Every finding on record at Pearl of Montclare, The

Based on observation, interview, and record review, the facility failed to a.) ensure medications were administered as ordered by the resident's physician and b.) provide pain management in accordance with the resident's comprehensive care plan and resident's goals for care and preferences. These failures affect two (R1, R2) out of four residents and caused R1 to experience severe pain while recovering from a spinal fracture in the facility.Findings include: R1's Face sheet documents that R1 was admitted to the facility on [DATE], with diagnoses not limited to wedge compression fracture of fifth lumbar vertebra, malignant neoplasm of unspecified site of unspecified female breast, and secondary malignant neoplasm of bone.R1's MDS/Minimum Data Set, dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R1 is cognitively intact.R1's POS/physician order sheet documents in part the following orders: Hydrocodone-Acetaminophen (Norco) Tablet 5-325 MG *Controlled Drug* Give 2 tablet by mouth every 6 hours as needed for moderate to severe pain. Do not exceed 3000 mg acetaminophen per day from all sources- Start date 06/02/2026.Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate)- Give 1 tablet by mouth every 12 hours as needed for moderate to severe pain. Can give if severe pain after therapy session- start date 06/02/2026.On 07/11/2026 at 9:54AM, V9 (Licensed Practical Nurse/LPN) located on the first floor 1C unit performing a medication administration pass for R1. Surveyor informs V9 of the need to observe V9's medication pass. V9 unlocks the medication cart and quickly pulls a bingo card out of the narcotic lock box, puts two tablets into a clear medication cup, quickly places the bingo card back into the narcotic lock box and locks it. Surveyor inquires to V9 about the accuracy of the medication that she just placed into the medication cup. V9 then unlocks and reopens the narcotic lock box and observes R1's Norco medication bingo card. V9 compares R1's Norco bingo card to R1's Norco reconciliation drug count sheet and observes that she did not remove R1's Norco medication from the bingo card and R1's Norco drug count is still the same as the reconciliation drug count sheet. V9 then grabs a bingo card labeled in part as follows: Hydrocodone-Acetaminophen (Norco) 5-325mg with R2's name. V9 then compares R2's Norco bingo card to R2's Norco reconciliation drug count sheet and observes that the count does not match the number of pills inside of the bingo card. V9 states she has not yet administered Norco to R2 today. V9 states she must have been moving too fast and grabbed R2's Norco medication and placed it inside the medication cup to be administered to R1. V9 states she will now take R2's Norco medication pills and tape them back into R2's Norco bingo card and administer R1's correct medication to R1. V9 is then observed walking to the nurses' station with R2's Norco bingo card and placing the pills back into the bingo card, placing tape behind the pills to secure them into the bingo card and then placing R2's Norco bingo card back into the narcotic lock box.On 07/11/2026 at 9:22AM, R1 states she has been living in the facility for approximately 6 weeks and was admitted for short term rehabilitation due to a fracture in her spine. R1 states she is prescribed Norco for her back pain, and this medication works for her. R1 states from 06/13/2026 to 06/16/2026, her Norco medication was not administered to her in the facility. R1 states the facility forgot to reorder her Norco medication in time, and this caused her to be in severe pain. R1 states her pain rating was between 7/10 to 10/10 during the time she went without her Norco medication. R1 states the facility tried to give her other pain medications, but they were not effective at managing her pain. R1 states she continued to experience pain in her lower spine that radiated down to her right hip. R1 states she receives therapy five days a week in the facility, and her Norco medication is what helps her to participate in therapy because Norco is effective at relieving her pain. R1 states multiple nurses tried to retrieve her Norco medication from the emergency supply located in the automated medication dispenser/AMD but were not successful in doing so. R1 states she had to wait to receive her Norco medication until it was delivered from the pharmacy after approximately three days. R1 states she spoke with V2 (Director of Nursing/DON) and made her aware that she had not received her Norco medication in 3 days. R1 states that V2 did not offer an apology for R1 having to be in severe pain and V2 did not express sympathy for R1's pain.On 07/11/2026 at 3:16PM, V9 (LPN) states she is not sure why R1 did not have her Norco medication on hand in the facility. V9 states she administered the pain medication Morphine to R1 during the time that R1 did not have her Norco medication. V9 states R1 informed her that Morphine or Acetaminophen pain medication doesn't do anything for managing R1's pain.On 07/12/2026 at 9:36AM V16 (Pharmacy Customer Service Representative) states R1's Hydrocodone-Acetaminophen (Norco) medication was first ordered from the facility on 06/02/2026 and delivered to the facility on [DATE]. V16 states this medication consisted of a five-day supply of 32 tablets. V16 states the next order for R1's Norco medication refill was received on 06/07/2026 and it was delivered on 06/07/2026 to the facility. V16 states for this refill, the pharmacy sent a five-day supply of 30 tablets to the facility. V16 states the next order for R1's Norco refill was not received until 06/16/2026, nine days after the previous five-day supply was delivered to the facility. V16 states R1's Norco refill order received on 06/16/2026, was delivered to the facility on [DATE] at 3:12PM and received by V15 (LPN). V16 states the facility should have an emergency supply of Norco medication that is kept in the AMD in the facility. V16 states the facility is responsible for contacting the pharmacy to inform the pharmacy if a certain medication has been depleted and needs to be refilled in the AMD. V16 states all staff nurses and the DON/Director of Nursing should have access to the AMD in the facility. V16 states if a staff needs to get access to the AMD, the nursing staff should enter a request to the pharmacy then the pharmacy sends a code back to the facility's designated telephone number via text message. V16 states this is how an access code is retrieved in order to gain access to the AMD for emergency supply medications.On 07/12/2026 at 12:29PM, V2 (Director of Nursing/DON) states she remembers that sometime in June 2026, she received a call from V17 (LPN) informing her that she was trying to retrieve Norco medication from the AMD in the facility. V2 states she gave V17 instructions on how to successfully retrieve the Norco medication and V17 should have administered the Norco medication to R1 once it was retrieved from the AMD. V2 states as of right now, she is not sure if V17 successfully retrieved the Norco medication from the AMD to administer to R1. V2 states sometime in June 2026, she spoke with R1 when R1 called her office and informed her that R1 did not receive her narcotic medications. V2 states she also remembers another nurse informing her that the nurse was having issues with obtaining a new Norco prescription to send to the pharmacy. V2 states she is not sure who this nurse was but V2 gave the nurse instructions to contact the medical director or the therapy director to retrieve a new Norco prescription for R1 to send to the pharmacy. V2 states she is not sure how long R1 went without having her Norco pain medications in the facility. V2 states residents' medications are refilled by the nurses by either calling the pharmacy or refilling through the resident's electronic health record/EHR system. V2 states the facility's AMD is automatically restocked by the pharmacy based on the electronic inventory. V2 states the pharmacy usually makes a delivery in the late evening to restock the emergency medications in the AMD. V2 states she has never contacted the pharmacy to inform then that the AMD has to be restocked. V2 states pharmacy keeps track of this on their own. V2 states to her knowledge, the facility has never been without Norco stocked in the facility's AMD. V2 states all the nursing staff working in the facility should have access to the AMD and is aware that there is a telephone number to call to retrieve an access code. V2 states the importance of making sure residents receive their prescribed pain medication is to relieve pain and give the resident comfort. V2 states that if a resident's pain is still uncontrolled, then the physician should have been contacted to see if a different pain medication could have been ordered or if other pain management modalities could have been implemented per the physician orders. V2 states if a resident's pain is not controlled, then this could lead to the resident still being in pain, not wanting to eat or participate in activities, and it will affect their quality of life. On 07/12/2026 at 1:08PM, surveyor located inside of the unit 2C medication storage room with V2 (DON) and V9 (LPN). V2 states she does not have access to the AMD. V9 observed logging into the AMD. Surveyor observes that the facility's AMD documents that the medication Norco 5-325mg was retrieved from the AMD by V17 (LPN) on 06/16/2026 at 7:36AM and 7:37AM.R1's MAR/medication administration record dated 06/2026 and Norco drug sheet dated 06/2026 does not document that Norco was administered to R1 by V17 (LPN) or any other nurse on 06/15/2026 during the 11:00PM-7:00AM shift or on 06/16/2026 during the 7:00AM-3:00PM shift.On 07/12/2026 at 4:06PM, V2 states she is aware that V9 (LPN) taped R2's Norco medication back into the bingo card. V2 states that this is not the proper protocol to follow and V9 (LPN) has since been in-serviced regarding the proper way to dispose of narcotic medications.Facility's list of medications located inside the Automated Medication Dispenser/AMD dated 07/12/2026 documents that medication Hydrocodone-Acetaminophen 5-325mg is inventoried inside the facility's AMD.Record review documents that R1's pain rating was a 10/10 on 06/13/2026 during the 11:00PM-7:00AM shift. R1's Norco medication was then administered by V8 (LPN) at 2:24AM on 06/14/2026. R1's Norco drug count sheet documents a count of 0 after V8 administered R1's Norco on 06/14/2026 at 2:24AM.R1's pain rating was an 8/10 during the 7:00AM-3:00PM shift on 06/14/2026. R1's Norco medication was not administered during this shift. Morphine Sulfate 1 Tablet 15 MG was administered by V9 (LPN) at 9:55AM during this shift.R1's pain rating was a 7/10 during the 3:00PM-11:00PM shift on 06/14/2026. R1's Norco medication was not administered during this shift. Morphine Sulfate 1 Tablet 15 MG was administered at 10:06PM during this shift.R1's pain rating was a 10/10 during the 11:00PM-7:00AM shift on 06/14/2026. R1's Norco medication was not administered during this shift. Morphine Sulfate 1 Tablet 15 MG was administered at 2:16AM during this shift.R1's pain rating was a 10/10 during the 7:00AM-3:00PM shift on 06/15/2026. R1's Norco medication was not administered during this shift. R1's Morphine Sulfate was not administered during this shift.R1's pain rating was a 10/10 during the 3:00PM-11:00PM shift on 06/15/2026. R1's Norco medication was not administered during this shift. R1's Morphine Sulfate was not administered during this shift.R1's pain rating was a 10/10 during the 11:00PM-7:00AM shift on 06/15/2026. R1's Norco medication was not administered during this shift. Morphine Sulfate 1 Tablet 15 MG was administered at 12:34AM during this shift.R1's pain rating was documented as 0/10 during the 7:00AM-3:00PM shift on 06/16/2026. R1's Norco medication was not administered during this shift. R1's Morphine Sulfate was not administered during this shift.R1's pain rating was documented as a 0/10 during the 3:00PM-11:00PM shift on 06/16/2026. R1's Norco medication was then administered during this shift by V15 (LPN) at 10:00PM.R1's care plan dated 06/05/2026 documents in part, The resident has acute/chronic pain related to fracture of the L5 (lower back) vertebra, Arthritis, Cancer of the bone, breast cancer, and liver cancer and history of Left TKA (Total Knee Replacement). Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.Facility policy dated 03/20/2020 titled Medication Administration documents in part, All medications are administered safely and appropriately. Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. Read each order entirely. Remove medication from drawer and read label three times; when removing from drawer, before pouring and after pouring.

Based on observation, record review, and staff interview, the facility failed to ensure hot foods were served and maintained at safe and appetizing temperatures during meal service, in accordance with facility policy. This deficient practice had the potential to affect all 106 residents receiving food from the kitchen and placed residents at risk for receiving unappetizing meals, reduced food intake, decreased nutritional status, dissatisfaction with meals, and possible foodborne illness from improper food temperature control. The findings include: Facility CMS-671 documents a census of 108. V9, Administrator, stated there are 2 residents that are not receiving food from the kitchen. On 5/22/2026 at 10:58 A.M. R2 stated food is terrible, The quantity is not enough and some of the food is overcooked. Food is always cold. I don't bother to ask them to reheat it, I just eat it. This morning, I had eggs, and they were cold.The Minimum Data Set (MDS) dated [DATE], shows R2's cognition was intact with a fifteen out of fifteen points required on the Brief Interview for Mental Status (BIMS). On 5/22/2026 at 2:45 P.M, R4 was wheeling himself down back to his room after lunch service. R4 stated food during lunch was not warm enough for R4 today and it's always served cold. R4 stated R4 has told the Chef during food committee meetings about his concerns about food being served cold several times already. The Minimum Data Set (MDS) dated [DATE], shows R4's cognition was intact with a fifteen out of fifteen points required on the Brief Interview for Mental Status (BIMS). On 5/22/2026 at 2:52 P.M. R5 stated she is the Resident Council President and affirmed food is served cold often and has heard this concern from other residents as well during the monthly food committee meetings with V5, Dining Services Director present. On 5/22/2026 at 11:30 A.M. during meal service observation in the kitchen with V5 (Dining Services Director) and V6 (Cook), meal tray temperatures were checked prior to service and measured as follows: fish 176 F (degrees Fahrenheit), sweet potatoes 171 F, mashed potatoes 165 F, and peas with mushrooms 180 F. V5 stated the 1st floor is served first, then 3rd floor followed by 4th floor and the 2nd floor is served last.At 12:05 P.M., after the last tray was served on the 1st floor, temperatures taken from the test tray revealed: fish 114 F, sweet potatoes 132 F, and peas with mushrooms 104 F. V5 stated food temperatures should hold at 165 F but temperatures drop while trays are transported and delivered to residents.At 12:36 P.M., after the last tray was served on the 2nd floor, temperatures from the test tray revealed: fish 90 F, sweet potatoes 126 F, and peas with mushrooms 93 F. V5 stated these temperatures were not acceptable and acknowledged the 2nd floor did not have the same insulated hotbox meal carriers used on other floors. V5 further stated food not maintained at required temperatures presents a potential health hazard and will correct it right awayOn 5/22/206 at 12:31 P.M. V3, Certified Nursing Assistant (CNA), stated she has received multiple complaints about food being served cold and she had to reheat the resident's meal tray in the microwave in the kitchen. The last time V3 received a complaint about cold food was a couple of weeks ago. Today no one complained of cold food to V3. On 5/22/206 at 12:31 P.M. V7, Medical Records Supervisor/CNA, stated she delivers meal tray on 2nd floor daily but has not received any complaints about food being served cold.On 5/23/26 at 10:08 A.M., V8 (Dietary Technician) stated residents had raised concerns during food committee meetings regarding food not being served at an optimal temperature, although those concerns were not documented in meeting minutes because V8 addressed them verbally to state if they were to receive cold food, we can offer them a new plate in the kitchen and we can warm it up for them. V8 also stated, V5 is also present at those meetings so she would address those concerns regarding cold food as well. V8 stated the residents do bring up concerns about food being cold in the past several times, but last meeting in May they didn't bring it up. V1 presented facility policy on Sanitation and Food Safety which documents under Hot Food: Hold at 135 F or greater throughout the ervide process.

