/tolerated and obtain weights on [R11], as per orders and monitor per protocol. Notify of any sign weight changes. R11's rehospitalization discharge documents dated 4/29/2024 showed R11 should have received a high calorie and high protein diet, be offered 2 liters of water orally daily, and continue with an oral nutritional frozen supplement dessert twice daily. R11's Medication Review Report dated 6/12/2024 showed a diet order for general diet mechanical soft texture with regular thin consistency and liquid protein for wound healing. The report did not show R11's discharge hospitalization dietary recommendations or weight monitoring orders. R11's EMR showed the following weights: 2/18/2024-202.8 lbs. (Pounds) at the hospital 3/15/2024-203 lbs. at admission 3/16/2024-203 lbs. 4/03/2024-204.5 lbs. 4/24/2024-165.2 lbs. at the hospital 4/29/2024-205.6 lbs. at readmission 4/30/2024-206 lbs. 5/14/2024-167.8 lbs. 6/12/2024-148.4 lbs. On 6/12/2024 at 2:48 PM, V2 (Director of Nursing/DON) said resident weights are monitored weekly for four weeks during admissions and readmissions and then monthly or as ordered. V2 said weight discrepancies should be assessed and residents should be reweighed. V2 said identified weight loss should be referred to the dietician for evaluation. V2 said residents who need assistance with feeding should be fed to meet their nutritional needs. On 6/13/2024 at 10:06 AM, V19 (Registered Dietician Consultant) said R11's readmission nutritional assessment was done based on his weight on 4/30/2024. V19 said she was not notified of R11's identified significant weight loss on 5/14/2024. V19 said R11's medical condition had changed from his admission, and she had reassessed his nutritional needs. V19 said R11 was now started on a high-calorie drink of 120 ml (milliliters) three times a day, gelato frozen supplement dessert with lunch, and pudding with dinner for additional calories. V19 continued to say part of R11's significant weight loss could have been avoided if his weight had been monitored and communicated correctly. On 6/14/2024 at 11:42 AM, V31 (Physician) said she was notified on 6/12/2024 of R11's weights and believed R11's weight from 3/15/2024 was a discrepancy. V31 continued to say R11's significant weight loss from 5/14/2024 to present could have been intervened if caught earlier. V31 said she expected the facility to follow its weight policy protocol to assess residents' nutrition. The facility's policy titled Weight with the reviewed date of 7/14/2023 showed General: To establish a policy for the consistent, timely monitoring and reporting of resident weights Guideline: 1. All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly. 2. Weekly weights will also be done with a significant change of condition, food intake decline that has persisted for more than one week, or with a physician order .4. The DON or designee to determine a list of reweighs will review all weights upon completion. 5. Once the reweighs have occurred any resident with an unexplained significant or insidious weight loss will have a weight loss investigation . The facility's policy titled Medication Pass Supplementation Program with the reviewed date of 10/30/2023 showed Guideline: 1. Based on the nutritional assessment the Registered Dietician, Health Care Provider or staff nurse may recommend a calorie dense supplement at med pass. 2. The nurse .will ask for an order. The order will include the amount and frequency of the supplement .

Based on observation, interview and record review, the facility consistently failed to provide palatable, appetizing meals to residents. This failure resulted in weight loss for R3 and R20 due to insufficient calories, prolonged feelings of sadness, anger, frustration, and low self-worth for R1, R2, R4, R13, and R18, and financial hardship to the residents and families of R1, R3, R13, and R21 who bought food to supplement their food intake. This applies to 12 of 12 residents (R1-R4, R6, R9, R13, R14-R15, R18, R20 and R21) reviewed for food palatability a sample of 22. The findings include: 1. Face sheet, dated 6/5/24, shows R3's diagnoses included end stage renal disease, dependence on renal dialysis, type 1 diabetes, deficiency of Vitamin K, and depression. POS (Physician Order Sheet), dated 6/5/24, shows R3's diet order included carbohydrate controlled, renal, low concentrated sweets, low potassium. MDS (Minimum Data Set), dated 3/25/24, shows R3 was cognitively intact. Nutrition progress note, dated 1/22/24, shows R3's weight after dialysis was 174 pounds and R3's appetite varies but is usually good. The note shows R3's weight appeared to be stabilizing after previous weight loss due to fluid being removed in the hospital. Nutrition progress note, dated 4/27/24 shows R3 experienced a significant weight loss of 19.3 pounds in three months. The note shows R3's appetite varies but is usually good. Nutrition progress note, dated 5/29/24, shows R3's post dialysis weight was 153 pounds. The progress note shows R3 had a weight decrease of 9.1 pounds in three months. The note shows R3's appetite varies but is usually good. On 6/4/24 at 8:35 AM, R3's breakfast ticket showed she was to be served cold cereal, 2 eggs over easy, fresh fruit as available, apple juice, 2 hard boiled eggs, 1 slice of toast, 2 slices of bacon, and milk of choice. R3's tray ticket notes showed, No scrambled eggs and R3 received scrambled eggs, 1 sausage link, cereal, 4 ounces of apple juice and 8 ounces of milk. R4 stated her toast was burnt on both sides but soggy on one side. R3's toast was very dark brown. R3 took a bite and stated the toast was chewy. On 6/3/24 at 12:55 PM during lunch service, R3 complained she received a deli sandwich with 2 slices of thin deli meat and no cheese on 2 slices of bread for lunch. On 6/5/24 at 10:33 AM, R3 stated I write on my menu, turn it in, and they give me what they want! This has gone on two years! It makes me feel like they don't care! Pepper hurts my tongue and it makes me made I take the time to fill out the menu and they ignore me! Then they send foods that hurt my tongue! R3 stated she orders food from outside when she can afford to do so approximately twice a month. R3 stated It's a financial hardship because I can't buy shoes or clothes or mouthwash! I get the smaller sizes because I can't afford the economy sizes when I spend money on ordering food! I also buy snacks with my money. I use my social security - that's all I get! So I order twice a month and get stuck with what they give me other meals. I lost weight because I can't stand it! It's nasty! We would rather have something else. And when they send sandwiches, it is no meat and all bread! You're eating a bread sandwich! On 6/5/24 at 12:37 PM, V14 (Dietitian) stated R3 weighed 172 pounds in January 2024 and R3 lost 18 pounds in 5 months. V14 stated R3 received dialysis and some weight fluctuation could be fluid but not eating enough at meals could contribute to R3's weight loss. V14 stated R3 was not on a planned weight loss program and R3's weights were trending down since December 2023. V14 stated R3 orders food from outside the facility because she does not like the food the facility served. V14 stated R3 did not want to remain on a renal diet because R3 was requesting more food choices. V14 stated R3's appetite may be good, but did not mean she was eating what was served from the facility. 2. Face sheet, dated 6/5/24, shows R20's diagnoses included low back pain, hypertension, personality disorder, mild cognitive impairment, delusional disorders, and nonspecific abnormal finding of lung field. The MDS Assessment, dated 3/27/24, shows R20's cognitive status was moderately impaired. Dietitian note, dated 1/30/24, shows R20 weighed 129 pounds and experienced unintended weight loss R/T (related to) inadequate energy intake AEB (as evidenced by) weight loss and documented intake of 26-100%. The note shows R20 had a significant weight lost of 16.2 pounds in six months, her appetite varied and R20 was being provided a high calorie drink, yogurt at breakfast, and ice cream at lunch and dinner to supplement her intake. Monthly weight report, dated 1/2024 to 6/2024, shows R20's weight was 123.6 May 2024 representing further weight loss of 5.4 pounds. POS, dated 6/5/24, shows R20 received a no added salt diet and received a high calorie drink 120 milliliters twice a day since 9/14/23. On 6/5/24 at 1:40 PM, R20 stated I was surprised I lost so much weight! I'm not eating! R20 stated she loved milk but never receives it on her meal trays. R20 stated once in a while she gets fruit juice, but mainly only receives the unsweetened lemon drink. R20 stated she is provided yogurt at breakfast and ice cream lunch/dinner for calories but is not fond of yogurt and can only eat ice cream once in a while. R20 stated she is able to eat the breakfast most days at the facility but often can not eat the lunches or dinner because the food has no seasoning or taste. R20 stated the facility used to provide seasoning packets that she loved and would put on the food to be able to eat the food but they stopped providing them on her meal trays. R20 stated she did not eat lunch that day because it had no flavor. On 6/5/24 at 12:37 PM, V14 (Dietitian) R20's weight loss was due to a lack of calories and was not on a planned weight loss program. V14 stated she had not spoken to R20 about her weight loss and was unsure if she was eating the meals at the facility or taking the supplemental nutritional items she was given. V14 stated she added the high calorie supplement, yogurt at breakfast, and ice cream at lunch and dinner to provide more calories because R20 was losing weight. V14 stated she writes that R20's appetite varied, but meant her intake varied. V14 stated R20 was not mentioned in weight meetings for not eating. 2. On 6/4/24 at 7:48 AM with R13, R4 (Resident Council [NAME] President) stated she lived at the facility [AGE] years and the food has never been as bad as it was currently. R4 stated the dinners were the worst meal at the facility. R4 and R13 provided a copy of the facility menu of the week, dated 6/2/24 to 6/8/24, and R4 stated, If you look at the menu you get you would say, 'WOW! They are eating well!' But it doesn't come that way! R4 stated the hot food served at the facility was ice cold by the time she received it. R4 stated the sandwich she received a couple nights prior only had one paper thin slice of turkey, no cheese, and no mayonnaise or mustard. R4 constantly has a cheeseburger or grilled cheese substitute for meals because of the poor food quality of food served. R4 stated the dinners were the worst meal at the facility. R4 stated the bread is served tasting stale and the staff respond that the bread is toasted when she complains. R4 stated the facility had not had a working toaster for months and was not sure what the facility was doing to the bread, but she typically had to take the crusts off because they were so hard. R4 stated the facility used to serve a nicer meal on Sundays lunch. R4 stated the prior Sunday, the facility served a hot dog and onion rings with no catchup or other condiments. They were served a small amount of potato salad and small piece of cake. R4 stated the residents preferred to eat in the main dining room because the food was served right from the kitchen to their tables and food is served hotter, but they are no longer able to eat in the dining room and they put the residents in the small dining room away from the kitchen R4 stated her son comes to visit and brings food for R4. On 6/4/24 at 8:18 AM, R4's breakfast tray was served and R4 agreed to allow her tray to be used as a test tray. The eggs tasted grainy and luke warm, the sausage tasted luke warm, and the bacon was dark reddish-brown and looked well cooked but was limp when picked up and left a puddle of grease on the plate. The toast was served in a plastic baggie, appeared brown, and tasted very chewy. R4's tray ticket showed she was to be served orange juice, cold cereal, low-fat milk, 2 fried eggs over easy, a juice of choice, hot or cold cereal, toast, 2 slices of bacon, milk of choice and coffee/tea. R4 was served scrambled eggs, one sausage link, one slice of bacon, toast in a baggie, unsweetened lemon beverage, and skim milk. R4 stated she does not like skim milk and prefers 2% milk. R4 received no butter for her toast and R4 stated the residents had not been served butter in a long time. R4 stated she complained in a resident meeting they were not receiving butter and the food service manager responded, If I give it to you, I can't give you something else. R4 stated the residents are consistently served the unsweetened lemon beverages and not real fruit juice. R4 stated, They give this watered-down sugar free lemon crap! If I get real juice I am thrilled to death! R4 stated last week the resident council meeting was canceled because R2 (Resident Council President) came to the meeting a stated, 'I'm going to cancel the meeting because it does no good! Every month the write it down on the paper and nothing is done!' I agreed with him and told the staff I wouldn't do the meeting either! R4 stated she fully supported R2's frustration with the facility not responding to any of the ongoing resident concerns such as food palatability. R4 stated the residents complained but none of the staff were listening. On 6/5/24 at 8:59 AM, R4 received a replacement tray and this time received 2 eggs over easy, 2 sausage, orange juice, cereal and toast. On 6/5/24 at 9:33 AM, R4 stated she lives on food brought from outside by her sons and friends because of the poor food quality and the menus not served properly. R4 stated she has food brought in at least 4 times a week which she pays for. R4 stated she also pays for friends to bring in snacks to eat so she had food when she could not eat the facility food. R4 stated she spends no less than $40 to $50 a week on food to supplement the facility meals. R4 stated she was very upset the facility food quality declined drastically in the last year and stated, What am I, chopped liver!? Everything they have taken away like the food and not resolved! I feel like they don't care about us as human beings. We are just a number. It's not human! R4 stated at resident council some residents say the food is all they have to look forward to every day. R4 stated, It makes me worry about how people in the facility are struggling. That's all they have! That's scary! And we don't ever get a choice about the food! Take it or leave it! If you don't eat your meal, they just pick it up because the staff know there are no options! R4 stated since IDPH (Illinois Department of Public Health) has been in the building watching food service on 6/3/24 and 6/4/24, she began receiving fried eggs, juice and milk as instructed on her tray tickets. R4 stated, In the last 2 months I have received juice only 4 to 5 times! How do you think it makes us feel that they can serve us juice all of a sudden when the state is here!? 3. On 6/5/24 at 9:32 AM, R18 stated she has complained about the food quality and menus for two years. R18 stated It's hard and I am sick and tired of not being able to eat! My sister brings food once a week. There is nothing to eat and it makes me sick! I cry once a day because it's so bad and not enough food! R18 stated she was angry, sad, frustrated daily for months regarding the food served at the facility. 