Based on observation, interview, and record review the facility failed to ensure the low air loss mattresses were used in accordance with facility policy to promote effective pressure redistribution (inappropriate layering of multiple linens) for two residents (R2 and R4); and failed to ensure a resident (R5) with a acquired stage 4 pressure ulcer received wound care as ordered by the physician resulting in the development of a wound infection, requiring IV (intravenous) antibiotic therapy. These failures affected 3 of 3 residents (R2, R4 and R5) reviewed for pressure ulcers in the sample of 61. Findings include: R5 has a diagnosis which includes but not limited to reduced mobility, sepsis, other lack of coordination and non-ischemic myocardial injury. R5's Brief Interview for Mental Status (BIMS) dated 2/10/26 shows that R5 has a score of 7 which indicates that R5 has some cognitive impairments. On 3/30/26 at 10:12 am, Surveyor observed V2 (Director of Nursing, DON) administer R5's IV antibiotic's, identified as Vancomycin. During this interview V2 stated that the IV antibiotics was prescribed for R5's sacral wound infection. On 03/21/25 at 9:06 am, Surveyor observed V8 (Registered Nurse, RN, Wound Care Nurse), V11 (Restorative Aide), and V10 ( R5's Physician) perform wound care on R5's acquired stage 4 sacral wound that had 100 % necrotic tissue, foul odor, moderate serous drainage, and visible bone exposed. V10 stated that R5's wound had a foul odor and that R5 was receiving IV antibiotic's for sacral wound infection. V10 was then observed performing bedside sharps debridement to R5's sacral wound removing necrotic tissue. On 4/1/26 at 10:00 am, V8 (Registered Nurse, RN, Wound Care Nurse) stated that she has been the wound care nurse for eight days at the facility. V8 explained that R5's sacral wound was a stage IV pressure ulcer with mild odor and drainage when V8 first observed R5's sacral wound. V8 then stated that R5 currently has wound care orders for sacral wound treatment every shift and IV antibiotics Vancomycin for his sacral wound infection. V8 stated that nurses should treat a residents wound per the physicians orders on the residents physicians orders sheet (POS) and that empty boxes on the resident Treatment Administration Record (TAR) indicates that the nurse did not sign off on the wound care and the treatment was not performed. V8 further explained if a residents treatment is not performed the wound can decline and it may cause an infection. V8 also stated that during the times of R5's missing signatures on his TAR that indicate that R5 did not have treatment rendered, V8 was not employed at the facility. On 4/1/26 at 10:30 am, V2 (Director of Nursing, DON) stated that pressure ulcers began at a stage 1 with un-blanchable redness. V2 then explained when R5's acquired sacral wound was first observed on 3/6/26, she observed R5's sacral wound as an unstageable pressure ulcer with necrotic tissue. V2 then explained that nurses follow the physicians orders and Treatment Administration Record (TAR) to treat the residents wounds. Surveyor and V2 reviewed R5's current TAR for R5's sacral wound treatment order with no documentation on 3/12/26, 3/14/26, 3/17/26 and 3/21/26. V2 explained that on 3/12/26, 3/14/26, 3/17/26 and 3/21/26 treatment was not rendered for R5's sacral wound and that if treatment is performed the nurse must document performing the treatment by signing the residents TAR. V2 then stated, If a resident does not receive treatment as ordered by the physician there is a potential for the wound to decline and potential for infection in which he (referring to R5) is currently being treated for. V2 then explained R5's sacral wound was first observed as a unstageable pressure ulcer wound on 3/6/26 and was able to be staged as a stage 4 on 3/24/26 with bone exposed. On 4/1/26 at 1:04 pm, V10 (R5's Wound Care Physician) stated that he has treated R5's sacral wound for the last 3 weeks and upon initial treatment of R5's acquired sacral wound, R5's sacral wound presented as a full thickness wound that was beyond the subcutaneous layer with necrotic tissue, moderate serous drainage and no signs of infection that V10 classified as an unstageable wound. V10 then explained that when a pressure ulcer wound initially develops there is non blanchable erythema seen. V10 further explained when a wound is necrotic there is ischemia of the skin over a long period of time, and the capillaries become ischemic the longer the pressure the more ischemic the tissue becomes. V10 then explained that he initially ordered R5's sacral wound with daily wound care with a Santyl dressing. V10 then explained Upon debridement of R5's sacral wound V10 prescribed and order for Dakin's treatment three times a day and ordered IV antibiotics due to concerns for osteomyelitis. V10 also explained that he ordered a x-ray of R5's sacral wound that was negative for osteomyelitis and that V10 then did perform a wound culture with R5's sacral wound because R5's primary care physician reviewed V10's wound care notes and ordered IV antibiotic's to treat R5 for sacral wound infection. V10 stated that if a residents wound care orders are not performed as ordered by the physician the residents wound can worsening, deteriorate, have an increase in bio infectious bacteria and develop a wound infection. On 04/01/26 at 12:00 pm, Surveyor requested R5's initial Wound Assessment Detail report for 3/6/26 when R5's acquired sacral wound was first observed by V2 and V2 stated that there was no documentation for R5's acquired sacral Wound Assessment Detail until 3/9/26. R5's Minimum Data Set (MDS) dated [DATE] shows that is at risk for pressure ulcers and does not currently have unhealed pressure ulcers. R5's Minimum Data Set (MDS) dated [DATE] shows that is at risk for pressure ulcers and has a stage 4 pressure ulcer. The facility's document presented by V3 (Infection Preventionist, IP, Assistant Director of Nursing, ADON, Registered Nurse, RN) shows that R5 is receiving IV (intravenous) Vancomycin 1500 mg (milligrams)/ ml (milliliter) q (every) 12 hours . R5's Physician Order Sheet (POS) active order as of 03/31/26 shows R5 has order for cleanse sacrum wound with NS (Normal Saline) and pack with moist 1/4 strength Dakin's followed by dry 4x4 gauze than (then) a foam border silicone dressing every shift. Every shift for wound care. R5's Physician Order Sheet (POS) active order as of 03/31/26 shows R5 has order for Vancomycin HCL (hydrochloride) use 1500 mg (milligram) intravenously every 12 hours for wound infection until 04/08/2026 23:59 **Pharmacy to dose medication** R5's Treatment Administration Record (TAR) shows that R5 did not receive treatment to his sacral on 3/12/26, 3/14/26, 3/17/26 and 3/21/26. [According to V2 she initially found R5's wound on 3/6/26. However, no wound assessment was completed until 3/9/26. There are no treatment orders for R5's stage 1 on the TAR or POS.] R5's care plan dated 3/6/26 documents in part: Focus: Alteration in skin integrity – Resident has pressure ulcer to sacrum. Intervention: Treat per MD (Medical Doctor) order. R5's Pressure Ulcer Risk assessment dated [DATE], 2/27/26 and 3/2526 shows that R5 is at risk for pressure ulcers. R5's Wound Assessment Detail dated 3/9/26 shows that R5 has facility acquired pressure ulcer identified by V2 (Director of Nursing, DON) on 3/6/26 with measurements of 8.0cm (centimeter) by 6.0 cm by unknown depth, with necrotic hard, firm, adherent 100% without debridement. R5's Wound Assessment Detail dated 3/12/26 shows that R5 has facility acquired pressure ulcer identified by V2 (Director of Nursing, DON) on 3/6/26 with measurements of 11.0cm (centimeter) by 7.5 cm by unknown depth, with necrotic hard, firm, adherent 50% , necrotic soft 50% with debridement. R5's Wound Assessment Detail dated 3/17/26 shows that R5 has facility acquired pressure ulcer identified by V2 (Director of Nursing, DON) on 3/6/26 with measurements of 10.5cm (centimeter) by 7.5 cm by 2.0 cm with necrotic hard, firm, adherent 100% with debridement. R5's Wound Assessment Detail dated 3/24/26 shows that R5 has facility acquired pressure ulcer identified by V2 (Director of Nursing, DON) on 3/6/26 with measurements of 10.5cm (centimeter) by 8.5 cm by 2.5 cm, with necrotic hard, firm, adherent 100% , with debridement. The facility's document dated March 2026 and titled Wound Prevention and Healing documents in part Intent: To provide wound care treatments/services (using a multidisciplinary approach) based on evidence standards of care under the direction of a physician. The facility document dated March 2026 and titled Wound Prevention Healing documents in part: Intent: To provide wound care treatments/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician . 10. Wound Care and Treatment: a. Wound care treatments are provided within an individualized plan of care under the direction of a physician. 11. The Multidisciplinary Wound Care Team: 1. The Wound Care team is responsible for identifying problems, coordinating care, and promoting development of the team and the program. The facility document dated March 2026 and titled Treatment/Services to Prevent/Heal pressure Injury documents in part: Intent: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preference, goal for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Procedure: b. A resident with a pressure injury receives necessary treatment and services consistent with professional standards of practice, that are aimed to promote healing minimize complications and prevent the development of further pressure injury. R2's admission record diagnoses include but are not limited to cerebral infarction, heart failure, peripheral vascular disease, metabolic encephalopathy, hemiplegia and hemiparesis. R2's Minimum Data Set (MDS), dated [DATE], documents in part, Section C. Brief Interview for Mental Status (BIMS) Score is blank. Section M. Skin Conditions: Risk of Pressure Ulcer/Injury documents, resident at risk of developing pressure ulcers/injuries. On 3/30/26 at 11:30 am, R2 was in room lying on a low air loss mattress with multiple layers between R2 and the low air loss mattress. The layers observed under R2 consisted of a flat sheet, an incontinent pad and an incontinent brief. On 3/30/26 at 11:40 am, V18 License Practical Nurse (LPN) stated, There are three layers under R2 and should only be one layer for circulation and wound prevention. Having multiple layers will constrict the flow of the air and defeat the purpose of the air loss mattress, which is to prevent skin breakdown. R2's Physician Orders Set dated 4/1/26 documents, in part, Air loss mattress. R2's risk assessment dated [DATE] documents R2's Braden score is16 which indicates at risk. R2's care plan dated 3/17/26 documents in part, Focus: Alteration in skin integrity. Residents have a vascular wound of the right foot with necrotic tissue. Goal: Create an environment for healing. Intervention: Air loss mattress. R4's admission record diagnoses include but are not limited to reduced mobility, tracheostomy, hypertension, encephalopathy, seizures, hemiplegia and hemiparesis. R4's Minimum Data Set (MDS), dated [DATE], documents in part, Section C. Brief Interview for Mental Status (BIMS) Score is blank. Section M. Skin Conditions: Risk of Pressure Ulcer/Injury documents, resident at risk of developing pressure ulcers/injuries. On 3/30/26 at 12:50 pm, R4 was lying on a low air loss mattress with multiple layers between R4 and the low air loss mattress. The layers observed under R4 consisted of a flat sheet, a flat sheet folded multiple times and an incontinent brief. On 3/30/26 at 12:53 pm, V8 Registered Nurse (Wound Care) stated, There are 6 layers under R4 and there should only be one layer, a flat sheet under R4. All those layers defeat the purpose of the air loss mattress. That many layers are not preventing wounds and can develop wounds which defeat the purpose of the air loss mattress. R4's Physician Orders Set dated 3/27/26 documents, in part, Air loss mattress. R4's risk assessment dated [DATE] documents R4's Braden score is 13 which indicates moderate risk. R4 care plan dated 3/20/26 documents, in part, Focus: Actual Impairment to skin integrity skin tears to coccyx due to shearing. Healed as of 3/27/26 but with scar tissue. Intervention: Air loss mattress. On 4/1/26 at 12:07 pm, V2 Director of Nursing (DON) stated, An air loss mattress should only have a flat sheet. The purpose of air loss mattress is for the air to circulate back and forth to help with the distribution to relieve pressure. Multiple layers don't allow the air to breath and will defeat the purpose of having the air loss mattress. Facility's document titled, Skin Management: Specialty Mattress reviewed date 5/25, documents in part, Procedure: 1. As per manufacture guidelines, no more than 1 piece of linen will be placed between the mattress and the resident. Facility's policy/procedure document titled Specialty Mattress dated March 2026, documents, in part, Intent: It is the policy of the facility to ensure it identifies and provides needed interventions including specialty mattresses to aid in the healing of skin impairments. Procedures: As per manufacture guidelines, no more than 1 piece of linen will be placed between the mattress and the resident. The (undated) low air loss mattress Operation Manual documents, in part, Installation Instructions: Step 2. You may place a thin cotton sheet over the quilted mattress top cover. Operation Instructions: Step 5. Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient.

Based on observations, interviews and record reviews, the facility failed to prepare food in a kitchen where the stove did not drip oil onto the floor and where the dishwasher did not leak puddles of water into buckets. This applies to 101 residents (census of 103 residents minus 2 residents with gastronomy tubes) receiving food from the facility's kitchen. Finding Includes:On 03/30/2026 at 9:23 AM, there was oil dripping from a pipe connected to the kitchen's grill-top stove. There was cardboard placed under/next to the stove to catch the oil drippings. The cardboard contained a puddle of oil about 4 inches in diameter. Also, there was water dripping and seeping from the Hot Water Temperature Dishwasher and there were two large rectangular black buckets placed underneath to catch the leaks. Bugs were flying over the water buckets. V14 (Dietary Manager/Cook) said V14 did not know why oil was dripping from the stove and why the dishwasher was leaking. V14 said V14 would check it. On 3/31/2026 at 8:51 AM, the stove no longer contained cardboard underneath, but oil was still dripping from the stove leaving a puddle of oil on the floor. And hot water was now aggressively seeping from the middle section of the dishwasher. On 3/31/2026 at 9:03 AM, V14 (Dietary Manager/Cook) said the stove was missing a part that needed to be replaced to prevent the oil from dripping and V14 was still not sure why water was leaking from the dishwasher. On 04/01/2026 at 11:05 AM, there was still oil dripping from the stove. And one of the large black containers under the dishwasher contained water about 8 inches of dark liquid that looked like dirty water.V14 (Dietary Manager/Cook) stated they were still waiting for the repairs to be made to both the stove and dishwasher. On 04/01/2026 at 2:54 PM, V1 (Administrator) stated the kitchen is to report any necessary repairs to the maintenance department. V1 stated a pipe that needed to be added to the stove to prevent the oil from dripping and V1 was not sure why the dishwater was leaking. V1 stated that it is expected for the kitchen equipment to be repaired and in working conditions to prevent fires and keep residents safe. The facility failed to follow their undated Kitchen Appliances/Equipment policy which reports to conduct safety and operations inspections by visually inspect all appliances for damage, test functionality of appliances and proper operation of all controls and remove damaged items from kitchen use.

Based on observations, interviews and record reviews, the facility failed to prepare food in a safe sanitizing environment: staff did not wash hands after leaving and returning to food preparation, visibly soiled appliances/serving carts, and sticky floors throughout the kitchen/dining room. This applies to 101 residents (census of 103 residents minus 2 residents with gastronomy tubes) receiving food from the facility's kitchen. Finding Includes:During the puree session on 03/31/2026 starting at 9:32 AM, V16 (Cook) left the food preparation to switch out the blender to a food processor. V16 returned, took the hot dogs from the bin and placed them in the food processor without washing V16's hands. V16 left food preparation again, went to the refrigerator and returned with packaged hot dog buns to puree them. V14 (Dietary Manager/Cook) stated that it is important for kitchen staff to wash their hands upon returning to the food preparation area. On 03/30/2026 at 9:23 AM, the outside of the kitchen's dishwasher was visibly soiled, sticky substances throughout the entire surface. On top of the dishwasher the surface was filled with crumbs and syrupy-like yellowish substances throughout. Dishwasher handles on the inside and outside were also visibly soiled with buildup of yellowish-brown cake-like substances. V14 (Dietary Manager/Cook) agreed that the dishwasher top, surfaces and handles needed cleaning. On 03/31/2026 at 8:51 AM, the 3-level portable gray dining room cart was visibly soiled with what looked like cranberry juice and coffee stains. There were also yellowish-brown substances throughout the surface and corners of the gray cart. On top of the cart were beverages staff served to the residents: coffee, cranberry juice, tea bags, milk, etc. The 3-level portable blue kitchen cart was visibly soiled on the surfaces and in the corners with brown/yellow stains and buildup debris.On 3/31/2026 at 9:03 AM, V14 (Dietary Manager/Cook) agreed that the tray carts were soiled and needed cleaning. On 3/30/2026 at 9:23 AM, the kitchen floor was visibly soiled with buildup of what looked like sticky black substances and dried splatters near the refrigerator and stove aisles. On 3/31/2026 at 8:51 AM, the floors of the second-floor main dining room and dining preparation area were sticky creating suction and significant sounds while walking throughout those areas. The sticky substances were visible blotches and dried up splashes throughout the entire floor.On 3/31/2026 at 9:03 AM, V14 (Dietary Manager/Cook) stated that the floors in the kitchen and dining areas needed to be thoroughly cleaned. On 04/01/2026 at 2:54 PM, V1 (Administrator) stated it is expected the kitchen staff to mop the floor daily and follow up with a floor scrubber for the dining room. V1 added that daily deep cleaning for those areas is important. The facility failed to follow their undated Cleaning Standards policy which documents that non-food contact surfaces must be clean at all times including free of grease deposits, food residue, dust and other soil accumulations/debris. All foods served to residents on a pureed diet must be smooth, moist, cohesive and free of chunks or lumps. The consistency should resemble pudding, mousse, or applesauce with no visible solid pieces.

Based on observation, interview, and record review, the facility failed to ensure proper narcotic control count per facility policy due to the shift verification of controlled substances count form not being signed by one of two nurses (incoming and outgoing nurses) required to count narcotics during shift change and one nurse signing the controlled substances check form on her oncoming and outgoing shift on two floors of four floors reviewed for medication storage and labeling. This failure has the potential to affect 15 residents: 6 residents (R7, R9, R28, R30, R71, and R99) on 3 north cart and 9 residents (R2, R11, R12, R13, R19, R29, R68, R72 and R88) on the 2C cart. Findings include:On 3/31/2026 at 8:41 AM, V25 (Licensed Practical Nurse) verified she had not signed shift verification of controlled substances count form in the red narcotics book that contained 6 residents with controlled substances sheets. V25 stated it is the facility's policy for both nurses to sign the shift verification of controlled substances sheet after the narcotic count has been completed by the oncoming nurse and outgoing nurse. V25 stated the purpose of two nurses signing off on the shift verification of controlled substances count form is to ensure all narcotics are accounted for. On 3/31/2026 at 9:38 AM, V18 (Licensed Practical Nurse) verified she signed her initials on the controlled substances check form at 7:00 am on 3/31/2026 at the start of her shift and at 3:00 PM at the end of her shift on 3/31/2026 at the time she counts with the off going nurse at 7:00 AM and the current time now is 9:38 AM on 3/31/2026. V18 stated she always signed the controlled substances check form for both 7:00 AM oncoming box and 3:00 PM off going nurse times after completing the narcotic count with the offgoing nurse at 7:00 AM. V18 stated That is how we have always done it. V18 stated the purpose of signing the narcotic count is to make sure all narcotics are accounted for. V18 stated she does sometimes pass narcotics on her shift as a prn (when necessary) although she signs the narcotic count sheet at 7:00 AM for the narcotic count slot on the form at 3:00 PM. On 4/01/2026 11:36 am, V2 (Director of Nursing) stated the oncoming nurse counts with the off going nurse and the count should be accurate; the purpose of two nurses signing off on the narcotic count sheets is to verify that the nurse is legally attesting to the medication in the narcotic box and the controlled substance form matches what is in the bingo card; if the narcotic count is incorrect and investigation is started to address the missing medication because the count must be accurate; the narcotic count sheets are signed by 2 nurses at the specific time immediately after the count is completed; and she (V2) has done many in-services on counting narcotics and the nurses knows . Facility's Policy titled Narcotics Storage/Destruction dated 3/20/2026 and last review date 3/27/2026 documents two nurses must count narcotics at the beginning and end of each shift, initialing the narcotic count record. The two nurses should be the incoming and outgoing nurse.Facility's Nurse Supervisor RN/LPN job description undated on page 2 documents: Counts narcotics at the beginning and completion of each shift with the nurse leaving and coming on the shift.

Based on observation, interview and record review, the facility failed to ensure medications were properly stored in a locked medication cart. This failure affected all 11 residents on the 1C unit on the first floor. Findings include:On 3/31/2026 at 11:52 AM, V3 (Assistant Director of Nursing) was observed standing by R4's room at the beginning of unit 1C hallway talking to another staff member with her back facing the medication cart stationed against the wall halfway down the hallway on unit 1C. V3 was informed the surveyor would like to conduct a medication observation with her when she was done speaking with the staff member. Surveyors walked to the nurses' station where the medication cart was stationed and observed the medication cart was unlocked. Minutes later, V3 walked to the nurses' station and verified with the surveyors the medication cart on 1C was unlocked. On 3/31/2026 at 11:56 AM, V3 (Assistant Director of Nursing) stated I pushed the lock in before I left the cart. It must have popped out when I walked away. The lock may be broken. V3 stated the medication cart should be always locked so that no residents or any unauthorized individuals can access medications from the cart. V3 stated if the cart is not locked anyone can access medications from the cart and can cause a huge medication error. On 4/1/2026 at 11:43 AM, V2 (Director of Nursing) stated the medication cart should be locked at all times; the lock does not pop back out; we should always lock the cart when staff are not standing next to the medication cart; anyone can walk up and take medications from the cart; and not locking the medication cart is a safety hazard. Facility policy titled Medication Storage date created 5/19 and last reviewal date 12/2025 documents: Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access.

Based on observations, interviews and record reviews, the facility failed to puree food to a safe consistency which has the potential to cause choking among the recipients. This applies to 9 residents (R1, R20, R22, R24, R61, R62, R65, R76 and R80) in the sample of 9 receiving a puree diet. Findings include:On 03/31/2026 at 9:32 AM, V16 (Cook) pureed lunch menu items of hot dogs, hot dog buns and mashed potatoes. When processing the hot dogs, V16 grabbed a handful of hot dogs (approximately 5) and placed them in a blender along with a half cup of liquid. The results were a lumpy, bumpy and gritty texture. To correct this texture, V16 blended the components again. Then, V16 opened and placed both hands in the blender to check for smooth consistency. V16 repeated this kneading three times without success. V16 said this is how V16 determined the correct consistency by feeling the substance. V16 did not taste the purees. V14 (Dietary Manager/Cook) said that it was not acceptable for V16 to place V16's hands in the puree to test for consistency. V16 added the hot dog puree should be mashed potato consistency. Then, V14 attempted to puree the hot dog buns in a different blender which resulted in a gummy, sticky, thick, and stiff texture. V14 said the puree was acceptable and ready for surveyor testing. V16 stated that the hot bun puree consistency was acceptable as well. V14 and V16 stated that all purees should be a smooth consistency to prevent residents from choking. On 04/01/2026 at 2:54 PM, V1 (Administrator) stated it is important that they follow the doctor's order, so the kitchen provides puree consistencies according to their policy. V1 added this is important to prevent residents from choking while providing them with a safe dining experience. The facility failed to follow their Pureed Diet dated 6/23/2025 policy which documents All foods served to residents on a pureed diet must be smooth, moist, cohesive and free of chunks or lumps. The consistency should resemble pudding, mousse, or applesauce with no visible solid pieces.

Based on observation, interview, and record review the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care received grooming and shaving. This failure affected one resident (R36) out of 61 residents reviewed for ADL care. Findings include:R36's Face Sheet documents R36's diagnosis of adult failure to thrive, multiple sclerosis, dementia, anemia and anxiety disorder. R36's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact with little to no impairment. R36's Minimum Data Set, dated [DATE] shows R36 is independent for personal hygiene. On 03/30/2026 at 11:45 AM, R36 was sitting at the end of the hallway in front of the window. When asked about the facial hairs on R36's face, R36 responded that R36 would like the facial hair plucked or shaved. R36 said they usually do not ask if R36 wanted facial hair removed. R36's upper body posture was slouched or angled about 30 degrees in the chair. On 04/01/2026 at 2:54 PM, V1 (Administrator) stated residents should be groomed on a routine basis by the Certified Nursing Assistants. V1 said shaving is offered based on the resident's appearance or as needed. V1 added shaving and grooming is important for the residents' dignity and respect. The facility failed to follow their Supporting Activities of Daily Living (ADL) policy dated 12/2/2025 which documents Appropriate care and services will be provided for residents who are unable to carry out ADLs independently due to cognitive impairment or dementia.

Based on observation, interview and record review, the facility failed to ensure physician ordered high protein nutritional supplements were administered, failed to follow facility policies for nutritional assessments, monitor weights, monitor the effectiveness of interventions, and document meal intakes accurately for one of four residents (R23) reviewed for weight loss in a total sample of 61 residents. These deficient practices resulted in R23 sustaining a 7.5 percent significant weight loss from January 2026 through March 2026. Findings include:The Electronic Health Record (EHR) documents, in part, R23's diagnoses include: Hypertensive Heart Disease, Hyperlipidemia, Gastro-Esophageal Reflux Disease and Constipation. The Medication Administration Record (MAR) for February and March 2026 did not show R23 was on any diuretics that would affect her weight. A Weight Summary documents R23's weights as follows: on 1/1/26, weight 99.6 pounds on 2/3/26, weight 92.8 pounds, a five percent significant weight loss in one month; [NAME] 3/3/26, weight 92 pounds, a 7.5 percent significant weight loss in two months. R23 had no re-weights performed after a significant weight change as per facility policy. The Physician Order Sheet (POS) shows that an intervention for a high calorie drink to be increased from twice a day to three times a day was not added until 2/10/26, one week after the five percent weight loss was identified. On 3/3/26, when R23 continued to lose weight, an intervention to increase a high calorie frozen dessert from once a day to two times a day was not ordered until 3/11/26, eight days after the weight loss. R23 is currently on a mechanical soft textured diet for improved nutrition. On 3/30/26 at 12:26 PM, R23 was sitting in bed with a lunch meal of grilled cheese which was cut in half, tomato soup and pasta salad. R23's meal ticket reads: lightly grilled, (cut in quarters) grilled cheese sandwich. R23 did not have a high calorie frozen dessert on her tray as ordered. The meal ticket did not indicate R23 should receive a high calorie frozen dessert. R23 ate less than half of the soup, less than half the grilled cheese sandwich and the pasta salad was untouched. R23 was having difficulty chewing the bread and stated, tomato soup is salty and the grilled cheese is hard. R23 tapped the half sandwich on her plate as she described how hard it was. The sandwich was dark brown in color and hard. The sandwich was not lightly grilled and not cut into fourths as printed on her mechanical soft meal ticket. At 12:44pm, R23 was still chewing the food that was in her mouth originally.R23's Nutrition - Amount Eaten meal intake form dated 3/30/26 documents R23 ate 76-100 percent of her lunch meal even though it was observed that R23 ate less than half of her meal. On 3/31/26 at 12:36 PM, R23 was sitting up in the dining room with a lunch meal of chopped hot dog in a hot dog bun and steak fries. R23 did not have a high calorie frozen dessert on her tray as ordered. The hot dog bun was whole and dry and without any liquid to moisten it. R23 ate less than half the hot dog and none of the fries. R23 stated, It's too hard to swallow the bread. The Meal Intake Form dated 3/31/26 showed that R23 ate 76-100 percent of her lunch meal even though it was observed that she ate less than half of her meal. On 3/31/26 at 1:17 PM, V23 (Director of Rehabilitation/Speech Therapist) indicated that R23 is on a mechanical soft diet due to broken teeth and difficulty chewing meat. When asked about R23's difficulty eating her mechanical textured lunch meals for the last two days, V23 stated, She has never had issues with swallowing. V23 stated the standards for a mechanical soft diet is that meats and foods should be ground up and cut into minced/ground pieces. V23 stated, Grilled cheese should be cut into fourths with soft bread.On 3/31/26 at 12:42 PM, V12 (Traveling Supervisor) was in the 2nd floor dining room passing out High Calorie frozen nutritional desserts. R23 did not receive one. V12 said R23 does not get one. V12 stated that the frozen dessert would be printed on the meal tickets once the Director of Nursing or the nurse receives a physician order and then they notify the dietary department. On 3/31/26 at 12:48 PM, V14 (Director of Dining Services) stated the high calorie frozen dessert supplement is to help residents increase appetite and increase weight for those residents with significant weight loss, due to the higher calories. V14 looked at several meal tickets for R23 and confirmed the high calorie frozen dessert was not printed on R23's meal tickets because no one let V14 know of the change. V14 further confirmed that unless it was printed on the meal ticket, R23 would not receive it. Both V12 and V14 confirmed R23 has not received high calorie frozen desserts from the dietary department recently. R23's medical record shows that V27 (Dietitian) only performed two nutritional assessments for R23 despite the significant weight loss triggers. One assessment was dated 1/31/26 and the other was dated 3/1/26. Neither of these nutritional assessments documented: height, usual body weight and/or ideal body weight as per facility policy. R23's electronic record denotes that R23's weight was performed monthly despite triggering for significant weight changes in two consecutive months. On 4/1/26 at 9:29am, V4 (Restorative Nurse) stated that R23 has only been weighed monthly and that there was no order for weekly weights to be done. On 3/31/26 at 1:37 PM, V27 (Dietitian) stated, Nutritional supplements get ordered for people that have poor oral intake. Primarily added to help those with gaining weight or to stop losing weight. V27 indicated that after R23 had significant weight losses, there were high calorie desserts with lunch and dinner ordered on 3/11/26. High calorie drink was added on 2/3/26. V27 did not know why it took seven and eight days to put interventions into place after significant weight loss triggers. V27 stated, I have not monitored (R23's) meals to see if she is eating and to see how her intake is. The staff do that and input the information into the computer. I did not monitor if (R23) was receiving the nutritional supplements. The inaccurate documentation for meal intakes was discussed. V27 stated that he would like to see dietary intake in the 75-100 percent (%) range. V27 stated, When eating 50% and paired with drop in weight, I'll recommend more interventions. On 4/1/26 at 12:10pm, V27 said additional interventions which could have been added were: weekly weights; asking about food preferences; checking if the mechanically soft diet was texturally right; cueing the resident during meal time, and placing the resident in a high visible area for dining monitor intake more closely. V27 said he did not suggest any of these interventions for R23. V27 said a 7 pound weight loss would be considered a significant weight loss since it was greater than a five percent weight loss. According to V27, R23's usual body weight was below her ideal body weight and weekly weights should have been done. V27 stated I will [NAME] up to that. I should have communicated to the dietary department that a change was made in orders and a high protein frozen dessert was added. Especially because there is no way for our systems to communicate electronically. V27 indicated that he is newly certified and a newer dietitian for the facility. On 4/1/26 at 11:05 AM, V2 (DON - Director of Nursing) stated, Dietitian recommendations are relayed to the doctor. Doctor gives the order. Once it's in the system, our (electronic system) does not communicate with the dietary electronic system. So, the dietitian aid should convey those orders or order changes to the dietary department. V2 said she meets with the dietitian and the dietitian aid weekly on Wednesdays to discuss any resident weight loss and any changes in diets. V2 stated that the dietitian aide will let the dietary department know of any changes. It was clarified with V2, three different people gave three different responses for how the facility notifies the dietary department of any changes in dietary orders. On 3/31/26, the dietary department indicated V2 (DON) would let them know. On 3/31/26, V27 (Dietitian) stated he would email the dietary department regarding the change; and now V2 said the Dietary Aide would notify the dietary department. V2 not aware of V27 emailing the dietary staff unless he changed the process. V2 said the facility policy is that any resident with a significant weight loss of five percent, 7.5 percent, or 10 percent should be on weekly weights times four weeks. V2 stated, (R23) should have been weighed weekly to monitor her closely.On 4/1/26 at 12:49pm, V26 (Physician) stated he doesn't focus on the weight, but focus' on nourishment. R23 should be receiving the supplements as ordered to stay nourished and if they weren't, this would be a problem and the resident would continue to lose weight. With significant weight loss, V26 would expect weights to be done every two weeks and for the facility to be monitoring bloodwork. R23's current BMI (Body Mass Index) is documented in the progress notes dated 3/1/26 as 15.9 percent, which is low. R23's medical record denotes that she has not had any blood work performed since 2/16/26. R23's Nutrition Care Plan documents: Interventions: 1) Monitor/document/report to MD (Medical Doctor) for signs and symptoms of dysphagia, pocketing, choking, coughing, drooling. Holding food in mouth. Several attempts at swallowing, refusing to eat. 2) Provide and serve diet as ordered. 3) Provide and serve supplement as ordered. 4) RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (as needed). A facility policy with a review date of 3/20/26 and titled, Physician Orders documents: Intent: Facility has a process to ensure that all Physician Orders are documented appropriately.A facility policy with a review date of 5/15/25 and titled, Nutrition/Hydration Status Maintenance documents: Intent: it is the policy of the facility to provide Nutrition/Hydration Status Maintenance Services in accordance with State and Federal regulations. Procedure: 1. Nutritional assessments are completed on residents and include body mass index, usual body weight, height, weight, ideal body weight, and diagnosis. A facility policy with a revised date of 12/15/25 and titled, Weight Management documents: Procedure: 3. Monitoring and Review: b. A re-weight will be obtained for any significant or unexpected weight change, including but not limited to: i. 5% change in one month, 7.5% in 3 months and 10% in 6 months. 4. Re-Weight Process: a. Re-weights will be obtained promptly to confirm accuracy. An undated facility policy titled, Characteristics & Procedures for Consistency Modified Foods documents: Policy: Mechanical Soft, Dysphagia and Puree Diets will be prepared to the food characteristics listed below. Ground; Mechanical Soft. Note 1: bite size pieces no larger than 1/2 inch. Note 2: Most entrees of this consistency are served with additional sauce or gravy to ensure adequate moisture is maintained.