4. On 6/5/24 at 8:20 AM, R13's tray ticket showed she was to be served juice of choice, hot or cold cereal, 2 hard boiled eggs, a donut, 2 slices of bacon, milk of choice and coffee or hot tea. R13 received only unsweetened lemonade beverage, hot cereal, 2 hard boiled eggs, and 1 slice of bacon on her breakfast tray. R13 stated her eggs felt and tasted cold. R13 stated I love milk! But they don't give it to me often. No waffles were served. R4 stated, They give this watered-down sugar free lemon crap! If I get real juice I am thrilled to death! On 6/5/24 at 9:33 AM, R13 stated I have to fight to get a proper meal and it makes me sad all day! Breakfast is important to me. Emotionally it just brings me down the whole day if breakfast is bad or not right. It happens here at least three days a week since December when I came! I get pissed off! Food is important to me! I am Italian! I get angry about the food. When it comes to the food, I don't feel taken care of since I have been here. R13 stated her day was ruined at lest 3-4 times a week because her breakfast is bad or not served correctly. R13 stated, If you have a decent breakfast, you can go on with your day - you have the energy and mindset and you feel satisfied and you can do well with your day! R13 stated she has friends/family bring in food from outside to supplement the meals at the facility. R13 pulled a chicken and tuna salad meal packages out of her dresser drawer. R13 stated she has to eat them 2-3 times a week because she can not eat the food served. 5. On 6/5/24 at 10:16 AM R21 stated she did not like the taste of most foods at the facility and made attempts to adjust her menus to avoid the unpalatable foods. R21 stated, I used to indicate what I didn't like to eat on the menus and turn them in but I would still get the foods. It makes me mad they don't listen! This has gone on for 6-8 months! It causes me to be frustrated they keep giving me foods I don't eat! I don't like to cause trouble but I gotta eat! I only get $60 each month and it doesn't go very far. If I want to be happy and have something to eat, I have to use all of the $60! I don't feel I should have to pay for food when I give every cent to this place to stay here and already pay for the food served! I should be able to do something else with my $60 other than pay for food I am already paying for! I get anxiety about what they are going to send every day at every meal. I wait to see if they are going to give something I hate! Then they will serve the same thing every day for a week! They make out a menu and don't stick to it! I circle what I want, send it back, and then they send whatever they want! They run out of food on the weekends. I ask CNAs (Certified Nursing Assistants) for something and they tell me food service is out of it when they call. It makes me angry and upset! This has gone on every day for at least 6-7 months but probably longer. They only give us a lemon drink at meals - I can't remember the last time I had real juice at breakfast! I like orange juice! .They just serve bug-juice! Koolaid! 6. On 6/3/24 during initial tour of the facility, R1 stated when he asks for a deli sandwich, he receives two pieces of bread and one thin slice of deli meat and one slice of cheese. R1 stated sometimes he is served only potato chips and a dessert with the deli sandwich as his meal. R1 stated he received a hot dog and did not think the temperature reached 100 degrees Fahrenheit and tasted cold and uncooked. R1 stated , over and over again. They don't own the problem. R1 stated the staff only respond to residents with what they think residents want to hear and do not solve the problem. On 6/5/24 at 9:20 AM, R1 stated his sister brings in submarine sandwiches for a standby meal when he is unable to eat the food the facility serves. R1 stated he has been extremely disappointed because he and the residents complain at food and resident meetings and there is nothing done about their concerns. R1 stated he attended the food meetings and the facility tells you what they want you to hear and you feel let down! R1 stated, When the staff in the kitchen don't pick up the phone when you try to ask for a substitution, it doesn't make you feel good! My sister pays for the sandwiches because she wants me to have something to eat. I eat one of the sandwiches three to four times a week. I would like to have a decent meal! I don't expect a five star restaurant food but would like something I enjoy eating! It doesn't make me feel good at all and it has been going on for months! 7. On 6/3/24 at 2:00 PM, R2 stated he was the Resident Council President and he canceled the resident council meeting the week prior because he did not want to participate in another meeting listening to the same complaints from residents and the facility promising to address the problems and then doing nothing. R2 stated issues regarding the poor food quality, hot foods being served cold, food palatability, and other food issues came up frequently at resident council meetings and the facility decided to have a separate food council to discuss the concerns. R2 stated he was tired of discussing the concerns and describing the problems to administration and none of the issues being resolved by administration. R2 stated, They cut and cut and cut. They don't maintain the gardens on the patio, the food is terrible. Same s*** all of the time! We are on the fourth dietary manager! R2 stated he was tired of hearing ongoing concerns about the food with no resolutions from the facility. R2 stated he gave up arguing with the facility about the kitchen because he was tired of the B.S. R2 stated when residents open up their meal trays, the food is not appetizing. R2 stated on 6/3/24 they received breaded fish and it looked horrible. R2 stated the toaster was broken for months and residents have complained with no resolution. R2 stated he was supposed to receive toast that morning for breakfast but received plain bread instead. On 6/5/24 at 9:10 AM, R2 stated he complained to the facility about the food quality for two years since the new company took over at the facility. R2 stated, It makes me feel bad. It makes me feel horrible inside. We feel like second class citizens since the new food service took over! Resident council meeting minutes, dated 5/29/24, show the meeting was canceled by R2. Food Focus Group minutes, dated 3/20/24, show residents complained hot foods were served cold to residents and the presentation of the meals should be improved. Food Focus Group minutes, dated 4/3/24, show residents complained hot food was served cold to residents. Food Focus Group minutes, dated 5/8/24, show residents complained fruit juices served were watery and weak, food presentation was poor, an alternative menu was promised but was not available,, too many hot dogs were served on the menu, and the pizza was served cold. 7. On 6/3/24 during initial tour of the facility, R6 stated the toaster was broken for at least three months and it seemed like staff were putting bread in the microwave to toast it. R6 stated she once received a sausage patty served on two slices of bread when she was supposed to receive a hamburger. R6 stated when she does receive a hamburger there is usually no onion, lettuce, tomato or other condiments. R6 showed a picture of a meal from her phone which showed a hamburger on a bun with a scoop of mashed potatoes on the place. The picture showed a mustard packet, a yellow beverage and a piece of unfrosted cake in a plastic baggie. R6 showed a picture of her tray ticket for that meal which showed, No substitute found for deli sandwich with cheese on a bun, lettuce, tomato, onion, macaroni salad, no substitute for carrot cake, choice of milk, unsweetened beverage of choice. R6's tray failed to include macaroni salad, lettuce, tomato, onion, ketchup and milk. R6 stated the waffles the facility serve were delivered cold and slimy as if they were just taken out of the freezer and left to thaw on the plate. R6 stated the pancakes were served the same way. R6 stated on 6/2/24 she was served onion rings that were so hard they could cut walls. R6 stated the residents complained at resident council and food council with no resolutions. R6 stated the last milk she was served was a while ago. R6 stated, They don't give a decent meal. R6 stated the residents complained at resident council and food council with no resolutions. R6 stated, We just want a decent meal. 8. On 6/4/24, observations during the breakfast service included: - At 8:30 AM, R14 had her breakfast tray in her room and stated, The bacon looks awful! R14's received a small croissant in a baggie that was very hard on the bottom. -At 8:38 AM, R15 received toast on her tray but stated she could not eat the facility toast because the crusts were too hard. 9. On 6/3/24 all residents were distributed a piece of paper which stated, Date: 6/3/24 Instead of BBQ Ribs for lunch on 6/3/24, we will be serving Salmon Filets and Breaded Fish. Management Observations during the lunch meal included: - At 1:05 PM, R9 stated the food served at the facility was terrible on a normal day. R9 stated the chicken and other meat was served dry, the residents were not served [NAME] slaw/macaroni salad when on the menu, the hot food is served cold, and the facility rarely served milk. R9 stated, We don't get a choice. We just have to accept the regular menu. We have no choices on what we eat here at all. On 6/5/24 at 11:56 AM, V15 (Food Service Manager) stated the toaster was not broken and she was working with the food service staff to improve the palatability of the food served. V15 stated she she had only worked at the facility three weeks and observed the food service staff serving unsweetened lemon beverages for 100% fruit juice and was working to correct the staff. On 6/3/24 at 4:04 PM, V13 (Corporate Food Service Manager) stated the facility orders frozen bread for the residents and the toaster was not broken at the facility. Facility policy and procedure Palatability and Nutritive Value, revised 3/9/23, shows, Food will be prepared, held, and served in a manner that preserves nutritive value and palatability . 3. Best efforts will be made to present hot food hot and cold foods cold at the point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary. 5. Food service staff will monitor palatability of food at point of service by periodic test tray evaluations and review of resident council concerns. Facility policy and procedure Food Temperatures at Point of Service, revised 6/27/23, shows, Food will be prepared, held and served in a manner that preserves nutritive value and palatability .3. Best efforts will be made to maintain nutritional value and hot foods hot and cold foods cold such as batch cooking and keeping foods refrigerated and taking out of refrigeration in small batches. 4. Best efforts will be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary. 5. Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns.

Based on observation, interview and record review, the facility consistently failed to serve food items on their facility planned and approved menu to ensure adequate nutritional intake. This failure resulted in weight loss for R3 and R20 due to insufficient calories, prolonged feelings of sadness, anger, frustration, and low self-worth for R1, R2, R4, R13, and R18, and financial hardship to the residents and families of R1, R3, R13, and R21 who brought in food to supplement their food intake. This applies to 19 of 19 residents (R1-R4, R6-R14, R16-R21) reviewed for menus served as planned in a sample of 22. The findings include: Facility Week At A Glance menu, dated 6/2/24 to 6/8/24 and distributed to facility residents, shows the following menu items were planned to be served at the facility: Sunday, 6/2/24 Breakfast: Juice of choice, milk of choice, coffee/tea, hot/cold cereal, pancakes with margarine/syrup, scrambled eggs Lunch: Hot dog on a bun, onion rings, potato salad, lemon cake, milk, beverage Dinner: Tomato Basil Soup, Grilled Cheese and tomato, coleslaw, brownie, milk, beverage Monday 6/3/24 Lunch: Savory ribs, baked sweet potato, scalloped corn, fruit ambrosia, wheat bread, beverage of choice, milk of choice Tuesday 6/4/24 Breakfast: Juice of choice, milk of choice, coffee/tea, hot/cold cereal, waffles, bacon. 1. Face sheet, dated 6/5/24, shows R3's diagnoses included end stage renal disease, dependence on renal dialysis, type 1 diabetes, deficiency of Vitamin K, and depression. POS (Physician Order Sheet), dated 6/5/24, shows R3's diet order included carbohydrate controlled, renal, low concentrated sweets, low potassium. Nutrition progress note, dated 1/22/24, shows R3's weight after dialysis was 174 pounds and R3's appetite varies but is usually good. The note shows R3's weight appeared to be stabilizing after previous weight loss due to fluid being removed in the hospital. Nutrition progress note, dated 4/27/24 shows R3 experienced a significant weight loss of 19.3 pounds in three months. The note shows R3's appetite varies but is usually good. Nutrition progress note, dated 5/29/24, shows R3's post dialysis weight was 153 pounds. The progress note shows R3 had a weight decrease of 9.1 pounds in three months. The note shows R3's appetite varies but is usually good. MDS(Minimum Data Set) Assessment, dated 3/25/24, shows R3 was cognitively intact. On 6/4/24 at 8:35 AM, R3's breakfast ticket showed she was to be served cold cereal, 2 eggs over easy, fresh fruit as available, apple juice, 2 hard boiled eggs, 1 slice of toast, 2 slices of bacon, and milk of choice. R3's tray ticket notes showed, No scrambled eggs. On R3's breakfast tray she received scrambled eggs, 1 sausage link, cereal, 4 ounces of apple juice and 8 ounces of milk. R3 received no eggs over easy or hard boiled eggs and no fresh fruit. On 6/5/24 at 10:33 AM, R3 stated I write on my menu, turn it in, and they give me what they want! This has gone on two years! It makes me feel like they don't care! Pepper hurts my tongue and it makes me made I take the time to fill out the menu and they ignore me! Then they send foods that hurt my tongue! R3 stated she orders food from outside when she can afford to do so approximately twice a month. R3 stated It's a financial hardship because I can't buy shoes or clothes or mouthwash! I get the smaller sizes because I can't afford the economy sizes when I spend money on ordering food! I also buy snacks with my money. I use my social security - that's all I get! So I order twice a month and get stuck with what they give me other meals. I lost weight because I can't stand it! It's nasty! We would rather have something else. And when they send sandwiches, it is no meat and all bread! You're eating a bread sandwich! On 6/3/24 at 12:55 PM during lunch service, R3 received a deli sandwich with 2 slices of thin deli meat and no cheese on 2 slices of bread for lunch. R3 also received tomato, 2 pickles, ice cream, bag of potato chips, and an unsweetened lemon beverage. R3's tray ticket, dated 6/3/24, shows R3 was to be served scalloped corn, and a choice of milk which she did not receive. Grievance, dated 5/29/24, shows R3 complained a nurse refused to bring R3 a snack requested by R3 around 3:00 AM on 5/28/24 The form shows R3 stated she was hungry and could not sleep. On 6/5/24 at 12:37 PM, V14 (Dietitian) stated R3 weighed 172 pounds in January 2024 and R3 lost 18 pounds in 5 months. V14 stated R3 received dialysis and some weight fluctuation could be fluid but not eating enough at meals could contribute to R3's weight loss. V14 stated R3 was not on a planned weight loss program and R3's weights were trending down since December 2023. V14 stated R3 orders food from outside the facility because she does not like the food the facility served. V14 stated R3 did not want to remain on a renal diet because R3 was requesting more food choices. V14 stated R3's appetite may be good, but did not mean she was eating what was served from the facility. V14 stated it was her expectation that the facility followed the planned menu and should not be making changes to the menu unless products did not come in or there was a diet holiday. V14 stated if the facility was not consistently serving 100% fruit juice she was concerned residents may not be meeting their daily Vitamin C and calorie requirements as the fruit juice at breakfast of the planned menu met the requirement for a high quality Vitamin C product. V14 also stated daily 100% fruit juice provided approximately 90 calories each day. V14 stated if the facility was not consistently serving milk as planned, V14 was concerned residents were not meeting their daily protein, calories, Vitamin D, and calcium requirements as the milk helped meet resident daily requirements for the nutrients and provided approximately 240 calories each day as planned. 