Based on observation, interview, and record review the facility failed to ensure alcohol beverages were monitored according to the physician's order by allowing 1 resident (R69) to store ten cans of beer in his personal refrigerator located in R69's room. This failure affects 1 resident in a total sample of 61 residents.R69's Face Sheet dated 4/1/2026 documents a diagnosis of but not limited to hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, gout, retention of urine, and peripheral vascular disease, Minimum Data Set Section C dated 1/2/2026, documents a BIMS (Brief Interview Mental Status) Score of 15 with indicates R69 has an intact cognition, care plan does not have a focus for alcohol consumption.R69's physician order details dated 10/1/2024 was reviewed and does not specify the amount or number of ounces a can of beer R69 can have at dinner time. R69's physician order sheet dated 3/30/2026 documents R69 may not have alcohol.R69's care plan does not document a focus for alcohol use. On 3/30/2026 at 10:47 AM, V6 (Licensed Practical Nurse) verified R69 had 10 cans of beer (five 12-ounce cans of beer and five 8-ounce cans of beer) in his room stored in his (R69's) personal refrigerator. V6 stated she (V6) was not sure if the resident had orders to have beer in his refrigerator. V6 opened R69's electronic health record and verified R69's physician's order documents R69 can have one beer a day after dinner and beer is to be stored at the nursing station. On 3/30/2026 at 2:37 PM, V4 (Restorative Nurse) verified the resident had five 12-ounce cans of beer and five 8 -ounce cans of beer in his refrigerator. V4 stated she is not sure if the resident has an order for alcohol, you must ask the nurse taking care of the resident if there is an order for the resident to have alcohol. On 3/31/2026 at 2:31 PM, surveyor observed alcohol beverages of five 12-ounce cans and five 8-ounce cans of beer in R69's refrigerator.On 4/1/2026 at 11:25 am, V2 (Director of Nursing) stated R69 has an active order to have one can of beer (dinner). V2 is not aware of how many beers R69 has in his refrigerator. V2 is not aware of R69's order documenting beer one time a day and beer should be at the nursing station. V2 is not aware R69 does not have alcohol care planned, verified the order dated 10/1/2024 documents one beer one time a day and beer is kept at the nurses station and the order was discontinued on 3/28/2026 because R69 needed reevaluated for alcohol privileges. V2 doesn't know how he is being monitored but R69 has not had any behaviors and as is alert and oriented. V2 said if R69 is noted with slurred speech or lethargy his alcohol privileges will be revoked for intoxication. Facility's policy titles Physician Orders dated 7/1/2020 with a last review date of 3/20/2026 documents the facility has a process to ensure that all Physician Orders are documented appropriately and physician orders will be entered, updated as needed and revised as necessary.Facility's policy titled Resident Alcohol Use in Long-Term Care (LTC): Clinical Guidance documents Alcohol use (e.g.) is not prohibited in long-term care and may align with resident rights and preferences.#3. Ordering alcoholOrders must be clear and specific (type, amount, frequency, timing).Example: Beer, 12 oz, one daily with dinner.DocumentationInclude alcohol use in the care plan.Document risk assessment, medication review, and monitoring approach.Ensure the MAR reflects complete order details.

Based on observations, interviews, and record review the facility failed to monitor resident's personal refrigerator temperature logs; and failed to ensure that resident's personal refrigerators had a thermometer. These failures affected three residents (R19, R56, and R84) out of 61 residents in the total sample.Findings include: R56's diagnoses include but are not limited to asthma, hydrocephalus, heart disease, hyperlipidemia, dementia, polyneuropathy, and anemia. On 3/30/26 at 10:50 am, R56's personal refrigerator was noted with a temperature log taped to the side of R56's refrigerator. The last date the temperature log was checked was on 3/29/26. R56's refrigerator did not have a thermometer inside the refrigerator. On 3/30/26 at 11:00 am, V20 Housekeeper stated, Housekeeping is responsible for checking the resident's personal refrigerators. I (V20) did not check R56's refrigerator because it doesn't have a thermometer. I need to call maintenance to get a thermometer. The refrigerators temperatures are checked every day to make sure the food doesn't spoil. Every refrigerator should have an inside thermometer. On 3/31/26 at 12:45 pm, R56's personal refrigerator temperature log was not checked. The last date R56's personal refrigerator was checked was 3/29/26. On 4/1/26 at 1:25 pm, V7 Housekeeping Supervisor stated that the housekeeping department checks the resident's personal refrigerators, and they should be checked every day. The refrigerators are checked daily to make sure the temperature doesn't drop below 36 degrees or get above 40 degrees. A thermometer should be inside the refrigerator. If the temperature goes above 40 degrees, the food can spoil, and the residents can get sick. On 4/2/26 at 8:45 am, V1 Administrator stated, The resident's personal refrigerators should be checked daily, and a thermometer should always be in the refrigerator. The facility's practice is to check the personal refrigerators daily. The policy says to check the refrigerators weekly. We go beyond the policy for good practice. I don't know why our policy says weekly and our refrigerator temperature log says daily, so we should be checking the resident's personal refrigerators daily. The facility's document undated and titled, Food Refrigerator Temperature Log documents, in part, Adjust refrigerator temperatures as necessary to maintain temp between 35-40 degrees Fahrenheit. Night Shift Please Record Temps Daily. Write needed adjustments in comments. Facility's policy titled, Food Brought in the Facility by Family or Vistors reviewed 3/2/26, documents, in part, Intent: It is the right of the residents of this facility to have food brought in by family or other visitors. The food will be handled in a way to ensure the safety of the residents. Facility's job description undated and titled, Housekeeping Aide documents, in part, Job summary: Performs a variety of general housekeeping/cleaning duties in various areas to maintain the center in a sanitary, safe, attractive and orderly condition. General Requirements: a. Works in a safety-conscious manner, which ensures that safe work practices are used in order not to pose a risk to self or others in the workplace. Reports any safety violations or hazards to supervisor b. Complies with company policies and procedures and local, state, and federal regulations. R19's Face Sheet documents R19's diagnosis of anemia, coronary artery disease, heart failure, hypertension, and hyperlipidemia. R19's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment. R84's Face Sheet documents R84's diagnosis of anemia, atrial fibrillation, coronary artery disease, heart failure, orthostatic hypotension, and diabetes. R84's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 6 indicating cognitively impairment. On 03/30/2026 at 11:40 AM, R19 did not have a thermometer in R19's refrigerator nor did R19 have daily temperature logs on R19's refrigerator. On 03/30/2026 at 11:44 AM, there was no thermometer in R84's refrigerator. R84 stated that R84 did not have thermometer in R84's refrigerator. On 04/01/2026 at 2:54 PM, V1 (Administrator) stated residents with personal refrigerators should have thermometers and daily log sheets. V1 said temperatures should remain in safe temperature range to ensure food does not spoil so residents do not get sick. The facility failed to follow their Food Storage policy dated 12/30/2025 which documents Personal refrigerators must be checked at least weekly for safety. Staff must check resident refrigerator temperatures weekly.

Based on interview and record review the facility failed to notify a physician and resident representative of a significant change in condition/status (newly identified deep tissue pressure injury) for one resident (R5). This failure affected 1 resident in the total sample of 3 residents reviewed for notification of changes. Findings include: R5 has diagnosis which include but are not limited to: cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, dysphagia oropharyngeal phase, other lack of coordination, other reduced mobility, polycythemia vera, elevated white blood cell count, cerebral edema, type 2 diabetes mellitus without complications, unspecified protein calorie malnutrition, acute respiratory R5's Brief Interview for Mental Status (BIMS) dated 1/21/26 shows a score of 12 which indicated that R1 has moderate cognitive deficits. R5's progress note dated 1/19/26 at 11:30 am authored by V7 (Licensed Practical Nurse, LPN, Wound Care Nurse) documents, in part: PT (Physical Therapy) notified WCN (Wound Care Nurse) of skin condition to patients buttocks. On assessment, dtpi (Deep Tissue Pressure Injury) to sacral region. R5's Wound Summary dated 1/19/26 at 11:37 am, shows that R5 acquired a Deep Tissue Pressure Injury 1.20 cm x 0.40 cm with unknown depth. R5's Physician Order Sheet (POS) does not show orders for R5's sacral wound or management of R5's sacral wound. R5's Treatment Administration Record (TAR) dated January 2026 does not shows treatment for R5's sacral wound. On 2/25/26 1:02 pm, V7 (Licensed Practical Nurse, LPN, Wound Care Nurse) stated that on 1/19/26 the physical therapist who is now known as V16 (Occupational Therapist)) reported that R5 had a wound to his sacral area. V7 stated that she assessed R5's sacral wound and informed R5's physician of R5's sacral wound, however upon Surveyor and V7 review of R5's progress notes there was no family notification, physician notification or physicians orders implemented for R5's sacral deep tissue pressure (DTPI) injury wound. V7 stated that she did not carry out physicians orders for R5's sacral wound and stated, I must have forgot. V7 then explained that when a resident acquires a new wound the residents family and physicians must be notified and documentation of the conversation should be placed on a progress note in the residents medical record. V7 also explained if a resident's order for a wound is not implemented the resident's wound could worsen. On 2/25/26 at 3:00 pm, V16 (Occupational Therapist) stated that she was R5's Occupational therapist at the facility. V16 explained that she does not recall the exact date in question, however, she recalls when she was assisting R5 with care she observed R5 with a reddened spot to his tailbone area. V16 further explained that when she left from R5's room, V7 was standing in the hallway outside of R5's door and she immediately reported the skin breakdown to V7 who stated, I will take care of it (referring to R5's sacral wound). On 2/26/26 at 1:57 pm, V2 (Director of Nursing, DON) stated that she recalls R5 at the facility. V2 stated that she does not recall R5 having a wound at the facility. V2 explained that when a resident acquires a wound the nurse is made aware through the communication board, the wound care order from physicians orders for treatment of the wound, as well as a progress note regarding the residents change in condition assessment form. V2 also explained that when a resident acquires a wound the residents physicians and family should be notified regarding the residents change of condition and the conversation should be documented in the residents progress notes. V2 then explained if there is no order for a treatment for a residents wound the wound could deteriorate. The facility policy dated 10/09/2021 and titled Notification of Change in Condition, Discharge and Transfer documents, in part: Policy Statement: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Procedure: 1. The nurse will immediately notify the resident, resident's physician and the resident representative(s) for the following (list is not all inclusive): .c. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. The nurse will notify the resident, resident's physician and the resident representative(s) for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician . 3. Document the notification and record any new orders in the resident's medical record. 4. Educate the resident and/or representative about the proposed plan to treat, manage or monitor the resident's change in condition.

Based on interview, and record reviewed the facility failed to ensure that a resident (R1) with a pressure ulcer received necessary treatment and services to promote healing. This failure affected one of three residents reviewed for wound care.Findings include:R5 has diagnosis which include but are not limited to: cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, dysphagia oropharyngeal phase, other lack of coordination, other reduced mobility, polycythemia vera, elevated white blood cell count, cerebral edema, type 2 diabetes mellitus without complications, unspecified protein calorie malnutrition, acute respiratoryR5's Brief Interview for Mental Status (BIMS) dated 1/21/26 shows a score of 12 which indicated that R1 has moderate cognitive deficits.R5's Scale for Predicting Pressure Score Risk dated 12/10/25, 12/24/25, 1/1/26, and 1/6/26 shows that R5 is at risk for pressure ulcers. R5's progress note dated 1/19/26 at 11:30 am authored by V7 (Licensed Practical Nurse, LPN, Wound Care Nurse) documents, in part: PT (Physical Therapy) notified WCN (Wound Care Nurse) of skin condition to patients buttocks. On assessment, dtpi (Deep Tissue Pressure Injury) to sacral region.R5's Wound Summary dated 1/19/26 at 11:37 am, shows that R5 acquired a Deep Tissue Pressure Injury 1.20 cm x 0.40 cm with unknown depth.R5's Physician Order Sheet (POS) does not show orders for R5's sacral wound or management of R5's sacral wound.R5's Treatment Administration Record (TAR) dated January 2026 does not shows a treatment for R5's sacral wound. R5'S Care Plan Report does not show a problem statement (focus), measurable goals, or individualized interventions related to R5's sacral wound. On 2/25/26 at 12:37 pm, V8 (LPN) stated that she was R5's nurse prior to R5's discharge/transfer to the local hospital on 1/21/26. V8 explained that she only assessed R5's front side for skin alterations/breakdown and did not look at R5's buttocks stating that she could not turn R5 by herself. V8 stated that she was not aware of R5 having a wound to his sacral region.On 2/25/26 1:02 pm, V7 (Licensed Practical Nurse, LPN, Wound Care Nurse) stated that on 1/19/26 the physical therapist who is now known as V16 (Occupational Therapist)) reported that R5 had a wound to his sacral area. V7 then stated that she assessed R5's sacral wound and informed R5's physician of R5's sacral wound, however upon Surveyor and V7's review of R5's progress notes there was no family notification, physician notification or physicians orders implemented for R5's sacral deep tissue pressure (DTPI) injury wound identified on 01/19/26. V7 further explained that she did not carry out physicians orders for R5's sacral wound and stated, I must have forgot. V7 then explained that when a resident acquires a new wound the residents family and physician must be notified and the documentation of the conversation should be placed on a progress note in the residents medical record. V7 also explained if a residents orders for a wound is not implemented the residents wound could worsen. On 2/25/26 at 3:00 pm, V16 (Occupational Therapist) stated that she was R5's Occupational therapist at the facility. V16 explained that she does not recall the exact date in question however, she recalls when she was assisting R5 with morning care she observed R5 with a reddened spot to his tailbone area. V16 further explained after she observed R5's reddened tailbone, she immediately informed V7, who was standing in the hallway outside of R5's door. V16 explained that V7 stated, I will take care of it (referring to R5's sacral wound).On 2/26/26 at 1:57 pm, V2 (Director of Nursing, DON) stated that she recalls R5 at the facility and explained that she does not recall R5 having a wound at the facility. V2 explained that when a resident acquires a wound the nurse(s) are made aware through the communication board, the wound care order from physicians orders for treatment of the wound, a progress note regarding the residents change in condition is documented and an assessment form is completed. V2 also explained that when a resident acquires a wound the residents physicians and family should be notified regarding the residents change of condition and the conversation should be documented in the residents progress notes. V2 then explained if there is no order for a treatment for a residents wound the wound could deteriorate. The facility policy dated 10/09/2021 and titled Wound Prevention and Healing documents, in part: Policy Statement: To provide wound care treatment/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician. 1. b. Braden scale will be completed to determine the patient's level of Risk and implement interventions to prevent development of pressure injuries. 10. Home care and treatments: a. Warm care treatments are provided within an individualized plan of care under the direction of a physician. 11. The multidisciplinary wound care team: 1. The wound care team is responsible for identifying problems, coordinating care, and promoting development of the team and the program. 2. Certify wound care nurses and trained nurses are responsible for oversight of wound care rendered to all wound care patients, including the patient assessments, evaluation treatment regimens, plans of care, care outcomes, and cost effective of the treatment plan of care.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of <5% for 2 (R2 and R5) residents of 4 (R2, R4, R5, and R6) residents reviewed for medication administration. There were 33 opportunities with 3 errors resulting in 9.09% medication administration error rate. Findings include: On 05/27/2025 at 11:15am, V5 (Licensed Practice Nurse) dispensed R2's medications including: Senna 8.6 mg/tab x 2 tablets - this is an error. R2's (Active Order as Of: 05/27/2025) Order Summary Report documented, in part Senna S Oral tablet 8.6-50mg (Sennosides-Docusate sodium) give 2 tablets by mouth two times a day. Folic Acid 800mcg x 1 tab - this is an error. R2's (Active Order as Of: 05/27/2025) Order Summary Report documented, in part Folic Acid Oral tablet 1 MG (1000mcg) 1 tablet by mouth one time a day. On 05/27/2025 at 2:52pm with V2 (Director Of Nursing), this surveyor requested V5 to show V2 the Over the Counter containers of Senna and Folic Acid that were administered to R2. V5 showed the containers to the surveyor and to V2. Inquiring if the orders and what were administered to R2 were the same, V2 stated these are not the same medications. V5 stated I have been giving him these medications. R2's (Active Order as Of: 05/27/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) swelling, mass and lump lower limb bilateral, non-pressure chronic ulcer of part of left and right lower leg. R2's (05/07/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 09. Indicating R2's mental status as moderately impaired. On 05/28/2025 at 9:25am, V11 (Registered Nurse) dispensed R5 medications including: Calcium Carbonate 500mg x 1 tab (brand name: Alkums) - this is an error. R5's (Active Order as Of: 05/28/2025) Order Summary Report documented, in part Calcium Carbonate-Vitamin D tablet 500-200Mg, give 1 tablet by mouth in the morning. R5's (Active Order as Of: 05/28/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypokalemia, hyponatremia, and hypertension. R5's (04/29/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R5's mental status as cognitively intact. The (undated) Facility provided 'Alkums Antacid' documented, in part Active ingredient (in each tablet) Calcium Carbonate 500mg. Of note, vitamin D is not listed as an active ingredient. The (undated) Nurse supervisor RN/LPN Job description documented, in part JOB summary: Within scope of practice, coordinates care delivery, which will ensure that patient's needs are met in accordance with professional standards of practice through physician orders, center policies and procedures, and federal, state, and local guidelines. General Nursing Care Responsibilities. Demonstrates the ability to administer medications according to facility policy. Demonstrate ability to carry out physician orders. The (05/02/2025) Administering Medications documented, in part Policy Statement: The Facility will ensure that medications are administered in a safe and timely manner, and as prescribed. Procedure: 3. Medications are administered in accordance with prescriber orders. 8. The individual administering the medication checks the label THREE (3) times to verify the right medication and right dosage.

Based on interview and record review, the facility failed to report an abuse allegation to Illinois Department of Public Health (IDPH) for one resident (R1) out of 4 residents reviewed for abuse. Finding include: R1's Face sheet documents that R1 was admitted to the facility on [DATE] with diagnoses not limited to: Toxic encephalopathy, unspecified abnormalities of gait and mobility, other reduced mobility, type 2 diabetes mellitus without complications, acute kidney failure. Essential (primary) hypertension. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R1 has a Brief Interview for Mental Status (BIMS) score of 5, indicating that R1 has a severe cognitive impairment. Care plan (dated 04/14/2025) documents that R1 is noted with potential communication deficits- may have difficulty completing her thoughts, trouble with word choices. On 04/15/2025 at 11:06AM, during a complaint investigation survey, surveyor inquired for V1 (administrator) to bring the surveyor the facility reportable binder. At 11:31AM, surveyor received the reportable binder and after reviewing it, surveyor noted that R1's abuse allegation from 03/20/2025, was not in the facility's reportable binder. Surveyor interviewed V1 to determine why the reportable was not submitted to the state agency. On 04/15/2025 at 11:35AM, V1 (administrator) stated, R1 was admitted to the facility on [DATE]. On 03/20/2025, when R1's family came to the facility to visit R1, they noticed the discoloration to R1's left eye. V2 (director of nursing) and I, went to assess R1 and R1's son and V5 (R1's daughter) were present during the assessment. During the assessment, I saw R1 with a discoloration to the left eye, which looked different from the right eye. R1's skin is of dark complexion, and the discoloration did not appear red. We asked the resident what happened. R1 mentioned that during the ambulance transport to the facility, the night prior, something fell on R1's head inside the ambulance. R1 was not sure what fell on her head. R1 was explicit about saying that they did not mean for anything to fall on R1. R1 mentioned that the paramedics put back whatever fell on R1's head. R1 is alert and oriented. I told the family that I would call the ambulance for the ambulance to start the investigation. I did not have the ambulance transport form. I had to ask the hospital's case manager for the name of the ambulance company. I contacted the ambulance company and I spoke to the manager, and I informed them of the allegation that something had fallen on R1's head during transportation. The next day, on 03/21/2025, the manager from the ambulance company called me back and informed me that there was no such incident noted on their end. I had asked the manager for a written report because I wanted to provide the ambulance report to R1's daughter. The manager informed me that he would send the report. R1 was very specific about how R1 obtained the discoloration under her eye. Nobody noted the discoloration under R1's left eye when she was admitted to the facility because R1 admitted to the facility late, round 9:30PM. R1 reported the ambulance incident in front of her son and daughter. R1's physician was notified, and the physician ordered an x-ray. The x-ray result was negative. The report from the ambulance company came much later, on 04/01/2025. The daughter received the report. There was not much follow up because shortly after that, R1 went to the hospital on 03/28/2025 and returned to the facility on [DATE]. I conducted an investigation of R1's left eye discoloration. I interviewed the resident, as part of the investigation. If R1 was not able to tell me what happened to her eye, or if R1 did not remember how it happened, then it would trigger an abuse investigation and I would report it to the state agency (IDPH). Based on the interview with the resident, I did not deem it as an abuse allegation. R1 was adamant that it was not intentional and that something fell on her head inside the ambulance. I informed the ambulance company to conduct their own investigation. I have the origin for the discoloration on R1's eye, so we know how it happened and that the patient stated that it was not intentional. When the ambulance company denied that the allegation occurred, I did not feel that I should report it to the state agency, and the resident was at the hospital at the time. R1 still has the same discoloration under her left eye that she had on 03/20/2025. The family mentioned that the discoloration was not her usual discoloration. I saw R1 yesterday, (04/14/2025) and it looks the same as it looked on 03/20/2025. Ambulance Investigation Report (dated 04/01/2025) documents in part: After the completion of the investigation, there was no incident found during the transportation and/or transfer of the patient while in the care of the ambulance crew. Injury Investigation Policy (dated 10/03/2020) states in part: It is the policy of the facility to investigate any unexplained resident injury. Abuse Prevention Policy (undated) states in part: After an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation. (C.) Initial report. An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed.