2. Face sheet, dated 6/5/24, shows R20's diagnoses included low back pain, hypertension, personality disorder, mild cognitive impairment, delusional disorders, and nonspecific abnormal finding of lung field. MDS, dated [DATE], shows R20's cognitive status was moderately impaired. Dietitian note, dated 1/30/24, shows R20 weighed 129 pounds and experienced unintended weight loss R/T (related to) inadequate energy intake AEB (as evidenced by) weight loss and documented intake of 26-100%. The note shows R20 had a significant weight lost of 16.2 pounds in six months, her appetite varied and R20 was being provided a high calorie drink, yogurt at breakfast, and ice cream at lunch and dinner to supplement her intake. Monthly weight report, dated 1/2024 to 6/2024, shows R20's weight was 123.6 May 2024 representing further weight loss of 5.4 pounds. POS, dated 6/5/24, shows R20 received a no added salt diet and received a high calorie drink 120 milliliters twice a day since 9/14/23. On 6/5/24 at 1:40 PM, R20 stated I was surprised I lost so much weight! I'm not eating! R20 stated she loved milk but never receives it on her meal trays. R20 stated once in a while she gets fruit juice, but mainly only receives the unsweetened lemon drink. R20 stated she is provided yogurt at breakfast and ice cream lunch/dinner for calories but is not fond of yogurt and can only eat ice cream once in a while. R20 stated she is able to eat the breakfast most days at the facility but often can not eat the lunches or dinner because the food has no seasoning or taste. R20 stated the facility used to provide seasoning packets that she loved and would put on the food to be able to eat the food but they stopped providing them on her meal trays. R20 stated she did not eat lunch that day because it had no flavor. On 6/5/24 at 12:37 PM, V14 (Dietitian) stated R20's weight loss was due to a lack of calories and was not on a planned weight loss program. V14 stated she had not spoken to R20 about her weight loss and was unsure if she was eating the meals at the facility or taking the supplemental nutritional items she was given. V14 stated she added the high calorie supplement, yogurt at breakfast, and ice cream at lunch and dinner to provide more calories because R20 was losing weight. V14 stated she writes that R20's appetite varied, but meant her intake varied. V14 stated R20 was not mentioned in weight meetings for not eating. V14 stated she was told by the facility diet tech that milk was not being served on trays at dinner approximately a month prior. V14 stated she spoke with a corporate food service representative and V14 stated she was told milk was always available. V14 could not confirm that milk was being consistently served at the facility at meals by food service. 3. On 6/4/24 at 7:48 AM with R13, R4 (Resident Council [NAME] President) stated she lived at the facility [AGE] years and the food has never been as bad as it was currently. R4 stated the dinners were the worst meal at the facility. R4 and R13 provided a copy of the facility menu of the week, dated 6/2/24 to 6/8/24, and R4 stated, If you look at the menu you get you would say, 'WOW! They are eating well!' But it doesn't come that way! R4 stated the menu is rarely served as it is written and the foods that are served are very small portions. R4 stated most dinners served are only a sandwich and chips and are served at approximately 5:15 PM. R4 stated the sandwich she received a couple nights prior only had one paper thin slice of turkey, no cheese, and no mayonnaise or mustard. R4 stated the sandwich may only come with potato chips and an unsweetened lemon beverage. R4 stated, That's not a real meal! R4 stated she begged for a different sandwich to be served as a night snack but only gets a few cookies or a peanut butter and jelly sandwich. R4 stated she was diabetic and becomes concerned about her blood sugars. R4 stated recently for dinner they were served a grilled cheese and tomato sandwich but residents did not receive the coleslaw that was planned on the menu. R4 stated her son comes to visit and brings food for R4 to supplement the facility food served. At 8:18 AM, R4's breakfast tray was served and R4 agreed to allow her tray to be used as a test tray. R4's tray ticket showed she was to be served orange juice, cold cereal, low-fat milk, 2 fried eggs over easy, a juice of choice, hot or cold cereal, toast, 2 slices of bacon, milk of choice and coffee/tea. R4 was served scrambled eggs, one sausage link, one slice of bacon, toast in a baggie, unsweetened lemon beverage, and skim milk. R4 stated she does not like skim milk and prefers 2% milk. No waffle was served as planned on the menus distributed to residents. R4 failed to receive her orange juice, cold cereal, and 2 fried eggs. R4 stated this was the first time they received toast in a long time. R4 received no butter for her toast. R4 stated the residents had not been served butter in a long time. R4 stated she complained in a resident meeting they were not receiving butter and the food service manager responded, If I give it to you, I can't give you something else. R4 stated the residents are served juice only once in a great while. R4 stated the residents are consistently served the unsweetened lemon beverages and not real fruit juice. R4 stated last week the resident council meeting was canceled because R2 (Resident Council President) came to the meeting a stated, 'I'm going to cancel the meeting because it does no good! Every month the write it down on the paper and nothing is done!' I agreed with him and told the staff I wouldn't do the meeting either! R4 stated she fully supported R2's frustration with the facility not responding to any of the ongoing resident concerns such as menus not served. R4 stated the residents complained but none of the staff were listening. On 6/5/24 at 8:59 AM, R4 received a replacement tray and this time received 2 eggs over easy, 2 sausage, orange juice, cereal and toast. On 6/5/24 at 9:33 AM, R4 stated she lives on food brought from outside by her sons and friends because of the poor food quality and the menus not served properly. R4 stated she has food brought in at least 4 times a week which she pays for. R4 stated she also pays for friends to bring in snacks to eat so she had food when she could not eat the facility food. R4 stated she spends no less than $40 to $50 a week on food to supplement the facility meals. R4 stated she was very upset the facility food quality declined drastically in the last year and stated, What am I, chopped liver!? Everything they have taken away like the food and not resolved! I feel like they don't care about us as human beings. We are just a number. It's not human! R4 stated at resident council some residents say the food is all they have to look forward to every day. R4 stated, It makes me worry about how people in the facility are struggling. That's all they have! That's scary! And we don't ever get a choice about the food! Take it or leave it! If you don't eat your meal, they just pick it up because the staff know there are no options! R4 stated since IDPH (Illinois Department of Public Health) has been in the building watching food service on 6/3/24 and 6/4/24, she began receiving juice and milk as instructed on her tray tickets. R4 stated, In the last 2 months I have received juice only 4 to 5 times! How do you think it makes us feel that they can serve us juice all of a sudden when the state is here!? 4. On 6/5/24 at 9:32 AM, R18 stated she has complained about the food quality and menus for two years. R18 stated It's hard and I am sick and tired of not being able to eat! My sister brings food once a week. There is nothing to eat and it makes me sick! I cry once a day because it's so bad and not enough food! R18 stated she was angry, sad, frustrated daily for months regarding the food served at the facility. 5. On 6/4/24 at 7:48 AM, R13 stated the residents receive scrambled eggs almost every day in spite of what is listed on the breakfast menu. R13 reviewed the weekly menu which showed a version of scrambled egg being served Sunday, Monday, Wednesday, Thursday and Saturday. R13 stated even the days scrambled eggs are not listed the residents are often served scrambled eggs and not the menued item. R13 stated waffles and bacon were planned for 6/4/24 breakfast, but stated there was a great chance they would receive scrambled eggs. R13 stated she gave up trying to select items on her menus or write in substitutions as it did no good because the kitchen served whatever they wished. R13 stated residents are told to call food service prior to 10:00 AM if they want a substitution for the lunch menu, but no staff answer the phone when residents call. On 6/5/24 at 8:20 AM during breakfast service, R13's tray ticket showed she was to be served juice of choice, hot or cold cereal, 2 hard boiled eggs, a donut, 2 slices of bacon, milk of choice and coffee or hot tea. R13 received only unsweetened lemonade beverage, hot cereal, 2 hard boiled eggs, and 1 slice of bacon on her breakfast tray. R13 stated her eggs felt and tasted cold. R13 stated I love milk! But they don't give it to me often. No waffles were served. R13 stated, They give this watered-down sugar free lemon crap! If I get real juice I am thrilled to death! On 6/5/24 at 9:33 AM, R13 stated I have to fight to get a proper meal and it makes me sad all day! Breakfast is important to me. Emotionally it just brings me down the whole day if breakfast is bad or not right. It happens here at least three days a week since December when I came! I get pissed off! Food is important to me! I am Italian! I get angry about the food. When it comes to the food, I don't feel taken care of since I have been here. R13 stated her day was ruined at lest 3-4 times a week because her breakfast is bad or not served correctly. R13 stated, If you have a decent breakfast, you can go on with your day - you have the energy and mindset and you feel satisfied and you can do well with your day! R13 stated she has friends/family bring in food from outside to supplement the meals at the facility. R13 pulled a chicken and tuna salad meal packages out of her dresser drawer. R13 stated she has to eat them 2-3 times a week because she can not eat the food served. R13 stated the only time in the last three months she received milk was if she received cold cereal for breakfast. Otherwise she was never served milk at breakfast, lunch or dinner. R13 stated, I know it's on the menu three times a day! But I never get it! 6. On 6/5/24 at 10:16 AM R21 stated, I used to indicate what I didn't like to eat on the menus and turn them in but I would still get the foods. It makes me mad they don't listen! This has gone on for 6-8 months! It causes me to be frustrated they keep giving me foods I don't eat! I don't like to cause trouble but I gotta eat! I only get $60 each month and it doesn't go very far. If I want to be happy and have something to eat, I have to use all of the $60! I don't feel I should have to pay for food when I give every cent to this place to stay here and already pay for the food served! I should be able to do something else with my $60 other than pay for food I am already paying for! I get anxiety about what they are going to send every day at every meal. I wait to see if they are going to give something I hate! Then they will serve the same thing every day for a week! They make out a menu and don't stick to it! I circle what I want, send it back, and then they send whatever they want! They run out of food on the weekends. I ask CNAs for something and they tell me food service is out of it when they call. It makes me angry and upset! This has gone on every day for at least 6-7 months but probably longer. They only give us a lemon drink at meals - I can't remember the last time I had real juice at breakfast! I like orange juice! But what is on the menu is not what is served! They just serve bug-juice! Koolaid! 7. On 6/3/24 during initial tour of the facility, R1 stated when he asks for a deli sandwich, he receives two pieces of bread and one thin slice of deli meat and one slice of cheese. R1 stated sometimes he is served only potato chips and a dessert with the deli sandwich as his meal. R1 stated there is not enough food at dinner to not be very hungry by breakfast. R1 stated he asked for salad at lunch and dinner several times during resident meetings. R1 stated he still does not get salads and stated he asked over and over again. They don't own the problem. R1 stated the staff only respond to residents with what they think residents want to hear and do not solve the problem. On 6/3/24 at 1:12 PM, R1 was eating one of his two hamburgers served at lunch. On his lunch plate, R1 had cooked corn, canned fruit and an unsweetened lemon beverage. R1's tray ticket showed he was to be served, Daily items: Tossed salad with cucumber if available . Savory ribs, baked sweet potato, scalloped corn, chilled fruit ambrosia, wheat bread, beverage of choice, and choice of milk which he did not receive. On 6/5/24 at 9:20 AM, R1 stated his sister brings in submarine sandwiches for a standby meal when he is unable to eat the food the facility serves. R1 stated he has been extremely disappointed because he and the residents complain at food and resident meetings and there is nothing done about their concerns. R1 stated he attended the food meetings and the facility tells you what they want you to hear and you feel let down! R1 stated, When the staff in the kitchen don't pick up the phone when you try to ask for a substitution, it doesn't make you feel good! My sister pays for the sandwiches because she wants me to have something to eat. I eat one of the sandwiches three to four times a week. I would like to have a decent meal! I don't expect a five star restaurant food but would like something I enjoy eating! It doesn't make me feel good at all and it has been going on for months! 