Based on interviews and records reviews, the facility failed to follow a resident's (R95) fall care plan intervention and physician recommendation with multiple history of falls to ensure soft head helmet was applied while in bed for 1 (R95) out of 1 resident reviewed for falls. This failure resulted in R95 sustaining a left subdural hematoma after falling and hitting head on the floor on 2/4/25. Findings Include: R95's clinical records show an initial admitted [DATE] with included diagnoses but not limited to anxiety disorder, traumatic subdural hemorrhage, other lack of coordination, other abnormalities of gait and mobility, and epilepsy. R95' Minimum Data Set (MDS) dated [DATE] shows R95 has moderate cognitive impairment and is dependent with staff assistance on toileting, positioning in bed, personal hygiene, and dressing. R95's Witnessed Fall dated 2/4/25 at 7:10 PM documented by V9 (Wound Care Licensed Practical Nurse) reads in part: Writer alerted by CNA [Certified Nursing Assistant]/Staff that the resident was in her room attempting to walk without assistance and she fell hitting her left side of her head onto the floor as well as her left side of her body. Patient was in low bed with floor mat next to the bed. Resident unable to give description. R95's progress notes dated 2/5/25 at 6:10 AM documented by V38 (Licensed Practical Nurse) revealed R95 was sent to the hospital and was admitted for Acute chronic subdural hematoma. R95's hospital records HISTORY OF INJURY Event/HPI [History of Present Illness] dated 2/5/25 documents in part: [AGE] year-old female presents as a level 2 trauma transfer from outside hospital after mechanical fall at facility. She was walking, lost her balance, and struck the left side of her head. Denies loss of consciousness. She was transferred to our hospital for a left subdural hematoma. SICU (Surgical Intensive Care Unit admitted [DATE] brief HPI revealed R95 suffered from a mechanical fall and sustained an acute on chronic left frontal subdural hematoma. R95's fall risk assessment dated [DATE] shows R95 is moderate risk for falling. This fall risk assessment also shows R95 has inadequate vision, exhibits loss of balance while standing, requires hands on assistance to move from place to place, had history of falls in the past six months, and on psychotropic and sedative/hypnotic medications. R95's fall care plan initiated on 3/11/24 documents in part: [R95] had an actual fall with [NAME] balance, unsteady gait, and poor safety awareness with one fall intervention initiated on 3/14/24 that reads: Soft head helmet while resident is bed or during therapy session. R95's fall care plan also revealed R95 had multiples falls (more than 5) in the last six months. R95's progress notes dated 1/18/25 at 1:11 PM documented by V43 (R95's Physician) revealed R95 had history of skull surgery, wear helmet every shift, fall precautions, and aspiration precautions. On 3/11/25 at 12:33 PM, R95 was sitting on her wheelchair in the dining room with soft helmet on, alert and verbally responsive with forgetfulness. When Surveyor asked about the fall incident that happened on 2/4/25, R95 stated, I don't remember how I fell . They sent me to the hospital. I just woke up and I was in the hospital. R95 stated she has to wear her helmet all the time according to the doctor, but she does not know the reason why. On 3/11/25 at 3:08 PM, interviewed V2 (Director of Nursing/Falls Nurse) and stated that fall interventions in the resident's care plan are initiated and implemented based on the root cause of the resident's previous falls, the fall assessments, and based on the needs of the resident. V2 stated that care plans are individualized and updated accordingly. V2 stated that the purpose of the fall care plan interventions is for the resident to avoid more falls in the future and for the staff to know what to do for the resident. V2 stated that frontline staff is aware of the residents' care plan interventions and all interventions in the care plan should be implemented and followed by the staff on the floor working with the resident. On 3/12/25 at 10:14 AM, interviewed V9 about R95's fall incident on 2/4/25. V9 stated, it happened between 7:10 PM to 7:15 PM. V9 was sitting at the nurse's station doing documentation. V22 (Former Certified Nursing Assistant) alerted V9 that [R95] was on the floor. V9 stated she went inside R95's room and saw R95 lying on the floor beside the floor mattress without her soft helmet on and call light was off. V9 stated R95 hit her head but denied pain and no visible injuries upon V9 assessment on R95. V9 stated that when R95 is in bed, her helmet can come off and only being applied back on when R95 is up on her wheelchair. V9 stated the last time she saw R95 was around 6:30 PM when V22 was wheeling R95 on a wheelchair back in her room to put R95 in bed. V9 stated R95 was sent to the hospital because she hit her head and needed to be evaluated. V9 stated R95 is high risk for falling, has unsteady gait, will get up without asking for help, and needs constant monitoring and re-education. On 3/12/25 at 11:29, a phone interview was conducted with V21 (Medical Director/R95's Physician) and stated that R95 is very impulsive and had multiple falls that happened by falling off from the bed. V21 stated R95 should be wearing the soft helmet while in bed to minimize injury. V21 stated R95 had brain surgery, her skull was taken out and was put back eight months ago. V21 stated R95's skull is not intact and wearing soft helmet could minimize injury. V21 stated if R95 falls and hit her head without the soft helmet, she is high risk for severe injury on the head. On 3/12/25 at 11:52 AM, a phone interview was conducted with V22 about R95's fall incident on 2/4/25. V22 stated she remembers R95 to be alert but with forgetfulness and confusion at times. V22 stated, Sometimes [R95] knows how to use the call light sometimes she forgets. [R95] has the tendency to get up by herself all the time without calling for help. [R95] is high risk for falls. [R95] had multiple history of falls before. [R95] needs one staff assistance to get up from bed and she's incontinent, but sometimes she goes to the toilet with staff assistance if she's up in the chair. When I put [R95] to bed I don't put her helmet on. I only put it on when she's [R95] up in the wheelchair. On 2/4/25 after dinner at around 6:30 PM I put [R95] to bed she told me she was tired. [R95] did not tell me she was ready to sleep, she just told me she's tired. The last time I saw her [R95] was about 6:40 PM she was lying in bed awake watching TV [television]. [R95] was not wearing her helmet because we don't put the helmet on while she's in bed. I changed her [R95] diaper around 6:30 PM and I made sure her call light was within reach. So around 7:00 PM I was rounding because I always look at the fall risk rooms. I saw [R95] walking in circles in her room texting on her cellphone. As soon I saw that I went inside the room to put her [R95] back in bed but then she [R95] fell right in front of me. [R95] lost her balance. [R95] was not wearing her helmet and stood up by herself without asking for help. [R95] fell directly on the floor and hit her head. I think it was her [R95] left side of her head. I went to get the nurse [V9] right away. [V9] assessed [R95] and 911 sent her to the hospital. On 3/13/25 at 9:40 AM, a phone interview was conducted with V38 (Licensed Practical Nurse) and stated that she called the hospital in the morning of 2/5/25 and was informed that R95 was admitted for subdural hematoma. The facility's Fall Prevention and Management policy dated 4/8/24 documents 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. A comprehensive falls care plan is developed. Development of the fall interventions plan is based on results of the Falls Assessment as well as investigation of all circumstances and related resident outcomes. Facility will initiate monitoring of interventions for residents who fall in the facility and with history of fall, who trigger the Falls CAA, and when a resident falls. Frequency and duration of monitoring of interventions will be based on current risks.

Based on observations, interviews, and record reviews, the facility failed to follow their policies and dispose of food items past their expiration/best buy/use by dates, label opened food item, store food and food related items away from cleaning solutions, perform hand hygiene during dishwashing, and cover prepared food to prevent contamination. This has the potential to affect all 108 residents that receive nutrition from the kitchen. Findings include: On [DATE] at 9:03 AM, surveyor conducted an initial tour of the kitchen and food storage areas with V11 (Dietary Manager). During the tour of the facility's dry goods stock room on [DATE] at 9:05 AM, there was a gallon of maraschino cherries that expired on [DATE] in the bottom shelf. In the same bottom shelf, there was an opened jug of soy sauce with the 'best by' date of [DATE]. The label reads to refrigerate after opening. V11 did not know it had to be refrigerated. In the same bottom shelf, there was an additional jug of unopened soy sauce with a 'best by' date of [DATE]. There was also an unopened gallon of Caesar dressing with a 'use by' date of [DATE]. V11 stated that the facility's policy is to move all the old stock to the front of the shelves and the incoming stock to the back of the shelves. V11 stated V42 (Dietary Aide) and the other kitchen staff are supposed to check all the labels and toss the expired items. V11 stated when there is no written expiration date, the facility follows the 'use by' or 'best by' date to discard them. In a separate shelf there was an opened clear bag with brown powder inside it. The bag was tied manually and did not have a label. V11 stated it was brownie mix. V11 stated staff were supposed to label the bag when they opened it. In the back of the dry storage room, there was a shelf against the wall perpendicular to the large can racks against the window (contained cans of fruits). In the bottom shelf, there were opened bags of food lids next to two 1-gallon bottles of bleach cleaning solution. V11 stated the lids were for cups and bowls used during residents' meals. Additionally, underneath the shelf (resting on the floor), there was a case of six 1-gallon bottles of bleach cleaning solution. On [DATE] at 9:21 AM, V12 (Dietary Aide) and V13 (Dietary Aide) were cleaning up the breakfast trays. V12 was tossing the food waste and handing over the trays, dishes, and utensils to V13. V13 loaded the dirty dishes through the hot-temperature dishwasher. V13 then pulled out the washed trays, dishes, and utensils out the other end of the dishwasher without performing hand hygiene or changing gloves. V13 touched the clean dishes with the same dirty gloves throughout the washing process. On [DATE] at 9:29 AM, there was coffee grounds in a coffee liner lying on top of the metal table next to the coffee machine. The coffee grounds were open to air and located next to two buckets with solution. V11 stated the kitchen staff uses the buckets to sanitize and clean the kitchen. V11 stated staff opened the coffee grounds that morning and shouldn't have left them out next to the sanitation station. V11 verbally acknowledged that there could be cross contamination from the cleaning solutions splashing on the coffee grounds. The open coffee grounds remained on top of the metal table during return observations later that day at 11:40 AM. During the initial tour, there were also trays of uncovered, pre-portioned pears on the top counters. V11 stated they were 4-ounce servings of pears that one of the dietary aides prepared earlier that morning. Facility will serve them for lunch. The facility's heating and air conditioning unit was blowing over the uncovered pears. The pre-portioned pears were on the counter uncovered during return observations later that day at 11:40 AM. On [DATE] at 9:36 AM, V11 took the surveyor to the basement where the facility's walk-in refrigerator and freezer were located. In the refrigerator, there was a box of cucumbers in one of the top shelves. Multiple cucumbers were mushy, soft to touch, and had multiple black spots. V11 took the box out and stated staff should have tossed them out. In the freezer, there was a large, opened bag of ice in the bottom, left shelf. There was ice recrystallization (freezer burn) throughout the ice block. V11 stated the large bag of ice was there when V11 started working for the facility, which was seven months ago. V11 does not know what the facility used it for or why the facility purchased it. On [DATE] at 11:40 AM, V14 (Cook) started serving food from the kitchen tray line. Did not observe V14 check the temperatures of the food prior to plating. V11 showed the surveyor the kitchen's daily food temperature logs. The form for the current meal was empty. Surveyor asked V11 if V14 took the food temperatures. V11 did not know and asked V14. At 11:47 AM, V14 stated taking the temperatures prior to surveyor's arrival (before 11:30 AM) but forgot to write them down. Facility's undated General Infection Control in Dining Services policy documents in part: The Dining Department follows all local, state and federal regulations in order to assure a safe and sanitary department. Facility's undated Food Storage policy documents in part: All food stock and food products are stored in a safe and sanitary manner. All food stock is dated and used on a first in, first out basis. Facility's Labeling and Dating policy (last reviewed [DATE]) documents in part: Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. Facility's undated Chemical Storage Guidelines documents in part: Poisonous and toxic materials are to be stored only in areas designated for such use and for no other purpose, or in a storage area outside the food, equipment and utensil storage area. Facility's undated Dish Room - Safe Handling policy documents in part: Potential cross-contamination is prevented in the Dish Room. The task of loading the dirty dishes and utensils into the dishwashing machine is handled by one person. The task of removing the clean dishes and utensils from the dishwashing machine is handled by a different person. If there is only one person working in the dish room, the person will remove their gloves, wash their hands and put on fresh gloves whenever they cross over to the clean side of the dishwashing machine to unload the sanitized dishes and utensils. Facility's undated Food Temperatures policy documents in part: Temperatures of TCS (temperature controlled for safety) foods shall be recorded before being served from the steam table. Food temperatures shall be checked at the end of cooking and recorded before meal service on the Food Temperature log or production sheet.

Based on observation, interview and record review, the facility failed to ensure (a) oxygen and nebulization tubing were dated / changed; (b) BiPAP (Bilevel Positive Airway Pressure) and CPAP (Continuous Positive Airway Pressure) masks, oxygen and nebulization tubing were properly stored when not in used; and (c) obtain physician orders for use of BiPAP and CPAP. These failures affected four (R48, R61, R66, R86) out of four residents reviewed for respiratory care in a sample of 22. The findings include: R61's admission record showed admitted on 2/14/23 with diagnoses not limited to Unspecified atrial fibrillation, Acute on chronic systolic (congestive) heart failure, Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease. On 3/11/25 at 11:28 AM R61's room door signage indicated oxygen in use. Observed R61 lying in bed on moderate high back rest, alert and verbally responsive. Stated she has been residing in the facility for 2 years. Stated she was using oxygen and nebulization before, not able to recall when the last time she used it. Observed oxygen cannula and nebulization tubing at bedside not dated, tubings were hanging freely, touching the floor and not stored properly. On 3/11/25 at 11:32 AM Surveyor requested V4 (Licensed Practical Nurse / LPN) to R61's room and stated R61 is using oxygen as needed, unable to recall when the last time she used it. V4 said oxygen tubing should be changed at least weekly every Sunday at night shift and should be dated once changed. She said oxygen tubing and nebulization tubing should be stored in plastic bag when not in use to prevent contamination. On 3/11/25 At 3:00 PM V2 (DIRECTOR OF NURSING / DON) stated she has been working in the facility for over a year. She said oxygen and nebulization tubing should be changed weekly and as needed and should be dated once changed to know when it was changed last. V2 said oxygen tubing, neb tubing, CPAP / BIPAP tubing and mask should be stored properly in a clear bag when not in use to keep it clean. V2 said use of CPAP and BIPAP should have a physician order in resident's record. R61's order summary report dated 3/11/25 showed active order not limited to: Administer PRN (as needed) oxygen at 2/L if o2 sat is below 94% at room air, as needed for SOB/oxygen saturation below 94. Place 2 Liters of oxygen if saturation if goes below 93%. Care plan dated 4/19/24 showed in part: R61 has oxygen therapy at 2/L if O2 (oxygen) saturation is below 94% at room air PRN related to CHF (Congestive Heart Failure). MDS (Minimum Data Set) dated 2/10/2025 showed R61's cognition was intact. Facility's care and cleaning of respiratory equipment policy dated 11/11/24 showed in part: Disposable respiratory equipment will be replaced on a scheduled basis in order to minimize the risk of nosocomial infection. Nasal cannulas are changed weekly and as needed. Respiratory tubings, masks will be secured or placed in a container, original package or bag. 44103 On 3/11/25 at 9:36 AM, R48's resting in bed alert and able to verbalize needs. Surveyor noted R48's BiPAP mask on the floor connected to the machine not stored inside a bag. R48 stated she uses the BiPAP at night for sleep apnea. R48's face sheet has included diagnoses but not limited to obstructive sleep apnea and morbid obesity. R48's Minimum Data Set (MDS) dated [DATE] shows R48 is cognitively intact and requires staff assistance with her activities of daily living (ADL). R48's order summary report printed on 3/11/25 does not show any order for her BiPAP. On 3/11/25 at 11:37 AM, R66's lying in bed noted on oxygen at 4 liters per minute via nasal cannula. R66's oxygen tubing had no date when it was last changed. R66's nebulizer treatment was not in used sitting on R66's nightstand with the mask had no date when it was last changed and not inside a clear bag. Surveyor also noted R66's CPAP mask not in use and not stored inside a bag. R66 stated she uses her CPAP at night. R66's face sheet has included diagnoses but not limited to chronic obstructive pulmonary disease and Parkinson's disease. R66's MDS dated [DATE] shows R66 is cognitively intact and requires staff assistance with her ADLs. R66's order summary report printed on 3/11/25 documents in part: oxygen, continuous, at 4-5 liters/minute via nasal cannula, but no order for her CPAP. 49486 Resident #86 Respiratory Care 03/14/25 02:30 PM Findings Include: R86's Electronic Medical Record (EMR) revealed R86 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: encounter for palliative care, rhabdomyolysis, anemia, malignant neoplasm of large intestine, and malignant neoplasm of colon. On 03/11/25 at 10:34 AM, surveyor and V4 (License Practical Nurse/LPN) entered R86's room, observed her Oxygen Nasal Cannula on oxygen concentration tank, not dated and not in a plastic bag when not in use. V4 stated R86's oxygen nasal cannula tubing should have been contained in a plastic bag when not in use to prevent her from breathing in germs like bacteria, and the oxygen nasal cannula tubing should have been dated so that staff will know when next it should be changed. On 03/12/25 at 10:38 AM, V2 (Director of Nursing/DON) stated, it is V2's expectation that nurses will change oxygen tubing weekly, date and keep oxygen nasal cannula tubing in a plastic bag when not in use to prevent exposure to germs, maintain good hygiene, and prevent infection. R86's Minimum Data Set, dated dated dated [DATE] shows she is cognitively impaired. Physician Order Sheet (POS) with active orders as of 3/11/25 shows an order for Oxygen at 2 liters/minute for shortness of breath/SOB via nasal cannula. Change oxygen tubing every weeknight shift, every Sunday.