8. On 6/3/24 at 2:00 PM, R2 stated he was the Resident Council President and he canceled the resident council meeting the week prior because he did not want to participate in another meeting listening to the same complaints from residents and the facility promising to address the problems and then doing nothing. R2 stated issues regarding residents not receiving what they ordered, the food service not serving the planned menus, and other food concerns came up frequently at resident council meetings and the facility decided to have a separate food council to discuss the concerns. R2 stated he was tired of discussing the concerns and describing the problems to administration and none of the issues being resolved by administration. R2 stated, They cut and cut and cut. They don't maintain the gardens on the patio, the food is terrible. Same s*** all of the time! We are on the fourth dietary manager! R2 stated he was tired of hearing ongoing concerns about the food with no resolutions from the facility. R2 stated he gave up arguing with the facility about the kitchen because he was tired of the B.S. On 6/4/24 at 8:52 AM, R2's breakfast tray ticket showed he was to be served cranberry juice, hard fried egg, fresh apple, extra toasted English muffin, juice of choice, donut, and coffee or tea. Review of R2's tray showed R2 failed to be served cranberry juice, hard fried egg, fresh apple, English muffin, juice of choice, donut and coffee/tea. R2 stated he never receives eggs any way but scrambled and never receives English muffins at the facility. On 6/5/24 at 9:10 AM, R2 stated he complained to the facility about the food service for two years since the new company took over at the facility. R2 stated, It makes me feel bad. It makes me feel horrible inside. We feel like second class citizens since the new food service took over! Resident council meeting minutes, dated 5/29/24, show the meeting was canceled by R2. Food Focus Group minutes, dated 2/21/24, show residents reported there was not enough coffee and juice available for meals. Food Focus Group minutes, dated 3/20/24, show residents asked for fresh fruits at meals, residents complained snacks were not available at night, that there was still not enough juices available at meals, and the food often did not match the daily menu tickets. Food Focus Group minutes, dated 4/3/24, show residents again asked for fresh fruits at meals, snacks were inconsistently available at night, there was still not enough juice served with meals, some residents asked for double portions, and food service would order English muffins to be available the next week. Food Focus Group minutes, dated 5/8/24, shows residents again asked for fresh fruits at all three meals, fruit juices served were watery and weak, an alternative menu was promised but was not available, food portions were served small, too many hot dogs were served on the menu, English muffins were not available, and cucumbers were requested in salad but residents were told cucumbers were very perishable and did not last long. 9. On 6/3/24 during initial tour of the facility, R6 stated she is usually served food items completely different from the facility weekly menu and different from her tray ticket for the meal. R6 stated the residents rarely receive the menu items listed on the facility menu passed to residents weekly. R6 stated she once received a breakfast sausage patty served on two slices of bread when she was supposed to receive a hamburger. R6 stated when she does receive a hamburger there is usually no onion, lettuce, tomato or other condiments. R6 showed a picture of a meal from her phone which showed a hamburger on a bun with a scoop of mashed potatoes on the plate. The picture showed a mustard packet, a yellow beverage and a piece of unfrosted cake in a plastic baggie. R6 showed a picture of her tray ticket for that meal which showed, No substitute found for deli sandwich with cheese on a bun, lettuce, tomato, onion, macaroni salad, no substitute for carrot cake, choice of milk, unsweetened beverage of choice. R6's tray failed to include macaroni salad, lettuce, tomato, onion, ketchup and milk. R6 also stated the residents received scrambled eggs almost every day in spite of what is listed on the weekly menu they are provided. R6 stated they often did not receive waffles if they were planned on the menu. R6 stated the last milk she was served was a while ago. R6 stated, They don't give a decent meal. R6 stated the residents complained at resident council and food council with no resolutions. R6 stated, We just want a decent meal. 10. On 6/4/24, observations during the breakfast service included: - At 8:22 AM, the beverage cart in the 100 hall had coffee, hot water, and unsweetened lemon beverage on the cart. No 100% fruit juices were present on the cart. - At 8:25 AM, R7's tray ticket showed she was to be served a donut, juice of choice. R7's tray had no donut but was served a small croissant. R7 stated she often did not receive juice and the last time she received 100% fruit juice was a week ago. - At 8:30 AM, R14 had her breakfast tray in her room and was waiting for the nurse to bring milk which she was not served on her meal tray. R14's tray ticket showed she was to to be served orange juice, low-fat milk, donut, and fresh fruit as available. R14's received a small croissant in a baggie that was very hard on the bottom but no orange juice, donut, milk or fresh fruit were served. - At 8:40 AM, R10 stated she only received a little amount of food for breakfast. R10's tray card showed she was to receive orange juice, hot coffee, and milk of choice. Review of R10's tray showed R10 did not receive any juice, milk, or coffee which R10 stated she enjoyed if she receives them. - At 8:43 AM, R11's breakfast tray ticket showed she was to receive orange juice, donut, milk, and coffee. Review of R11's tray showed R11 did not receive juice, coffee, milk or the donut. R11 stated she preferred to receive all of the items. - At 8:45 AM, R16's breakfast tray ticket showed he was to receive juice and a donut. Review of R16's tray showed R16 failed to receive either. - At 8:48 AM, R17's breakfast tray ticket showed she was to receive a toasted English muffin, donut, and juice. None of the items were served to R17 for breakfast on her tray. - At 8:50 AM, when asked if she ever received fruit juice at breakfast, R18 stated, Never! R18's breakfast tray ticket showed she was to be served 2% milk, juice, donut, and coffee or tea. None of the items were served to R18 for breakfast. R18 received skim milk and only one slice of bacon instead of two listed on the tray ticket. R18 stated she liked tea and preferred 2% milk and not skim but did not receive either. - At 8:56 AM, R19's ticket showed he was to receive eggs over easy, bacon, toasted English muffin when available and juice. Review of R19's tray showed R19 received scrambled eggs, no bacon, no juice, and no toast or English muffins. R19 received skim milk and stated he only liked whole milk. - At 9:29 AM, V11 (Activities) had a weekly menu on her activity cart and confirmed the waffles were on the weekly menu for 6/4/24 breakfast. 11. On 6/3/24 all residents were distributed a piece of paper which stated, Date: 6/3/24 Instead of BBQ Ribs for lunch on 6/3/24, we will be serving Salmon Filets and Breaded Fish. Management Observations during the lunch meal included: - At 12:55 R7 stated, I don't want this s***! R7's lunch tray included salmon, a roll, and mashed sweat potato. R7's tray ticket showed R7 was to be served savory ribs (3 ounces), baked sweet potato (1 each), scalloped corn (4 ounces), chilled fruit ambrosia (4 ounces), and wheat bread (1 slice). - At 1:00 PM, R8 received salmon on her lunch tray. R8 stated she wanted the ribs on the planned menu distributed to residents. R8's tray ticket showed she was to be served savory ribs, baked sweet potato, scalloped corn, fruit ambrosia, wheat bread and choice of milk which she did not receive. - At 1:05 PM, R9 stated the facility fails to serve the planned menu more than you would like. R9 stated the food served at the facility was terrible on a normal day. R9 stated the residents were not served [NAME] slaw or macaroni salad when on the menu, and the facility rarely served milk. R9 stated,We don't get a choice. We just have to accept the regular menu. We have no choices on what we eat here at all. R9 was eating a lunch of salmon, cooked plain corn, mashed sweet potato, canned fruit cocktail, and two unsweetened lemon beverages. R9's tray ticket showed she was to receive savory ribs, baked sweet potato, scalloped corn, drained fruit, wheat bread which she did not receive. -At 1:09 PM, R10 and R11 were both eating their lunch which included a piece of breaded fish, corn, fruit cocktail, mashed sweet potato and unsweetened lemon beverage. R10's and R11's tray tickets both showed they were to be served the savory ribs, baked sweet potato, scalloped corn, chilled fruit ambrosia, wheat bread, unsweetened beverage, and choice of milk which they did not receive. - At 1:13 PM, R12's lunch tray ticket showed R12 was to be served ribs, baked sweet potato, diced carrots, fruit ambrosia, buttered wheat bread, unsweetened beverage, and milk. R12 did not receive any of the food items on his meal ticket. On 6/5/24 at 11:56 AM, V15 (Food Service Manager) stated she worked at the facility for three weeks and she witnessed the food service staff were not cooking and/or serving items on the planned menu. V15 stated she was not aware ribs were not available for lunch until the morning they were to be served, was not aware the staff did not prepare the ambrosia salad, and was not sure why the whole baked sweet potatoes were not served. V15 stated she observed the food service staff serving unsweetened lemon beverages on breakfast trays instead of providing the 100% juice and milk as planned on the facility menu. V15 reviewed the menu passed out to the residents and stated the menu they were following in the kitchen was different than the menu which was circulated to the residents. V15 stated there were waffles in house, but the menu she was following the kitchen did not have waffles on the planned menu as written on the menus the residents received. On 6/3/24 at 4:04 PM, V13 (Corporate Food Service Manager) stated the facility orders frozen bread for the residents and the facility had no ribs on hand for lunch. V13 stated there was no cream corn to make the corn casserole and V13 was not sure why the ambrosia salad was not sure. V13 also stated she was unsure why milk was not served during the lunch. Grievances, dated 1/1/24 to 6/2/24, show three grievances (3/11/24, 3/16/24, and 3/25/24) regarding residents not receiving correct menu items from dining services. Review of the menus show juice of choice milk of choice, and coffee/tea were to be served every breakfast. The menus show choice of milk was to be served at every lunch and dinner except Friday. The menus show a variation of scrambled eggs was served on Sunday, Monday, Wednesday, Thursday, and Saturday. Menu extensions, dated 6/3/24 and 6/4/24, show all diets, other than those with physician orders for clear and full liquids, were to be served milk at all three meals. The extensions showed all diets were to be served a choice of juice at breakfast. Policy and Procedure Menu Portion Sizes, revised 3/17/23, shows, Follow 'Serving Instructions' on the Daily Production Sheet versus the Extensions Sheets for portion size and plating instructions for each diet Policy and Procedure Menu Planning, revised 4/1/23, shows Menus will be written to provide nourishing, well-balanced diets . 2. Menus are reviewed by menu committee meetings with input from dietary managers and regional/facility dietitians. 3. Menu planning will consider the cultural backgrounds and food habits of residents. 4. Menus are w [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse. This resulted in R1's left pinky finger being pulled backwards during care and x-ray showed a non-displaced fracture of the left finger. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of The findings include: R1's face sheet shows she is a [AGE] year-old female with diagnoses including type 2 diabetes, osteoarthritis, macular degeneration, atrial fibrillation and non-displaced fracture of distal phalanx of left little finger. R1's Minimum Data Set assessment dated [DATE] show she is cognitively intact, has no behaviors, rejections of care, or delusions. She requires partial moderate assist with showers/bathing. The facility's Initial Report dated 3/19/24 documents R1 verbalized today, on Saturday March 16, 2024, that CNA (Certified Nursing Assistant) provided her a shower and was not gentle to her. R1's statement dated 3/19/24 documented by V3 states, On Saturday 3/16/24 PM shift, I was scheduled to get my shower. V6 was my CNA. She was not very nice, refused to clean the shower chair as somebody used it before me. She washed me with towel that was on the floor. She did not do a good job with my shower. She grabbed my left arm when I was transferred to a shower chair. She even hurt my left pinky finger while she was getting the towel I was holding. My pinky finger was bent backward . R1's Diagnostic Imaging Results dated 3/20/24 shows a transverse non-displaced fracture at the base of the distal phalanx of the left little finger. On 3/25/24 at 9:05 AM, R1 was observed in her room sitting in her wheelchair. Her left pinky finger was wrapped with elastic bandage. R1 said on 3/16/24 around 8:00 PM, V6 (Agency CNA) said I need to give you a shower. She wheeled me to the shower room. I asked her if she could clean the shower chair because it was used by someone else before me. She said I already cleaned it. I asked her again if she could clean the shower chair and she told me I already told you I cleaned it. She then grabbed me by my upper left arm and transferred me to the shower chair. She set the washcloth on the grab bar and the washcloth fell on the floor. She picked them up, I said I don't want to use them they are dirty. She did not listen to my request and used the dirty washcloth. She washed my face roughly, she then started washing my body. I was trying to get the towel from her, and she grabbed my left pinky and pulled it backwards. She was laughing, I said that hurt me. V6 was a rough lady. I'm not happy. On 3/25/24 at 10:11 AM, V4 (RN) said he was R1's nurse on 3/19/24 when she was complaining of pain to her left pinky finger. Her left pinky finger was red and swollen, I asked if anything happened. She told me on 3/16/24 she received a shower from V6(Agency CNA), and her pinky got pulled. R1 is alert and oriented, I asked her if it was done intentional and she did not answer me. On3/25/24 at 12:18 PM, V9 (Social Services) said I was asked to check on R1 to see how she was doing after an incident with V6 (CNA). R1 told me she was receiving a shower from V6, and it sounded like it was not a good experience. Something about their being a tussle with the washcloth. R1 was visibly upset and said she does not want agency staff to care for her. R1 has not made any complaints about staff in the past. On 3/25/24 at 2:35 PM, V5 (LPN) said on 3/16/24, R1 approached me after V6 gave her a shower. R1 told me she did not like the way V6 gave her a shower. She complained about the washcloth being dropped on the floor and she used the dirty washcloth to clean her. I was not R1's nurse that day, I reported to her nurse that R1 was not happy with the shower and that V6 should not take care of her anymore. Both the nurse and V6 were agency staff. On 3/25/24 at 2:39 PM, V3 (RN Supervisor) said she was notified on 3/19/24, R1 was complaining of pain to her pinky finger. I asked her did any body hurt you, and she said a CNA (V6) was not nice to her during a shower. When I asked her about her finger, she told me it was bent backward. V6 was trying to get the towel from her and R1 got hurt. R1 sustained a fracture to her left finger caused by some trauma. On 3/25/24 at 2:53 PM, V1 (Administrator) said V6 is placed on the DNR (Do Not Return) list for this facility. V1 confirmed R1 sustained a finger fracture, and R1 will be following up with the orthopedic physician. R1's nurses note dated 3/19/24 documents by V2 (DON) per R1 during shower on Saturday 3/16/24, while CNA (V6) was providing care and washing her body, she reported her finger was pulled back. R1's nurses note dated 3/20/24 documents (R1) returned back from a physician appointment. Left hand x-ray shows left hand digit fracture. R1 has swelling, redness and pain 3 out 10. R1's current care plan dated through May 2024 shows my comprehensive assessment reveals factor that may increase my susceptibility to abuse/neglect. I deny any history of abuse or neglect or mistreatment and no indicators of past recipient or a perpetrator of mistreatment .I am considered a vulnerable adult. The facility's undated Abuse Policy states, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint .Abuse is the willful infliction of injury .willful, as used in this definition of abuse, means the individual must have acted deliberately .physical abuse if the infliction of injury on a resident that occurs other than by accidental means .

Based on observation, interview, and record review, the facility failed to ensure bed heights were at the lowest level and failed to provide two staff assist to prevent injuries. As a result, R1 and R3 sustained left and right hip fractures, respectively, and were admitted to the hospital. This applies to 2 of 5 residents (R1 and R3) reviewed for falls in a sample of 14. Findings include: 1. R1's progress notes showed R1 had two falls on 03/23/2023 and one on 03/24/2023 and 03/30/2023. R1's Minimum Data Set, dated dated dated [DATE] showed R1 was dependent on her daily living activities and required two or more assistance for daily living care activities. The universal fall precaution in part showed Place the hospital bed in a low position when a patient (Resident) is resting in bed. On 12/14/2023 at 09:32, V9 (R1's Physician) said he had known R1 for a long time and her health conditions were deteriorating. V9 said R1 was bedbound and required two assists. On 12/14/2023 at 09:55 AM, V19 (Director of Rehab Therapy) said R1 was a total assist and was confused and has a history of high fall risk. V19 said R1 required two staff assistants for all her daily care activities, and her bed should be as low as possible to minimize the impact of falls. On 12/13/2023, V10 (Certified Nursing Assistant) said on 11/23/2023 at night, he changed R1's colostomy bag, and R1's linen was soiled. V10 said when he leaned to reach for clean linen to change her, R1 rolled over the left side of the bed and fell on the floor. V10 said he thought he needed to use two assistances only for mobility/transfer and said, Now I know. On 12/12/2023 at 01:22 PM, R1 was in bed and was not interviewable. R1's bed height was not at a lowest level,writer showed V4 (Registered Nurse) the level of R1's bed, and V4 said R1's bed should have been at a lower level. The Hospital Physician's history and physical report dated 11/23/2023 at 9:28 AM showed R1's colostomy bag was being changed around midnight when she sustained a witnessed fall as she rolled over from her bed to the floor. R1 was admitted to the intensive care unit (ICU), and R1's X-ray of her left femur was positive for hip fracture (intertrochanteric hip fracture), which was acutely displaced. R1 had a surgery on 11/28/2023. A review of the face sheet showed that R1 was a [AGE] year-old initially admitted on [DATE] and readmitted to the facility multiple times, including on 03/10/2022 with diagnoses including colostomy status, diabetes mellitus, hypertension, schizophrenia, anemia with chronic kidney disease, and retention of urine. A review of V18's (Registered Nurse) progress notes on 11/23/2023 at 01:15 AM showed that V18 heard a noise coming from the room; upon entering the room, the resident on her left side and she noted a small amount of blood from the left outer lining of the ear and paramedics were called. Progress noted further showed that when paramedics transferred R1 from the floor to the gurney, R1 said her left leg and back were hurting. On 12/12/2023, V2 (Director of Nursing) at 3:00 PM, and on 12/13/2024 at 9:37 PM, V18(Registered Nurse) said V18 and V10 (Certified Nursing Assistant) were assigned for R1 and V10 should have called for help. V2 said the facility follows universal fall prevention precautions. V18 said bedbound and fall-risk residents' beds should be as low as possible while in bed and use two staff assistance for activities of daily living care. V2 said R1 and R3's fall incidents with injuries were reported to IDPH. 2. R3's hospital Physician progress notes dated 11/24/2023 showed R3 presented to the hospital on 11/20/2023 after a fall, was diagnosed with a right hip displaced femoral neck fracture, and had had surgery. On 12/12/2023 at 01:12 PM, R3 was in bed and was interviewable. V12 (R3's POA, Power of Attorney) was by R3's bedside. R3's bed height was not in the lowest level. R3 and V12 said R3 had a fall a few weeks ago and had a fracture. V12 said he visits R3 frequently and does not see his bed in the lowest level. R3 said during the fire alarm check, he got scared, tried to get up, and fell from the bed to the floor. R3 said he did not think his bed was at a lower level. At 1:12 PM, V3 (Registered Nurse) witnessed the bed height at a higher level and said R3 is a high fall-risk resident, and the bed should be at a lower level while he is in bed. On 12/14/2023 at 09:55 AM. The facility's fall prevention and management policy, dated October 2021, showed in part, All residents and patients considered at risk for falling regardless of fall risk score. Universal fall precaution (Facility protocol) interventions will be implemented to all.

Based on observation, interview and record review, the facility failed to ensure a resident with recent attempt of elopement was provided adequate supervision to prevent elopement from the facility. The facility also failed to ensure all facility exit alarm systems were monitored by staff to be able to respond to residents exiting the facility from the 300/South unit. This failure resulted in Immediate Jeopardy when R1 eloped from the facility without being witnessed by facility staff on 3/25/22. This applies to 6 of 6 residents (R1- R6) reviewed for supervision in the sample of 6. The Immediate Jeopardy began on 3/25/22 at 2:00 PM, when R1 eloped from the facility without being witnessed by facility staff. R1 was found by a motorist from the local community when R1 reported to the motorist R1's car had been stolen. The motorist alerted 911 and R1 was returned to the facility by the local police after attempting to return R1 to his home residence because R1 was unable to communicate where he belonged. The Immediate Jeopardy was identified on 4/5/22. V1 (Administrator) and V3 (DON-Director of Nursing) were notified of the immediate jeopardy on 4/6/22 at 4:00 PM. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on 4/7/22 at 4:30 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan, including in-service training of staff on elopement drills and door alarm response and ensuring exit doors alarms are monitored by staff. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and R1 had multiple diagnoses including dementia with depression, symptoms and signs involving cognitive functions and awareness, difficulty in walking, metabolic [CONDITION(S)], attention-deficit [CONDITION(S)] disorder, and lack of coordination. R1's MDS (Minimum Data Set) dated 3/17/22, shows R1 had short and long term memory problems, could not recall staff names/faces, and made decisions regarding tasks of daily life with modified independence. R1 had moderate difficulty hearing, only sometimes made himself understood, and only sometimes understood others. The MDS showed R1 did exhibit wandering behaviors during the assessment period. On 4/5/22 at 9:31 AM, V10 (Receptionist) stated on 3/25/22 at approximately 1:45 PM while speaking with a family in the facility reception, V10 saw R1 attempting to leave the facility unaccompanied. R1 was walking toward the front exit door to the facility and when R1 approached within a few feet of the exit door, V10 stated she yelled, Sir, stop! V10 stated she asked where R1 was going and if she could help. R1 replied, I'm going home. I'm going home. V10 stated she recognized R1 was most likely a resident because the temperature outside was cold, R1 had no coat, and R1 was wearing only a white short sleeved T-shirt and gray sweatpants while attempting to go outside. V10 stated she redirected R1 through the double doors between the reception area and the resident room area of the facility and instructed R1 to report to the 100 nursing station to speak to a nurse. V10 stated she did not remember if there were any staff visible on the unit when she ushered R1 towards the 100 nursing station. V10 then returned to her desk, called the 100 unit nursing station, and spoke to V11 (Social Services) V10 informed V11 that R1 was directed to the nursing station because he was trying to leave the facility. V10 stated V11 responded R1 was probably confused because his scheduled discharge date was 3/26/22. V10 stated she did not see V11 until later after R1 was returned to the facility by the police. On 4/4/22 at 1:27 PM, V11 (Social Services) stated on 3/25/22, V10 called V11 at the 100 hall nursing station and stated she was sending R1 back to the 100 nursing unit because he was trying to leave the facility. V11 stated R1 may have been confused because he was scheduled to be discharged the following day and the family just concluded a meeting with R1 discussing discharging from the facility. V11 stated he never saw R1 after he received V10's call that she was sending R1 to the 100 unit nurses station. V11 stated at approximately 2:00 PM, V11 left the 100 unit to attend a staff meeting but had still had not seen R1. V11 stated at approximately 3:00 PM, V1 (Administrator) came to the 100 unit and informed staff that R1 returned to the facility with his family and the police. V11 stated facility residents were assessed for elopement risk based on their history of elopements, their cognitive impairments, and their ambulatory status. V11 stated if staff observe residents trying to open doors, the facility staff assess for root causes of the exit seeking and provide interventions such as exit alarm bracelets, placing residents on the elopement risk program, and assessing resident room placement to build in staff supervision. Door alarm system log, dated 3/25/22, shows the Main Dining Room door alarm was forced open at 2:00 PM. The log shows the alarm was silenced on 3/25/22 at 2:06 PM. On 4/7/22 at 9:52 AM, V18 (Police Dispatch Officer) stated a community member called 911 at 2:20 PM on 3/25/22 regarding R1 walking in the road and reporting his car was stolen. On 4/6/22 at 1:36 PM, V16 (Police Officer) stated on 3/25/22 he responded to a call from a motorist that was concerned about a male wandering in the middle of the road who reported that his car was stolen. V16 stated the motorist stated R1 was wandering in the middle of the road which had a 40 mile per hour speed limit. V16 stated when he arrived, R1 appeared dazed and not engaged. V16 stated another officer had responded to the call first and informed V16 that he did not believe a car was stolen but it seemed that R1 had some type of altered mental status which he thought was dementia. V16 stated R1's answers were not precise, R1 was confused, and it was apparent R1 had dementia or was having some type of mental condition. R1 provided his name and home residence address and told V16 his car had been stolen. V16 drove R1 to his home residence and V14 (Wife) told V16, R1 was supposed to be under the care and supervision of the facility. V16 returned R1 to the facility. V16 stated the weather was very cold and estimated R1 had been walking outside for approximately twenty minutes. On 4/5/22 at 7:15 PM, V13 (Police Officer) stated on 3/25/22, R1 was found near the intersection of Nerge and Greenbrier, approximately two blocks west of [NAME] Grove Road (approximately 0.5 miles from the facility), by a motorist in the local community who alerted 911 approximately between 2:00 PM and 2:30 PM on 3/25/22. V13 stated R1 told the motorist R1's car had been stolen. V13 stated V16 (Police Officer) originally responded, R1 provided V16 with his home residence address so V16 initially transported R1 to his home where his wife informed the police R1 was supposed to be under the care and supervision of the facility. R1 was then transported back to the facility. V13 stated meanwhile the police department received a complaint from V15 (Son) regarding R1's elopement from the facility and V13 met V16 and R1 at the facility to investigate. On 4/6/22 at 11:05 AM, V17 (Advanced Practice Nurse) stated R1's safety awareness was compromised and R1 would not be able to understand the safety risks of walking out of the building unsupervised when he eloped. V17 stated he was at risk for falls, walking into the road, and being hit by a car because of his lack of cognitive ability to understand what he was doing. V17 also stated she was told the outside temperature was approximately 40 degrees and R1 therefore may have been at risk for mild hypothermia. V17 stated she previously witnessed R1 independently walking to/from the bathroom and V17 reminded R1 he needed staff assistance for safe toileting assistance. On 4/4/22 at 12:08 PM, V1 (Administrator) stated V6 (Contract Worker) shut off the door alarm sounding at the main dining room door because he thought the door alarm was activated by the wind and not a resident leaving the building. V1 stated V6 looked around outside the door but did not see any residents outside the building. V1 stated V6 did not inform the staff he turned off the alarm and no resident head count was initiated. V1 stated contract workers were given alarm key cards to be able to disarm the facility alarms when entering and exiting the facility while performing work in the facility. V1 stated R1's family visited prior to R1's elopement to speak about his discharge the following day and V1 felt the meeting may have suggested to R1 that he needed to leave the facility. Final Investigation Report, dated 3/30/22, shows between 2:00 PM and 2:30 PM, R1 exited the building and was recovered by police nearby. The report shows at approximately 1:50 PM on 3/25/22, R1 was at the front of the building indicating he was leaving the facility. At that time, R1 was redirected back to the nursing unit at that time by the receptionist. Facility Behavior Management Guidelines, dated 3/2022, shows Wandering and exit seeking are behavioral symptoms of special concern in the elderly and, or dementia population. Patients are evaluated upon admission for a history of, or risk factors for wandering and, or exit seeking. Interventions to consider include: Structured activity programming, patient room placement in relation to egress doors, personal security bracelet, safe wandering interventions. Patients that have been identified as at risk for unsafe wandering or elopement are included in the Center Watch Process Personal security bracelets serve as an alert to the patient for safe boundary limits and as an alert to staff if the patient is close to an alarmed door Exit doors and stairwell doors are alarmed. Door alarms are checked for functionality per manufacturer's guidelines. Staff response drills are conducted monthly, encompassing each shift, and as needed. Findings are documented and submitted to the Safety and, or QAPI (Quality Assurance and Performance Improvement) Committee for review and follow-up as needed In the event a patient experiences a new or escalating behavior . Place the patient on Alert Charting, determine the root cause and implement non-pharmacologic interventions . Initiate modifications in the patient's plan of care as indicated or ordered 2. On 4/4/22, V10 (Receptionist) provided the document Patients with Exit Seeking which included the resident names of R2-R6. V10 stated there were five residents in the building who were at high risk for elopement, their pictures were kept in a binder at her desk, and each of the residents wore elopement alarm bracelets to assist in preventing elopement. Facility document Patients with Exit Seeking, dated 4/4/22, shows R2-R6 were all identified as residents at high risk for exit seeking/elopement. On 4/5/22 at 1:07 PM, on the empty 300 unit with V12 (Maintenance Director), when the exit doors were opened the exit doors alarm sounded and the 300/South nursing station alarm panel sounded, however no staff were present at the 300 nursing station because the 300 unit was vacant of residents. V12 stated the 300 unit exit door alarms were only wired to alert staff at the 300 unit nursing station, but no other nursing units received an alarm signal on their door alarm panels. The 300 unit was isolated in proximity to the rest of the building and the unit had one staff office in use. V12 stated the staff in the office on the 300 unit were not physically present at all times on the 300 unit. On 4/5/22 at 1:35 PM, V12 (Director of Maintenance) and V1 (Administrator) stated they were unaware the exit doors on the 300 unit did not alarm at the 100 unit nursing station for staff to be alerted that someone was attempting to exit on the 300 unit. V1 stated there were two staff with offices on the vacated 300 unit, but those staff were not present on the unit during nights or most weekends or when they were on other units seeing residents. Behavioral Symptoms Assessment, dated 3/31/22, shows R2 was exit seeking and wandering without intent or purpose and R2 had a history of disruptive behavior that could be unprovoked and purposeful, anxiety, delusions, recent change, departure from normal activities, Progress note, dated 3/31/22, shows Noted patient walking toward [Unit] Exit door. Patient stood by the door for a long time as if looking for something. [Personal security bracelet] strapped on left ankle with orders to check placement. R3's Care Plan shows, Exit seeking/elopement risk related to cognitive impairment . wandering. R3's Interventions include, Added to facility Exit Seeking Program on 9/5/2020. Alert bracelet 9/5/20 On 4/7/22 at 2:26 PM with V3 (Director of Nursing), R3 was slowly walking near her room and back and forth between the 300 and 100 nursing stations. R3 had a personal security bracelet on her right wrist. Behavioral Symptoms Assessment, dated 3/29/22, shows R4 was identified as having exit seeking