Based on observation, interview and record review, the facility failed to ensure low air loss mattress devices were on the correct weights setting for residents (R28, R29) with current pressure ulcer and for residents (R6, 91) who are at risk in developing pressure ulcers. This failure has the potential to affect four (R6, R28, R29, R91) out of four residents reviewed for pressure ulcer care in a final sample of 22. Findings Include: On 3/11/2025 at 11:15 AM, R91 was lying in bed and noted on a low air loss mattress with the weight dial on the machine set to 400 pounds. R91's Minimum Data Set (MDS) dated [DATE] shows R91 requires staff assistance with positioning in bed. R91's BRADEN scale dated 2/20/25 shows R91 is at risk in developing skin breakdown. R91's weight records show R91 weighs 136.6 pounds dated 3/5/25. On 3/11/2025 at 11:20 AM, R6 was sleeping in bed and noted on a low air loss mattress with the weight dial on the machine set to 350 pounds. R6's MDS dated [DATE] shows R6 requires staff assistance with positioning in bed. R6's BRADEN scale dated 12/6/24 shows R6 is high risk in developing skin breakdown. R6's weight records show R6 weighs 230 pounds dated 3/10/25. On 3/11/25 at 11:49 AM, R29 was sleeping in bed and noted on a low air loss mattress with the weight dial on the machine set to 400 lbs. R29's MDS dated [DATE] shows R29 requires staff assistance with positioning in bed. R29's skin progress notes dated 3/10/25 shows R29 has multiple pressure ulcers. R29's weight records show R29 weighs 137 pounds dated 3/5/25. On 3/12/25 at 10:14 AM, interviewed V9 (Wound Care Licensed Practical Nurse) and stated that residents who are at risk for developing pressure ulcers are placed on a low air loss mattress as preventative measure especially for those who needs assistance with positioning in bed. V9 stated that residents with current pressure ulcers are also placed on a low air loss mattress to help with wound healing to relieve pressure on the wound. V9 stated that the low air loss mattress should be set based on the current weight of the resident. V9 stated the low air loss mattress relieves pressure from the bony prominences, regulate pressure on specific areas of the body, and if it's not in the right setting that would deplete the purpose of the low air loss mattress. The restorative and the nurse should check the correct setting every shift. V9 stated that the facility uses a BRADEN scale to assess a resident for risk of skin breakdown. V9 stated R91 has no current wound but had history of having pressure ulcers on his sacrum. R91 is at risk for skin breakdown. R91 is on low air loss mattress for prevention of skin breakdown. R91 needs assistance with turning and repositioning. V9 stated R91's current weight is 136.6 pounds taken on 3/15/25. V9 stated 400 pounds setting for R91'sow air loss mattress is incorrect. V9 stated R29 is high risk for skin breakdown and has current pressure ulcer on her left heel. R29 is also requiring assistance with turning and repositioning. R29's current weight for is 137.0 pounds on 3/5/25. V9 stated if the dial is pointing to 400 pounds that is not the right setting for R29's low air loss mattress. V9 stated R6 is high risk for skin breakdown and is completely immobile. R6's current weight is 230.0 pounds on 3/10/25. V9 stated if the weight dial is pointing to 350 pounds that is not the right setting for the low air loss mattress. The facility's Wound Prevention and Healing policy dated 6/1/24 documents in part: Braden scale will be completed to determine the patient's level of risk and implement interventions to prevent development of pressure injuries. The facility's Skin Management: Specialty Mattress policy dated 6/24 documents in part: Settings will be observed every shift to ensure mattress is functioning properly. 49486

Based on interview and record review, the facility failed to utilize a gait belt during resident transfer, from toilet to wheelchair, for one of three residents (R1) reviewed for falls. This failure resulted in R1 falling and sustaining a left femur fracture. Findings include: Facility's incident report (Final of 7.13.2024) R1 is a [AGE] year-old on 8/13/2021. Diagnoses include Acute Systolic Congestive Heart Failure, Overactive Bladder, Hypertension, Anemia, Anxiety Disorder, Hyperlipidemia, Alzheimer Disease, Dementia Without Psychotic Disturbance, Legally Blind, and Polyarthritis. Patient is alert and oriented x3. Patient is legally blind and requires supervision with toileting/hygiene care, transfers, bed mobility, and ambulation with a rollator walker. Patient also utilizes a wheelchair for mobility as well. Patient is continent of both bladder and bowel. Patient was assisted to the bathroom on 7/8/24 by the nursing assistant with the use of a wheelchair. After the patient finished toileting and providing hygiene care to herself, she proceeded to wash her hands at the sink in the bathroom. The nursing assistant was standing in the doorway of the bathroom with the wheelchair and gave directions to the patient to stand up from the toilet seat and to take a step forward towards the sink, when all of a sudden patient got up and had a missed step while approaching the sink in front of her. There was a change in plane and patient fell on to her knees and then the patient leaned towards her left side resting her upper body against the wall. The nursing assistant informed the nurse. Patient was sent to the hospital via 911. According to hospital records patient sustained a left femur fracture and underwent a ORIF (Open Reduction Internal Fixation) of left femur on 7/10/24. R1's MDS (Minimum Data Set of 5/10/2024) documents R1 is severely visually impaired and is cognitively intact. R1's X-ray of hip (7/9/2024) documents: Comminuted fracture involving the distal femur which appears to extend to the articular surface distally is noted. 8/10/2024 at 9:53 AM, V9 (R1's son) said via telephone, R1 has had multiple falls; two within the last 30 days. R1 called V9, screaming in pain and told him she fell . V9 said R1 sustained a femur fracture. V9 said R1 is blind and would have never attempted to go to the bathroom on her own. 8/10/2024 at 2:57 PM R1 awake/alert sitting up in bed eating pizza. Appears neat/clean. Surveyor asked R1 about her recent fall (7/8/2024). R1 said. I thought someone was with me (in the bathroom). Someone should be with me when I'm in the bathroom, I'm blind. I don't know if anyone helped me to the bathroom. Nobody was there when I fell . I go in the diaper now because I can't get up. R1 added, She kept hollering at me to sit down. I called my son; I told him I broke my hip. Call my son, he can tell you what happened. (Son was not at facility when resident fell ). 8/10/2024 at 4:38 PM, V3 (LPN-Licensed Practical Nurse) via telephone said the CNA (Certified Nursing Assistant) told me R1 was on the floor in the bathroom. V3 stated, I went to bathroom; I saw the resident on the floor leaning against the wall. I asked the CNA what happened. She said the resident (R1) got up from the toilet, turned to sit down in the wheelchair and fell on the floor. The CNA told me she was standing behind the chair, holding the chair for the resident. She (CNA) said she (R1) could not move her leg. (R1) said she broke her leg. (R1) was unable to move her leg. We called 911, while I was waiting for 911, I (V3) did her (R1) assessment. I couldn't determine if she broke her leg. I asked R1 if she would be able to move her leg. I left her on the floor, 911 picked R1 up when they arrived and put her on the gurney. I forgot the CNA's name; I never saw her again. V3 insisted she left R1 on the floor while waiting for 911. I called the physician immediately but no there was no response. I was about to call the son; when he arrived at the facility; R1 called her son. 8/12/2024 1:35 PM, V5 (LPN-Licensed Practical Nurse) via telephone, said We use a gait belt with all the residents (when doing transfers); gait belts are part of their (CNA's) uniform. 8/12/2024 at 2:43 PM, V2 (DON) said, Yes, staff use gait belts. I don't remember if I asked her (V4) if she used a gait belt. (V4) was standing behind (R1)'s wheelchair. (V4) should have been in bathroom with (R1) and using gait belt. 8/12/2024 at 4:42 PM, V7 (Physical Therapist) via telephone, said R1 is legally blind, had a couple of falls, and requires a lot of cues. I evaluated her (after a fall), I don't exactly know how she fell , she was complaining of shoulder pain and couldn't lift her shoulder. (R1) is a contact guard assist (CGA) for transfers; hold her a little, use a gait belt. V7 added staff should use a gait when transferring R1. If a gait belt is not used (during transfers) the resident could fall with or without injury. V4 (CNA-Certified Nursing Assistant) was not available for interview. R1's Progress Note of 7/8/2024 at 15:22 (written by V3-Licensed Practical Nurse) Note Text: At 1300, the C.N.A came to the nursing station and reported, 'the resident fell in the bathroom'. On getting to the room noted the resident sat on the floor in front of the toilet seat and sink, leaned her back against the wall, straight the right leg and bent the right leg. The resident voiced, 'I broke my leg'. The resident is alert oriented x 3, able to make her needs known. The resident room and bathroom are clutter free and dry. There is adequate light in the room. Noted that the resident had shoes and socks on. The last time the writer saw the resident was during the lunch time at 12:00 p.m. Head to toe assessments were completed. Noted that the resident could not move nor stand on the leg. The resident still complained, 'I could not move my leg, I broke my leg'. The C.N.A assisted the resident to get up from the floor to the wheelchair and moved her to the side of the bed, then transferred her to the bed. The D.O.N. was made aware at 1307. Contact (resident's physician) with the order to send the resident out via 911. At 1307, the resident son was at the bedside at 1309. Called 911 @ 1354 and arrived at 1400 and transported the resident to the (local hospital).

Based on interviews and records review, the facility failed to ensure resident safety for one resident (R2) of three residents reviewed. This failure resulted in R2 falling and sustained right leg laceration. R2 was taken to the emergency room and received sutures on the right leg. R2 is not currently in the facility. Findings include: According to current POS (Physician Order Sheet), R2 is an [AGE] year-old individual admitted to the facility on [DATE]. R2's medical diagnosis includes but not limited to: Acute on chronic diastolic (congestive) heart failure, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2's Brief Interview for Mental Status (BIMS dated 8/4/2023 document R2's BIMS as 2/15, indicating R2's has severe cognitive impairment. R2's functional status dated 8/4/2023 documents R2 is dependent for toileting hygiene, Shower/bathe self, Lower body dressing, lying to sitting on side of bed, Chair/bed-to-chair transfer. Facility's MDS (Minimum Data Set) section GG (functional Abilities) defines Dependent as: -Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 11/14/2023 at 3:08PM, V2 (Director of Nursing-DON) said on 10/02/2023 about 12:00am, V15 (Certified Nursing Assistant-CNA) told V2 that R2 was in bed sleeping. V15 woke R2 up and told R2 V15 needed to change R2 because R2 had a bowel movement. V15 said R2 said OK, and when V15 attempted to change her, R2 started becoming restless. V15 said when R2 became restless, V15 stopped what she was doing and explained to R2 what V15 was doing but R2 remained restless. R2 then tried to slip out of bed so V15 tried to support R2's weight and lowered R2 to the floor. V2 said V16 (RN) entered the room at that time, and that is when V15 and V16 noticed blood coming out of R2's right lower leg. V2 said V16 applied pressured and called the physician because the pressure was not reliving the bleeding on R2's leg. V2 said the physician gave orders to V16 to call 911 and transport R2 to emergency room of the community hospital. V2 said after R2's fall and injury to the right lower leg, V15 was assessed and educated on bed mobility to determine what education V15 needed regarding bed mobility to prevent falls. V2 said V15 should have called someone else to assist her if R2 continued to be restless since V15 was having a hard time calming R2. V2 said R2 is a two person assist for transfer with mechanical lift when getting out of bed. V2 said V2 followed up with the community hospital and was informed R2 was admitted to the hospital with diagnosis injury to the right lower extremity and sutures were applied on right lower extremity. V2 said when V2 got the report from the hospital, V2 was not told how many sutures R2 received on her right leg. On 11/15/2023 at 3:15pm, V15 (Certified Nursing Assistant-CNA) said she went to R2's room to check on R2 to see if she was ok at about 11:00pm. R2 was wet with urine and had a bowel movement. V15 said she informed R2 she was going to change R2 and R2 consented. V15 said she was trying to clean R2 when R2 started yelling and screaming. V15 explained to R2 what V15 was doing. R2 calmed down but as soon as V15 started cleaning R2 again, R2 got agitated and tried to get out of bed. V15 said R2 cannot control her legs and started sliding out of bed so V15 tried to ease her to the floor while protecting her head. V15 yelled for help and V16 (Registered Nurse-RN) came to help but by the time the V16 came blood was observed on the floor. R2's right leg was observed with a cut on the side. V15 said she thought R2's leg got caught on the lower part of the bed as R2 was sliding down but V15 was not sure how the cut happened. V15 said she was not within reach of the call light when R2 fell . On 11/15/2023 at 3:33pm, V16 (Registered Nurse) said she was the Nurse for R2 when R2 fell . V16 said V15 (CNA) yelled for help, and when V16 went to R2's room, she found R2 on the floor one leg was bleeding. V16 said the length of the laceration was about 1.5cm. V16 applied pressure dressing but the laceration continued bleeding, therefore V16 called the physician who gave orders to call 911 and sent to R2 to the ER (emergency room ). V16 said R2 was a high fall risk patient. V16 said R2 was restless and agitated and was moving around during care. V15 was unable to control R2 because R2's legs are very heavy, therefore V15 protected R2's head and the legs were caught on the bed frame which caused laceration to R2's leg. V16 said usually R2 was calm during care and had never shown signs of agitation. V16 said, the day R2 fell and got injured, R2 was sleeping when V15 was changing R2. This woke R2 up and it caused R2 to be agitated and restless. V16 said the staff should wake the resident up before changing them to make sure they know what is happening. V16 said R2 moved her legs from side to side and her legs are very heavy and that is why R2 slide off the bed, causing the R2 to fall. V16 said R2 was usually a very calm and cooperative resident and was alert and could understand what she was being told to do. V16 said she did not know what happened that day to cause R2 to be agitated as R2 had never behaved like this before. On 11/16/2023 at 11:04am, V18 (Physical Therapy-PT) said V18 evaluates residents when they are admitted for physical therapy to assess for bed mobility, functional transfer, ability to ambulate or walk and stair usage. V18 said R2 was not on PT schedule at the time of the fall. V18 said R2 had knee contractures and R2 was discharged from therapy because of no progress in terms of transfer. V18 said R2 was recommended by physical therapy to use a mechanical lift for transfers. V18 said R2 was able to roll on each side with standby assistance for cuing and for safety. V18 said R2 was not able to sit up or pull herself up. R2 needed two people to scoot R2 up, sit her at the end of the bed or to reposition R2 because R2 was heavy. V18 said it would be very difficult for R2 to scoot herself up and down the bed or swing her legs out of the bed because of her lower body weakness. Facility policy titled Fall Prevention and Management, dated 10/29/2021, revised 10/30/2023 documents: -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. Nursing progress notes dated 10/2/2023 document: Staff (V15-Certified Nursing Assistant -CNA) called for help. Resident's (R2) room lying on the floor head up lying on her back. Right lower leg laceration noted. MD notified new order call 911 sent to ER (emergency room ). Facility Reported Accident Report (FRI) dated 10/03/2023 documents: -On 10/03/2023 facility got call from hospital ER (emergency room ) and was informed R2's admitting diagnosis of laceration of lower extremity with sutures for observations.