behaviors. Progress notes, dated 3/13/22 and 3/15/22, show R4 was observed as being confused, restless, and wandering. On 3/15/22, R4 attempted to get into the bed of her roommate, said she was going home, and was packing her belongings. Progress note, dated 3/24/22, shows R4 was awake during the night, confused, slightly agitated, restless, and wandering and R4 was brought to the nursing station for closer monitoring. Physician progress note, dated 3/29/22, shows R4 was moved to a room close to the nursing station due to wandering into other residents' rooms. Nurse practitioner note, dated 3/31/22, shows R4 showed signs of confusion and was observed wandering around the facility. Behavioral Symptoms Assessment, dated 3/29/22, shows R5 was identified as exhibiting exit seeking behaviors, agitation, irritability, or [CONDITION(S)]. The assessment shows, Patient regularly becomes upset, crying and searching for her family. This most often occurs in the mid-late afternoon When upset, patient is most often searching/waiting for her family members. Progress notes, dated 2/7/22, shows, Pt [Patient] found on the floor from her wheelchair. Pt was wandering to go outside. When I went to open the front door for other patient's family member, I found [R5] on the floor hallway Behavioral Symptoms Assessment, dated 3/30/22, shows, R6 regularly approaches staff and states that she would like to leave. She has been noted to approach exit doors, but not directly attempt to leave. This most often occurs at night. Progress notes, dated 4/1/22, shows, Up all noc (night). Refuse to go to bed. She is looking for a way out, looking for the door, she wants to go home. Always asking where is the door Wandering around the unit. The Immediate Jeopardy that began on 3/25/22, at 2:00 PM was removed on 4/7/22 at 4:30 PM when the facility took the following actions to remove the immediacy: On 3/25/22, door alarm function was checked on all outdoor exits and all door alarm key cards were deactivated with the exception of active facility staff. Door alarm annunciator panels at nursing stations were updated to reflected current names for designated areas for staff to identify from where the alarm is coming. Staff education began immediately to include Behavior Management Guidelines, Missing Person Protocol, and Response to Door Alarms/Panels - as of 4/5/22, 141/142 employees were educated. Agency staff will be educated at the start of their next scheduled shift by staffing scheduler, weekend supervisor, PM supervisor, or human resources director. On 3/25/22, residents not currently identified as a risk for exit seeking in the facility were re-assessed for current risk (based on cognitive status, mobility and exit seeking history) and no additional residents were identified as at risk for elopement. Review of the Center Watch Binder was completed to validate all current residents on the program. Personal security bracelets were validated for placement and function. Residents identified as exit seekers received complete review of plan of care and updated exit seeking assessments. Ongoing evaluation will be performed for newly admitted residents for elopement risk during the admission evaluation, with change of condition; any identified risk reducing interventions are put into place upon admission and added to the Center Watch Binder. On 4/5/22 at 2:00 PM, a staff member was assigned to remain at the South nurses' station to monitor the door until the alarms could be re-wired to a staffed nursing station. On 4/5/22 by 5:47 PM, the door alarm annunciator panel at East nursing station was updated to include alarms for the exit doors at rooms 321 and 328. At 5:30 PM, a door alarm check was completed to validate the doors alarm at the panel. On 4/6/22, staff education regarding responding to the South Unit door alarms heard at the East unit alarm panel was initiated - as of 4/7/22, 127/147 (86%) staff completed their education. Agency staff will be educated at the start of their next scheduled shift by staffing scheduler, weekend supervisor, PM supervisor, or human resources director. QAA meetings were held on 3/28/22 and 4/6/22. Ongoing facility monitoring will be conducted including the following: 1. The maintenance director/designee will conduct door checks on all external doors on the Egress Door Log for function daily for two weeks and weekly thereafter. All concerns or trends from monitoring will be forwarded to QAA for review/resolution. 2. The administrator/designee will randomly conduct Door Alarm Drills daily for two weeks with at least one drill on each shift per week to ensure appropriate function and response. Drills will be done three times weekly for the next two weeks, weekly x 4 weeks and monthly thereafter. 3. The administrator/designee will randomly interview five staff daily for two weeks with at least 1 staff on each shift each week for appropriate Door Alarm Response. Interviews will be completed three times weekly for the next two weeks, weekly for four weeks and monthly thereafter. 4. The administrator/designee will complete a QAPI (Quality Assurance Performance Improvement) Exit Seeking audit tool weekly for four weeks to ensure that all components of the Exit Seeking Guidelines [risk of elopement identified/revised, 1:1 post-elopement, security bracelet placed, order for security bracelet, placement and function validation of security bracelet, identified as an elopement risk on task list, identified in center watch binder, practitioner/family notified of elopement attempts, care plan] are in place for those residents identified as an elopement risk. The QAPI audit tool will be completed monthly thereafter or with a change for those identified as exit seeking. 5. The DON (Director of Nursing)/designee will conduct random audits daily for two weeks of MAR (Medication Administration Review) documentation [(Personal Security) Bracelets Audit] regarding placement and function of wander-guard bracelets and box. Audits will be conducted three times weekly for the next two weeks, weekly for four weeks, and monthly thereafter.

Based on observation, interview and record review, the facility failed to follow their policy for weighing newly-admitted residents every week for four weeks. This failure resulted in a resident's (R7) significant weight loss of greater than 20 percent going undetected. This applies to 6 of 7 residents (R3, R4, R7, R8, R10, R11) reviewed for weight loss in the sample of 15. The findings include: 1. On [DATE] at 11:40 AM, R7 was lying in her bed in a fetal position. R7 was not interviewable due to her cognitive status. R7's legs were uncovered. Her legs appeared thin and contracted. A strong odor was present in the room. V9 (CNA-Certified Nursing Assistant) said the strong odor was from R7's pressure ulcers on her buttocks. V9 removed R7's incontinence brief. R7 had two wounds on her buttocks covered by dressings dated [DATE]. The EMR shows R7's admission weight on [DATE] was 95.0 pounds. The facility does not have documentation to show R7 was weighed after her admission on [DATE] as shown on the facility policy. This surveyor requested R7 be weighed on [DATE]. R7 weighed 74.4 pounds on [DATE], a significant weight loss of 21.68 percent for the period [DATE] to [DATE]. V4's (Dietitian) Nutrition assessment dated [DATE] shows R7's usual body weight as unknown. V4 documented R7 had chewing problems and the inability to perform ADLs (Activities of Daily Living) without significant physical assistance. V4 documented R7 had less than 44 percent intake average in the last five days (intakes on [DATE] per nursing poor intake of only a few bites breakfast and lunch). V4 documented R7 was underweight and recommended a liquid supplement twice daily, nutritional juice with breakfast and monitoring R7's intake and weights. There is no documentation to show R7's weights were obtained and monitored by facility staff, including V4 (Dietitian). The facility does not have documentation to show R7 received or refused the nutritional supplements as ordered on [DATE], 12, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30, 2020 or on [DATE]-15, ,[DATE], 2020. The facility does not have documentation to show V4's recommendations were monitored or reevaluated. The EMR (Electronic Medical Record) shows R7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The EMR shows R7 was admitted to hospice due to dementia on [DATE] and expired at the facility on [DATE]. R7's MDS (Minimum Data Set) dated [DATE] shows R7 had severe cognitive impairment, required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS shows R7 weighed 95 pounds on admission to the facility and it was unknown if R7 had a weight loss or gain of 5 percent or more in the last month or 10 percent or more in the last 6 months. R7's MDS shows R7 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Hospice documentation dated [DATE] shows R7 Is at a moderate nutritional risk. Based upon the nutritional score, indicate actions to be taken: Monitor weight. R7's care plans entitled Nutritional status: Risk r/t (related to) COVID-19, chewing difficulty, unplanned weight loss, skin alteration, dementia which may impact eating was initiated on [DATE]. Interventions initiated [DATE] include: Review weights and notify physician and responsible party of significant weight change. On [DATE] at 2:30 PM, V4 (Dietitian) said the facility staff should do weekly weights for four weeks and monthly thereafter. V4 said, The purpose of doing the weights weekly times four is to get a baseline where the patient is at within that time frame. If there is significant weight loss I should be notified by the nursing staff. I don't think the facility is aware the weekly weights are falling through the cracks. I did not notify anyone regarding residents missing weekly weights. On [DATE] at 4:33 PM, V10 (Physician/Medical Director) said he is the physician caring for R7. V10 said he expects the facility to follow the policy for weighing residents every week for the first month after admission, and then monthly thereafter. V10 said he expects the facility to follow physician orders [REDACTED]. V10 said he was not informed of R7's weight loss. V10 said, The weight loss should have been addressed sooner than today. She has been in the facility six or seven weeks and should have been weighed multiple times before today. 2. The EMR shows R3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R3's MDS dated [DATE] shows R3 requires modified independence for daily decision making, requires supervision for eating, and extensive assistance with all other ADLs. The EMR shows R3's admission weight on [DATE] was 191.0 pounds. The facility does not have documentation to show weekly weights were done on R3 as shown in the facility policy. This surveyor requested R3 be weighed on [DATE]. R3 weighed 179.4 pounds, a significant weight loss of 6.07 percent for the 20-day period of [DATE] to 22, 2020. V4's (Dietitian) Nutrition assessment dated [DATE] shows facility monitoring should include monitoring R3's intake and weights. 3. The EMR shows R4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The EMR shows R4 was diagnosed with [REDACTED]. The EMR shows R4 was discharged from the facility to home with a family member on [DATE]. R4's MDS dated [DATE] shows R4 had modified independence with daily decision making, was totally dependent on facility staff for bathing, and required extensive assistance for all other ADLs. R4's MDS shows R4 was admitted to the facility with a weight of 160 pounds and it was unknown if R4 had a weight loss or gain of 5 percent or more in the last month or 10 percent or more in the last 6 months. The EMR shows R4's admission weight on [DATE] was 160.2 pounds. The facility does not have documentation to show weekly weights were done on R4 as shown in the facility policy. R4 was not weighed again until [DATE]. R4's weight was documented in the EMR as 102.4 pounds, a significant weight loss of 36.08 percent. The facility does not have documentation to show R4 was reweighed to check the accuracy of R4's weight of 102.4 pounds or that the significant weight loss was addressed on [DATE]. On [DATE], R4's weight was 100.8 pounds, and on [DATE], R4's weight was 94.6 pounds, a significant weight loss of 7.62 percent for the period of [DATE] to [DATE]. On [DATE] at 2:30 PM, V4 (Dietitian) said the EMR shows R4's weight went from 160.2 pounds down to 102.4 pounds from [DATE] to [DATE]. V4 said there is no documentation to show R4's weight loss of 58 pounds was addressed by any facility staff. V4 said, I saw (R4) in mid-December for weight loss, that was the first time. The staff should have been doing weekly weights on the resident for the first month, and they were not doing that. Also, if there is a difference of more than five pounds from the last weight, the facility should reweigh the resident to ensure the accuracy of the weight. There is no documentation to show the facility staff did a reweight on (R4) after her admission or on [DATE] after she showed a 58 pound weight loss. On [DATE] at 4:15 PM, V2 (DON-Director of Nursing) said R4's hospital records showed her weight on [DATE] was 52.1 kilograms (114.6 pounds), and on [DATE] R4's weight was 61.5 kg (135.3 pounds). V2 said she felt R4's weight of 160 pounds upon admission to the facility on [DATE] was not the accurate weight for R4 and the 135.3 pounds was a more accurate weight for R4. As of [DATE], there was not documentation in the medical record to show the facility felt R4's admission weight of 160.3 pounds was in dispute. 4. The EMR shows R8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R8's MDS dated [DATE] shows R8 is rarely understood, has moderately impaired cognition, and requires supervision with one-person physical assistance for eating. R8 requires extensive to total assistance with all other ADLs. The MDS shows R8 weighed 153 pounds on admission to the facility and it was unknown if R8 had a weight loss or gain of 5 percent or more in the last month or 10 percent or more in the last 6 months. The EMR shows R8's admission weight on [DATE] was 153.0 pounds. The facility does not have documentation to show weekly weights were done on R8 as shown in the facility policy. This surveyor requested R8 be weighed on [DATE]. R8 weighed 138.8 pounds, a significant weight loss of 9.28 percent for the 19-day period of [DATE] to 21, 2020. V4's (Dietitian) Nutrition assessment dated [DATE] shows R8's usual body weight is in the 170's (pounds). V4 recommended monitoring R8's intake and weights. 5. The EMR shows R10 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R10's MDS dated [DATE] shows R10 has moderately impaired cognition, requires supervision with setup help only for eating, and extensive assistance with all other ADLs. The MDS shows R10 weighed 110 pounds on admission to the facility, and it was unknown if R10 had a weight loss or gain of 5 percent or more in the last month or 10 percent or more in the last 6 months. The EMR shows R10's weight on [DATE] was 110.0 pounds. The facility does not have documentation to show weekly weights were done on R10 as shown in the facility policy. This surveyor requested R10 be weighed on [DATE]. R10 weighed 104.0 pounds, a significant weight loss of 5.44 percent for the 14-day period of [DATE] to 23, 2020. V4's (Dietitian) Nutrition Assessment for R10 was completed on [DATE] and shows R10's usual body weight is in the 140's (pounds). V4 recommended monitoring R10's intake and weights. 6. The EMR shows R11 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R11's MDS dated [DATE] shows R11 has moderate cognitive impairment, and requires supervision with most ADLs, including eating. The MDS shows R11's admission weight as 110 pounds and it was unknown if R11 had a weight loss or gain of 5 percent or more in the last month or 10 percent or more in the last 6 months. V4's (Dietitian) Nutrition Assessment for R11 dated [DATE] shows R11 has a loss of 15 pounds from her usual body weight. V4 recommended a house shake daily and monitoring R11's intake and body weight. On [DATE] at 4:30 PM, V1 (Administrator) said the facility did not monitor resident's weights as shown in the facility policy. The facility was asked to provide their weight policy. The facility provided the Weight Management Guideline dated [DATE]. The policy shows: Unplanned Weight Loss - The key for effective weight management is to appropriately identify weight variances and initiate nutrition strategies when indicated in time to reduce nutrition related complications. The treatment of [REDACTED]. For patients with late-stage or terminal illness, the optimal goal may simply be to satisfy the senses of taste and smell and to provide the social benefits of mealtime in order to maximize the patient's comfort. Unavoidable Weight Loss - Unavoidable weight loss occurs when the patient did not maintain acceptable parameters of nutritional status even though: patient's clinical condition and nutritional risk factors were evaluated, interventions that are consistent with patient needs, goals and recognized standards of practice were defined and implemented, and the impact of the interventions was monitored and evaluated. Weight Schedule: For newly admitted patients, obtain weight upon admission and weigh weekly for total of 4 consecutive weeks, then monthly.The continued need for weekly weights due to nutritional concerns is determined by the interdisciplinary team led by the registered dietitian.

Based on observation, interview and record review the facility failed to complete a comprehensive, individualized assessment of residents skin; develop and implement interventions including positioning to promote healing of wounds and prevention of new pressure sores. This applies to four of five residents (R6, R8, R11, R13) reviewed for pressure ulcers in a sample of 24. This resulted in R6 acquiring an unstageable wound to his left heel, a wound to his buttocks and a worsening unstageble wound to the right heel. The findings include: 1. R6 has medical [DIAGNOSES REDACTED]. R6 also has a BIMS (brief interview for mental status) score of 13 out of 15 on the January 31, 2016 MDS (minimum data set) showing him to be cognitively intact and interviewable. On January 8, 2016 at 8:00 AM, during the facility initial tour, R6 was in his room laying in bed with the head of the bed at a 45 degree angle. R6 had multiple dark purple bruising and skin tears to both arms. R6 stated he is on long term anticoagulants and oral steroids. R6 stated he didn't have any long sleeve shirts or anything to protect his arms. R6 was also noted to have a flat pillow under his legs with both heels resting on the bed. R6 stated he had burning pain in both heels and and his butt. When asked if he had any sores he stated, I'm not really sure. On February 8, 2016 at 11:35 AM, E12 (CNA) was providing incontinence care for R6. R6's rectal area and buttocks were cleansed and R6 had open red areas on both sides of his buttocks. R6 stated they were tender. E9 (RN, Registered Nurse) then came in to apply a skin protectant to the area and stated the wound looked like a stage II pressure ulcer. E9 stated the treatment nurse is the one who monitors these. E12 then removed both socks and R6 had large black areas on both heels. There was no dressing, offloading or heel protectors on R6. There were sero-sanguinous stains on R6's bed sheets under his heels. R6 stated he had heel protectors on in the hospital but not since his admission to the facility. R6 was stood up on both feet with socks on and was transferred to the wheelchair which had a pressure relieving cushion on it and a pillow was placed on top of the pressure relieving cushion. On February 8, 2016 at 12:00 PM, E10 (treatment nurse) stated R6 came in to the facility with an abrasion on his right heel and abrasions on his buttocks. E10 stated she had not seen R6 in about two days. E10 stated she was not aware of any sores on R6's left heel. E10 came into R6's room and observed large black/brown colored wounds on both heels. E10 stated R6's buttock wound was not a pressure sore it was an abrasion because its not on a bony prominence. There is no documentation, measurements or assessments of R6's buttock wounds. When asked how R6 obtained the abrasion E10 stated she didn't know. E10 stated the interventions R6 had in place to prevent pressure ulcers were skin protectant to his buttocks, air dispensing mattress, and to offload the heels with cushioned heel protector boots. E10 looked in R6's room and confirmed with R6 he did not have any heel protecting boots since his arrival in the facility. R6 was seen again on February 9, 2016 and February 10, 2016, in his room. On February 9, 2016 in the morning R6 was seen with heel protector boots on. On February 9, 2016 in the afternoon R6 was seen in the wheel chair sitting on a pillow on top of his pressure relieving pad. On February 10, 2016 in the morning, R6 was seen in bed with no heel protector boots and no offloading of his heels. On February 10, 2016 afternoon, R6 was seen in his wheelchair sitting on a pillow on top of his pressure relieving cushion On February 10, 2016 at 8:30 AM, R6 was receiving a nebulized inhaled treatment in his room via a face mask. R6 complained the mask was bothering his right ear. E13 (RN) stated to R6 the treatment was almost done but did not attempt to check the area. R6 was than noted to have a reddened open area behind his left ear. R6 was seen on multiple visits with the oxygen tubing around his ears and the padded area to have been below his ear on both sides. R6's admission assessment dated [DATE] documents the the skin assessment as: Left iliac crest bilateral oblique region with moderate skin rashes. There is no documentation of any abrasions to the buttock area. The assessment also documents the right heel has a small (approximately quarter sized) brown/black colored wound. There are no other skin abnormalities documented. The Braden score is documented as 19 (low risk) at that time. The next Braden score was done February 7, 2016 and documents R6 to be at risk with a score of 15. R6's admission note dated January 24, 2016 documents: Several wounds found on R6's body. See nursing assessment. There are no measurements or any other comprehensive assessments on these skin alterations/wounds. R6's TAR (treatment administration record) for January and February 2016 documents, Body audit every day shift, every 7 days for skin observation. There is an x checked on every day it was done but no details are documented about the skin assessment. R6's care plan dated January 24, 2016 documents R6 to be at risk for alteration in skin integrity related to steroid therapy, Braden risk and recent hospitalization . The goal was to decrease breakdown risk. The interventions listed were barrier cream to buttocks, diet and supplements, encourage reposition as needed, float heels as able and pressure reducing device on chair and bed. R6's risk factors were not identified and individualized interventions were not put into place. There is no guidance to staff on how or when to float the heels or what to float heels with or what as needed means. R6 came in with a right heel sore. This is not addressed in the care plan. There are no individualized interventions to heal that wound and prevent others. R6 uses oxygen and there are no interventions put in place to prevent pressure sores behind the ears from the oxygen tubing. On February 10, 2016 at 10:15 AM, E10 stated R6 came in with a discoloration of his right heel. E10 stated she did not assess R6 until a couple of days after he was admitted . E10 stated she did not write any assessment notes on R6 at that time of initial assessment. E10 stated she reviewed the sore and skin history with R6's wife and was told R6 always had scaly skin issues with his feet and if you pulled them off they would bleed. E10 stated when she observed the wound on the right heel on 2/8/16 it did look different than initially and the left heel wound was newly acquired. E10 stated she then had the nurse practitioner look at the wounds. E10 stated none of R6's wounds are considered pressure ulcers. R6 had a history of [REDACTED]. E10 stated concerning R6's arms that are bruised and have multiple skin tears, the physician ordered a [MEDICATION NAME] to be put on the skin tears. E10 stated for protection they just try to be careful during care. They can apply sleeves for protection or ask R6's wife to bring in long sleeve shirts. When asked why none of those interventions were in place E10 stated, I can't answer that. The first wound notes from the Nurse practitioner are dated February 8, 2016 and document, asked to see R6 due to open wounds on heels. This is over two weeks from the initial identification of the right heel wound and the first time the wounds were measured and documented as assessed. The description is: Right heel: full thickness ulcer/ abrasion , base 80% dark purple, 20% pink, small amount of sero-sanguineous drainage, no malodor, surrounding skin peeling/scaly. Measurements are 7.0 CM x 2.7 CM x O CM. R6's initial assessment on admission did not have measurements but was described as small quarter sized. Left heel : Full thickness ulcer/abrasion base 90% pink, 5% slough,5% purple, scant sero-sanguineous drainage, no malodor, surrounding skin peeling/scaly. Measurements: 1.7 CM x 1.0 CM x 0 CM. R6's nursing notes were reviewed from admission January 24, 2016 until February 10, 2016. On January 27, 2016 there is a nursing note that documents, Assessed bilateral heels and feet. Skin dry with diffuse areas of flaky tissue. Intact reddened bunion area on the lateral side of ball of right foot. R6 complains of pain to right side heel of the right foot when the foot is flat on the bed. Will elevate right heel with pillows when R6 is in bed. RN to re assess in the morning. The next skin related nursing note is January 29, 2016 which documents R6 complained of pain on his buttocks and was put to bed to get pressure off buttocks but refused to be turned. Neither of these days shows a thorough assessment was done of these areas nor was there any documentation that the physician was notified. There is no re-evaluation of these areas or interventions. On February 10, 2016 at 11:15 AM, Z2 (Physician) stated the Nurse practitioner had notified him on February 8, 2016 about R6's heel wounds Z2 stated these are from his feet being dependent on the mattress. Z2 stated R6 does have some degree of PAD (peripheral artery disease) but not to the extent to cause this. Z2 stated if it was related to PAD he would expect the wounds to start in his toes not the heels. The heel wounds are definitely pressure related. Z2 stated the wounds could definitely have been prevented by getting him out of bed or keeping pressure of his heels. Z2 stated he was not made aware of the wound on R6's buttocks. Z2 stated he was told R6 had a rash from the hospital not a wound. The facility policy dated January 2013 titled, Skin Practice Guide, documents the purpose of the guide is to describe the process steps for identification of residents at risk for developing pressure ulcers and identify interventions to assist with management of pressure ulcers and skin alterations. UnderMedical Guide Initiative, it shows residents admitted with skin alterations are evaluated by a health professional(MD, NP-Nurse Practitioner, or wound specialist) within 24 hours. This was not provided to R6. R6's Primary physician notes do not address or document any of his wounds. R6 was not seen by the NP until February 8, 2016, over two weeks since admission. The guide also documents under, Initial Plan of Care, Upon completing the initial plan of care, a resident specific care plan to include prevention , management and interventions with measurable goals. This was also not evident in R6's initial plan of care. The facility policy titled Skin Practice Guide. Dated January 2013 documents, the initial plan of care should have a patient specific care plan with measurable goals to prevent pressure ulcer development, promote healing and prevent infection. The policy under palliative care and advance care planning address the goals of wound care at the end of life. The interdisciplinary team, patient and family are involved in establishing those care plan goals and making decisions for future care. Care planning discussions are documented in the clinical record and integrated into the residents care plan. On February 9, 2016 at 2:50 PM, E4 (assistant director of nursing) stated R11 was admitted to the facility on [DATE] with a right hip brace following a fracture at home. R11 had no skin issues until February 2, 2016 when a small wound was identified on the lower right leg. Nurse's note dated February 2, 2016 at 10:33 AM, shows R11, complains of right lower leg pain. [MEDICATION NAME] given, effective result noted, wearing Newport brace on at all times, ambulatory with walker while in therapy. E4 said there is no documentation showing this complaint of pain was evaluated at the time. The next nursing entry is 12 hours later, on February 2, 2016 at 11:47 PM, and states a skin check was done at that time and an open area to the right posterior ankle, 1.0 x 1.5 x 0.5 moist with scant discharge, was observed. The Skin surrounding the area was reddened and swollen. E4 stated R11's brace remained on until February 4, 2016, even after staff identified the wound on February 2, 2016. Nurse's note dated February 4, 2016 at 11:46 PM, states, Noted skin surrounding wound has bruising which was not present during initial assessment on 2/2/16. Nurse Practitioner note dated February 5, 2016 at 1:39 PM, states, nursing staff noted unstageable pressure ulcer of right Achilles r/t brace yesterday. 2.0 x 3.5 x 0. Base 80% pink, 20% slough, serosang drainage. On February 9, 2016 at 2:50 PM, E4 stated R11's right Achilles pressure ulcer was a DTI (deep tissue injury) that opened up on February 5, 2016, and this is why the size doubled from over the course of two days. E4 confirmed R11 developed this wound in the facility, most likely caused by the brace. A Medical Practitioner Progress Note dated February 9, 2016 shows the right lower leg is described as an unstageable pressure ulcer as of the assessment on February 9, 2016: base 90% slough, 10% pink and small amount serosang drainage. R11 was sitting in her wheelchair on February 9, 2016 at 2:00 PM. The wound to R11's right Achilles was observed to be mostly slough with minimal amount of drainage. R11 said she thought the wound was caused by the brace she use to wear and it doesn't hurt as much as it use to. R13's electronic medical record under [DIAGNOSES REDACTED]. According to E10's (treatment nurse) note, R13 was found to have fluid filled blisters on both heels during ADL care on 12/08/15. The right heel was measured at 4.0 x 5.0 x 0 cm (centimeters), stage 2. The left heel measured 3.0 x 3.0 x 0 cm., stage 2. Z5, NP (nurse practitioner) documented both heels as stage 2 pressure ulcers and ordered skin prep daily, if blister ruptures discontinue skin prep and start [MEDICATION NAME] daily with dry gauze. Z5 also ordered pressure relieving boots when in bed. R13's initial care plan dated December 01, 2015 was reviewed. R13 was noted to be at risk for alteration in skin integrity related [MEDICAL CONDITION] and Braden identified risk areas for pressure ulcers. Interventions on the care plan were non specific. One intervention was to encourage to reposition as needed; use assistive devices as needed and float heels as able There were no specific devices listed to be used in the plan. R13's dressing change was observed on February 09, 2016 along with Z5 and E10 (treatment nurse). R13's pressure relieving boots were on the chair. Z5 stated the pressure relieving boots work better because they stay in place. However, the pressure relieving boots were not ordered until both of R13's heels broke down.

Based on interview and closed record review, the facility failed to utilize necessary fall preventive measures and provide supervision for 4 of 27 sampled residents, R3, R22, R24 and R26. One resident, R26 ' s fall resulted in head injury. R26 was transferred by ambulance to the emergency room and diagnosed with [REDACTED]. Findings include: R26 is an [AGE] year old resident admitted to the facility on [DATE] for skilled care due to Dementia, muscle weakness, abnormal gait and history of Cerebrovascular accident. The minimum data set (MDS) shows R26 as needing extensive assistance with 2 person physical assist for transfer to toilet. R26 has minimal difficulty with hearing, moderately impaired vision and usually understood with prompting or if given time to respond. Although preferred language is not coded on the MDS, R26 does not use an interpreter for communication. Care plan states R26 has cognitive communication and self care deficit, and at risk for falls with intervention to ensure chair alarm is in place when in bed and wheelchair. Nursing notes dated [DATE] states at 9am R26 was taken to bathroom by E13, Certified Nurses Aid (CNA) and sustained a fall from the wheel chair to the bathroom floor landing in a face down position. R26 was assessed by E14, Nurse, and found with moderate amount of nose bleeding, alert and responsive. E14 turned R26 on to back and noted a 1 x 1 centimeter abrasion on occiput and forehead. E14 wrote " no complaints of pain or discomfort noted. Unable to express what happened d/t (due to) history of cognitive deficit, unclear speech and language barrier, speak Polish " . R26 was put back in wheelchair, no shortness of breath or distress noted. At 9:40am R26 complained of neck pain, put back to bed. At 10:40am, R26 was transferred by ambulance to the emergency room and diagnosed with [REDACTED]. On [DATE] at 3pm, E3, Director of Nursing, (DON), told surveyor that R26 did not return to the facility. E3 stated that it is her understanding that R26 experienced post-operative complications while in hospital and passed away. E3 stressed that she is not sure of the accuracy of this information and would have to contact the hospital for more information. The facility reported the incident to the State agency on [DATE] and initiated an investigation on [DATE]. The final report was completed on [DATE] concluding that R26 " was attempting to self transfer to the toilet prior to completion of transport in the wheel chair " resulting in the fall. Interviews were conducted with E13, CNA, E14, Nurse, E15, CNA and E16, Physical Therapist. E2, Assistant Administrator, was present during each of these interviews for reasons, according to E2, that these staff persons were nervous about the interview process and requested her presence. Facility's investigation states E13, with help of Z3, transferred R26 from sitting to standing with walker and then to wheelchair. E13 noted R26 ' s buttocks at the edge of the wheelchair while approaching the toilet and R26 attempting to stand. E13 attempted to grab for R26 to pull him back onto chair and was unable to. During an interview with surveyor on [DATE] at 11:30am, E13, who appeared to be extremely nervous, stated she was unfamiliar with R26 and this was her first time taking care of him. R26 was in bed and needed to be transferred to wheel chair and then to toilet. E13 with the help of Z3 assisted R26 to his feet and, and with use of the walker, guided R26 to a sitting position in the wheel chair. Once in the bathroom, R26 began to slide his body toward the edge of chair, attempted to stand, lost his balance and fell near the sink. E13 was positioned behind R26 and behind the wheelchair and not able to catch R26 to prevent fall. E13 said " he was outside my reach " . E13 does not remember if R26 hit his head on the sink. E13 had no assistance with the transfer from wheelchair to toilet. E13 did not mention using a gait belt during transfer. R26's care plan did not address use of gait belt for transfer, however, facility ' s policy states gait belt to be used as necessary. E15, CNA, told surveyor during an interview on [DATE] at 1:20pm, that she usually take care of R26 but was off the schedule on the day of the fall. E15 stated that when she transfers R26 she would assist him from lying to sitting position, apply a gait belt, assist him to stand, and while still supporting him with the use of the gait belt, allow him to make small pivoting steps until positioned in front of the wheel chair and ease him down to sit. E15 performs a one person assist transfer from bed to chair and from chair to toilet. E15 stated she never uses the walker to assist with transfers and when transferring from wheel chair to toilet, once in the bathroom she steps in front of R26 while he is still seated, prompt him to grab the wall mounted hand bar and pull himself to a standing position, remove the wheel chair and guides and assist him to ease himself down onto the toilet. Facility's investigation states E14, Nurse, evaluated R26 prior to transfer back to chair and that R26 ' s range of motion (ROM) was within normal limits. R26 was transferred back to toilet and then back to wheelchair and 40 minutes later, while still in wheelchair, complained of neck pain. During interview with surveyor on [DATE] at 12:25pm, E14 stated she does not know what level of assistance R26 requires for transfers as she, E14 , never transfers him. E14 was at nurse ' s station when E13 came and said R26 was on the floor. E14 describes R26 to be alert and responsive at the time and stating he had no pain. E14 said she performed neurological exam which was normal and with 4 persons assist, assisted R26 back to wheelchair. Surveyor asked E14 to describe how R26 was transferred from the floor to the wheelchair. After a very long pause E14 said she placed a sheet on the floor next to R26's body, he was made to sit up, and a gait belt was applied to R26's waist. E14 then recanted the statement of placing a sheet on the floor next to R26. E14 said R26 was pulled to standing position using the gait belt and assisted to sitting position in the wheelchair. R26 ' s nose was bleeding and had an abrasion on top of head, and made no complaints of pain. R26 was then wheeled back into the room and sat in wheelchair near the bed. E14 stated that E16, Physical Therapist, then took R26 back to the toilet. E14 stated about ,[DATE] minutes later she went back to R26 ' s room and asked if he was in pain, at which time R26 complained of pain, pointing to his neck. E14 does not remember if R26 described nor rated his pain. E14 went on to say that R26 could only speak single words in English as he was Polish speaking and she, E14, requires a translator when communicating with R26. E16, Physical Therapist, told surveyor during an interview on [DATE] at 2:30pm that he works with R26 on a regular basis, and that R26 was showing improvement with ambulating. E16 stated R26 had limited hip abduction. E16 want on to say he went into R26 ' s room on the day of the fall to do a routine check and encountered Z3 in the hall upset, saying R26 had fallen earlier in the day. E 16 entered R26 ' s room to find him, R26, on the toilet, unattended, trying to get up. E16 said he was afraid R26 would fall again so he transferred R26 to his wheelchair. E16 stated that during therapy R26 is transferred with ' moderate ' assist requiring 1 person. E16 went on to say that R26 has poor trunk control due to a history of hip injury in the past. Facility's report states R26 fell at 9:00am. Hospital records shows R26 was assessed in the emergency room (ER) at 10:56 am, two hours after the fall. ER record states R26 arrived with numerous skin tears to head, the forehead, left elbow and left hand and " apparently he struck left side of the head on the sink " . R26 underwent surgical repair of the fractured cervical vertebrae and died on the 6th post fall day. R24 is a [AGE] year old resident with a history of multiple falls, unsteady gait, poor sitting balance, pelvic rocking movements, Dementia and poor safety awareness. Nursing notes dated [DATE] states that a certified nurse ' s aid (CNA)was transferring R24 from bed to wheelchair and eased R24 down to the floor. Facility ' s investigation of this incident revealed that the CNA did not seek help to perform the transfer and failed to read the transfer orders for use of a mechanical lift with 2 persons assist. R3 is an [AGE] year old resident with muscle weakness, Arthritis and chronic pain and history of multiple falls. Assessment done on [DATE] shows R3 has short and long term memory problem Incident Report dated [DATE] states R3 was found on the floor in front of her wheelchair, in the main dining room at 10am, during church service, sustaining a 3 centimeter laceration to her right forehead. Report states R3 was attempting to reach for a piece of paper on the floor. R3 was sent to the hospital. Prior to fall R3 was described as alert. R3 has a known history of right foot drop with loss of leg movement, and incident investigation states R3 refused to use the foot rest on the day of fall. R22 is an [AGE] year old resident with history of muscle weakness and Paralysis Agitans. R22 observed spending most of the time in his wheelchair. R22 told surveyor that he sustained a fall less than 2 weeks ago. Review of facility incident report log did not reveal an incident report which was presented to survey team upon request. Incident report dated [DATE] states R22 was found on the floor of his bathroom near his wheelchair. R22 stated he lost his balance and could not reach his wheelchair. There were no injuries upon assessment. The investigation states that the CNA, after transferring R22 to the toilet, left the room, failing to ensure that the wheelchair was locked. R22 tried to transfer himself off the toilet but the wheel chair rolled away from him as he tried to sit. R22 ' s MDS states he requires extensive 2 + persons physical assistance with transfer.

Based on closed record review and interview, the facility failed to provide to implement necessary transfer technique for one of 27 sampled residents, R26, who sustained head and neck injuries resulting from a fall. Findings include: R26 is an [AGE] year old resident admitted to the facility on [DATE] for skilled care due to Dementia, muscle weakness, abnormal gait and history of [MEDICAL CONDITION]. The minimum data set (MDS) shows R26 as needing extensive assistance with 2 person physical assist for transfer to toilet. R26 has minimal difficulty with hearing, moderately impaired vision and usually understood with prompting or if given time to respond. Although preferred language is not coded on the MDS, R26 does not use an interpreter for communication. Care plan states R26 has cognitive communication and self care deficit, and at risk for falls with intervention to ensure chair alarm is in place when in bed and wheelchair. R26 was taken to bathroom by E13, Certified Nurses Aid (CNA) on [DATE] and sustained a fall from the wheel chair onto the bathroom floor, landing in a face down position. E13 is unfamiliar with R26 ' s transfer needs as this was her first time taking care of him. E13 is employed on a prn (as needed) basis. E13 noted R26 ' s buttocks at the edge of the wheelchair while approaching the toilet and R26 attempting to stand. E13 attempted to prevent the fall but was unable to as R26 was outside her reach. E13 had no assistance with the transfer from wheelchair to toilet. E13 did not mention using a gait belt during transfer. R26 ' s care plan did not address use of gait belt for transfer, however, facility ' s policy states gait belt to be used as necessary. Immediately following the fall R26 was assessed by E14, Nurse, and found with moderate amount of nose bleeding. Nurses notes states E14 turned R26 on to his back and noted a 1 x 1 centimeter abrasion on occiput and forehead. E14 wrote " no complaints of pain or discomfort noted. Unable to express what happened d/t (due to) history of cognitive deficit, unclear speech and language barrier, speak Polish " . R26 was put back in wheelchair, and breathing assessed. At 9:40am R26 complained of neck pain and put back to bed. At 10:40am, R26 was transferred by ambulance to the emergency room and diagnosed with [REDACTED]. Facility ' s investigation states E14 evaluated R26 prior to transfer back to chair and that R26 ' s range of motion (ROM) was within normal limits. R26 was transferred back to toilet and then back to wheelchair and 40 minutes later, while still in wheelchair, complained of neck pain. During interview with surveyor on [DATE] at 12:25pm, E14 stated she is unfamiliar with the level of physical assistance R26 needs. E14 describes R26 to be alert and responsive upon assessment and stated he had no pain. E14 said she performed neurological exam which was normal and, with 4 persons assist, transferred R26 from sitting position, to wheelchair. E14 gave conflicting information on how R26 was transferred. R26 was wheeled back into the room and remained in the wheelchair near the bed. E14 stated that E16, Physical Therapist, took R26 back to the toilet. E14 stated about ,[DATE] minutes later she went back to R26 ' s room and asked if he was in pain, at which time R26 complained of neck pain. E14 went on to say that R26 could only speak single words in English as he was Polish speaking and she, E14 requires a translator when communicating with R26. Neither E13 nor E14 speak Polish. Incident investigation states it was 40 minutes before R26 complained of pain in the neck. Interview with E16 produced inconsistent information. E16 denied taking R26 back to the toilet but instead went into R26 ' s room and found him on the toilet, unattended, trying to get up. E16 said he was afraid R26 would fall again so he transferred R26 to his wheelchair and back to the bedside. E16 said that R26 has poor trunk control and limited hip abduction due to a history of hip injury in the past. R26 underwent surgical repair of the fractured cervical vertebrae and died on the 6th post fall day.