Based on observation, interview and review of records, the facility failed to protect resident's right to be free from physical abuse and mental abuse for 3 out of 3 residents (R23, R24, R42) for a total of 18 residents reviewed for abuse. These failures resulted in1 resident (R23) suffering pain after being roughly pulled during care by health care personnel (HCP) with a diagnosis of Right upper leg / hip fracture and (R24, R42) being spoken to rudely and refusing to provide assistance with ADL care causing mental anguish to 2 residents (R24, R42). Findings include: R23 is [AGE] years old, readmitted on [DATE] with medical diagnosis of displaced fracture of greater trochanter of right femur. R23 has a brief interview of mental status of 15 that means R23 cognition is intact. On 05/03/2023 at 02:11 PM, V15 (State Ombudsman) said the facility was ignoring an incident that happened with R23, the alleged victim, and V13 (Certified Nursing Assistant / Agency), the alleged perpetrator. V15 forwarded an email that in part reads: V13 screamed at R23 despite R23 asking V13 to be gentle. V13 was being rough with R23. V13 still works in the facility after incident. Another email dated 05/03/2023 at 05:11 PM was sent by V15 reiterating the facility was ignoring her (V15). It reads: They (facility) not ever saw the need to return my (V15's) call. On 05/03/2023 at 02:42 PM. V13's schedule and contact information was requested from V1 (Administrator). V1 said V1 would check and get back to give update. On 05/03/2023 at 02:45 PM. R23 said, Let me make this clear, this is how it happened. V13 (Certified Nursing Assistant) came inside my room and told me that she will change my diaper then V13 left room. After that 2 therapist (V26/PT and V27/OTA) came in because I was scheduled to have therapy. They offered to change my diaper because I was wet. I refused because I feel uncomfortable with male therapist changing me. About 10, 15, or 20 minutes later V13 came back really upset screaming and said that I should have let those 2 therapists (V26 and V27) change me. V13 then pulled my legs apart really hard making it really hurt bad (R23 was grimacing). V13 was rough handling me while changing me. I think she hurt me on purpose because she was upset that I did not allow the 2 therapists to change me. So, I was crying during therapy and the 2 therapists asked me what was wrong. At first, I told them (2 therapist) it was nothing. Then V24 (Therapist / Rehab Director) came and asked me and I told her what happened. V24 told me that I need to report it. R23 said, I felt bad, this same thing happened to me in another place (Nursing Home), they told me that's just how that person acts. I feel traumatized. On 05/04/2023 at 09:31 AM. V1 (Administrator) stated she only interviewed random residents. When asked why the therapist who was present during the incident was not interviewed. V1 said, I will look on it. Again, V1 was asked the same question. V1 again said, I will look on it. On 05/04/2023 at 09:51 AM. V24 (Director of Rehab and Therapy) said, R23 was relatively new during this incident. V26 (Physical Therapist) and V27 (Occupational Therapist Assistant) went into R23's room. R23 said that she needs to be change. V26 and V27 offered to change her but R23 said I would rather have a woman. The call light was turned on and one of the therapists went to go find a certified nursing assistant. Both V26 and 27 left the room. Twenty minutes later, V13 (Certified Nursing Assistant / Agency) went to R23's room but both V26 and V27 had already left. After V13 care, R23 said V13 was abrupt and rough in V13's care. R23 told V24, 'V13 makes me feel uncomfortable.' R23 was crying a bit while she was telling me (V24) about V13. R23 was in significant pain at that time. R23 has right hip fracture, hip replacement. Precautions needed with hip fracture medical diagnosis includes not crossing legs, don't pull legs wide apart, and no bending or leaning forward. I agree it is different when a person has physical pain and being handled correctly compared to when a person has physical pain and also emotional or psychological pain during care by V13, I cannot argue with that. I think V13 was upset because V13 just changed R23 and then V13 needed to change R23 again because R23 is scheduled for therapy. I know that is not a good reason because it is what they are here for. The staff that has primary duty to do incontinence care are the CNA (Certified Nursing Assistant). Although therapist like PT (Physical Therapist) or OT (Occupational Therapist) are also trained to perform incontinence care. On 05/04/2023 at 10:14 AM, with V26 (Physical Therapist) and V27 (Occupation Therapist Assistant), V26 said, R23 was in a lot of pain because of her medical diagnosis. R23 has fracture and has a lot of pain. She (R23) often feels uncomfortable. We had already left (R23's room) before V13 performed bedside care (to R23) but we were informed by V24 that R23 felt that V13 was abusive and was rough. On 05/04/2023 at 09:43 AM this surveyor left a message for V35 (Orthopedic Doctor). At 01:40 PM, V36 (Nurse Practitioner) calling for V35 said, R23 has minimal displace fracture, R23 requires restrictive weight bearing positioning and I would not extend her leg. Absolutely R23 has pain because of the fracture. V36 did not order pain medication but R23 currently has an order for pain medicine. On 05/05/2023 at 11:17 AM V13 (Certified Nursing Assistant) said before any questions were asked, I deal with too many clients and work too much. I cannot remember, I do not want to get upset with you. V13 then said, I worked on the floor and R23 was one of my residents. We were very busy that day. I think it was morning, R23 was so sweet, very needy but real nice. I went to see R23 and she said she has therapy later. I told R23 why we don't get her washed up and leave her pants half on. Later I went back to R23's room and told her that I was not available and told R23 that the therapist can change her (R23). Because everybody has a slot and everybody has a schedule, I need to take care of everybody not just R23. R23 did mention that therapist tried to change her. V13 was asked twice to describe what happened during incontinence care. V13 answered twice, Nothing happened. This surveyor asked V13 to describe what she can remember and had no implication to anything. V13 said, I opened up diaper, asked R23 to turn and assisted R23. I think R23 has something was with her legs. I think she has injury or something. I turned her on the right side towards the window so her weight is on the right side. R23 always complained that she is in pain all time because of her injury. I don't know if she told me to be gentle. I cannot remember. V13 said, An unknown staff told me there was a complaint with the resident (R23) and they told me who it was. I understood that the lady (R23) was very fragile. She (Unknown Staff) explained and mentioned therapy staff. I cannot remember what they told me. This surveyor asked V13 how many times she changed R23 before therapy? V13 said, Only 1 time. After clarifying with V13 the question, asking if changed R23 before breakfast and who changed her before therapy. V13 said with upset voice, I changed her, then R23 ate breakfast and changed her before therapy. That's the way she (R23) is, she also complained to me in the past. V13 was then very defensive about questions and got upset and verbally aggressive when it was mentioned that R23 has pain because of right leg / hip fracture. V13 said, I don't like to be ask anymore. I don't want to be blame of something. The only thing missing for me to become a nurse is my license! I think I need to get an attorney because I don't want to be blamed for causing a fracture to R23. Explained to V13 that no one is blaming her about the fracture because R23 has that medical diagnosis since admission. V13 said, I don't want to talk anymore! That's it! I will hang up! Review of R23's records are as follows: R23's Care Plan has occasional bladder incontinence related to activity intolerance, impaired mobility. Physical limitations due to fracture of right greater trochanter. After full care plan was reviewed there was no plan of care for abuse and pain. Facility Reported Incident investigation documentation (Initial and Final Report) does not include those therapists (V24, V26 and V27) as part of the investigation. Abuse and Neglect Policy and Procedure dated 03/24/2022 as revised, in part reads: To outline guidelines for the prevention of resident abuse and measures to be taken in the event any kind of resident abuse is suspected and identified. All residents have the right to be free from abuse and corporal punishment by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members, friends, or other individuals. For the purpose of this policy, resident abuse is defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. 45002 On 05/02/2023 at 10:29 AM, surveyor observed R24 and V39 (Son/POA for R24) sitting in R24's room. R24 stated that she is blind and that no one comes in and introduces themselves. V39 stated R24 has to go to the bathroom frequently and that a few CNA's come in and make comments like, I'm not doing this or I'm not doing that and have walked out of the room. V39 stated we made a complaint about one CNA in particular who was rude and reported that the CNA walked out on R24. V39 stated that the CNA was V30 (Certified Nursing Assistant). V39 stated, I am not sure what was done about that situation, all I know is that V30 was moved from 2nd floor to the 3rd floor. Surveyor asked R24 how did V30's action make her feel. R24 stated she felt terrible and it made her cry. R24 stated she told V16 (LPN) about the incident. R24's diagnosis documents in part: Legal Blindness. R24's MDS Section C Cognitive Patterns (February 17th, 2023) documents in part: BIMS score is 15, which means she is cognitively intact. R24's care plan documents in part: R24 is incontinent of bowel and bladder due to reduced mobility secondary to neuromuscular weakness. R24 is legally blind. V28 stated she is also aware of the incident that took place on Monday April 17th 2023, about CNAs' being rude to R24. V28 stated V1 notified her and asked her if she could go talk to R24. V28 stated R24 stated that she was very upset. V28 stated R24 told her the CNA was upset that she had to take her to the bathroom. R24 stated, Her attitude was nasty and she stated that she is not going to take care of me and walked out. When V28 asked R24 who the CNA was, R24 stated V30 (CNA). V28 asked R24 how she knew it was V30. R24 replied that she recognized her voice from the previous time V30 had worked with her (R24). V28 stated R24 told V28 that she was upset and that she had called her son to talk to V28. V28 stated, I am sure these incidents happened and I am not sure if any in-services were done. V28 stated she would report this to nursing and to V1 and make sure that V30 (CNA) will not work with her (R24) again. __ R42's Facesheet documents in part: Medical diagnosis- need assistance with personal care. R42's care plan documents in part: R42 has an ADL Self Care Performance Deficit secondary to impaired mobility, decrease in ADLs, Physical Limitations: Balance problems, gait, strength, endurance. On 05/02/2023 at 12:55 PM, surveyor observed R42 laying on her bed in her room. R42 stated a staff member was very rude to her. R42 stated, One time I had trouble with my bowel movements, and I was going frequently. A CNA came into my room, threw the diaper on my bed, didn't say anything and walked out. I am not sure who it was. R42 stated she told V16 (LPN). Surveyor asked R42 how she felt after the incident, R42 stated she mentally felt hurt and distressed. On 05/03/2023 at 1:00 PM, V16 stated that R42 did tell him about a staff member being rude to her. V16 stated that he told the administrator, and then V28 (Director of Social Services) came to talk to her (R42). V16 stated that R24 also notified him about V30 being rude to her. V16 stated that he told V28 and V28 went to talk to R24. On 05/04/2023 at 10:31 AM, V28 (Director of Social Services) stated when an abuse is suspected the expectation is myself or my co-worker notify the administrator and then we interview the person. We interview other residents, and then the nursing leadership departments will get statements from their staff. Usually, one of the nurse supervisors or V29 (Assistant Director of Nursing) will get the statements from the staff. Sometimes it does fall on V1 (administrator) to collect the statements if the nursing staff is unavailable. V1 is the abuse coordinator. If there is an allegation of staff members being rude to residents, the expectation is to do an official investigation. V28 stated, I do all the documenting and questioning. If I am notified first, then I would tell V1 (Administrator). After the investigation is complete, we make a decision if the allegation of abuse is substantiated or not. V28 stated she was notified of staff members being rude to R42. V28 stated she talked with her (R42). The incident took place on March 21st, 2023. V28 stated V16 (LPN) notified her that a couple of CNAs' were rude to R42 and if ask she (V28) could talk with her (R42). V28 stated she notified V1 about the incident only after talking to R42. When V28 talked to R42, R42 stated the CNAs' threw the diaper on her bed and walked away. I did not interview anyone else about this incident. On 05/04/2023 at 10:50 AM, V2 (Director of Nursing) stated she is not aware of any abuse allegation that took place with R42 nor the incident that took place with R24. On 05/04/2023 at 10:55 AM, V1 (Administrator) stated she did not do a full, thorough investigation for these two abuse incidents. V1 stated that after speaking to V28, she didn't think the allegation was abuse so she didn't do a full abuse investigation. V1 stated the incident against R24 took place on April 17th, 2023. V1 stated that when she looked back at the schedule, V30 didn't even work the day of the alleged event, so didn't bother to investigate further. On 05/04/2023 at 11:00 AM, V5 (Executive Director) stated V1 didn't do a full abuse investigation but a soft investigation because the impression V1 received from V28 (Director of Social Services) was that there was no abuse. Facility's soft investigation for R24's mental abuse allegation dated April 17th, 2023, documents in part: V30 didn't work on April 15th, or 16th. Reviewed facility's nurse/CNA schedule for April 2023. V30 last worked April 8th, 2023. Facility's abuse policy (3/24/22) documents in part: All residents have the right to be free from abuse and corporal punishment by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members, friends or other individuals. Mental abuse is defined as but not limited to humiliation, harassment, threats of punishment, withholding of treatment or services.

Based on observation, interview and record review the facility failed to transfer a resident (R2) using a total body lift during bedside care and failed to ensure one resident's (R2) environment was free of hazards. These failures resulted to R2 sustaining a laceration requiring hospital transfer and 25 sutures to R2's right leg. Finding include: R2's face sheet documents that R2 has diagnosis which includes but not limited to: Displaced bimalleolar fracture of left lower leg subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus without complications, history of falling, unspecified protein calorie malnutrition, hypothyroidism unspecified, hypertensive heart disease without heart failure, unspecified atrial fibrillation, chronic kidney disease unspecified, gout unspecified, gastro esophageal reflux disease without esophagitis, major depressive disorder single episode unspecified, polyarthritis unspecified, anemia unspecified, laceration without foreign body right lower leg subsequent encounter, encounter for other orthopedic aftercare, muscle weakness (generalized) dysphagia oral phase, other abnormalities of gait and mobility, and need for assistance with personal care. R2's Brief Interview for Mental Status (BIMS) dated 02/22/2023 documents that R2 has a BIMS score of 00 which indicates that R2 is cognitively impaired. R2's Care Plan dated 01/22/23 documents in part: Focus: R2 has an ADL (Activities of Daily Living) self-care performance deficit secondary to impaired mobility . Transfer: R2 requires a total body lift with transfers. Do not seat the resident next to the bed while the bed is being raised. On 04/10/23 at 11:30 am, R2 was observed awake, alert sitting in a wheelchair and without a total body lift transfer pad underneath R2 in the resident sitting area on the facility's second floor. Surveyor attempted to interview R2 and R2 was not able to answer questions. On 04/10 23 at 11:33 am, V4 (Licensed Practical Nurse, LPN, Agency) stated, R2 had recently sustained an injury to R2's right lower leg that is resolved. V4 was asked regarding R2's transfer status. V4 stated, R2 recently declined and required a total body lift for transfers. V4 also stated, R2 was receiving physical therapy and occupational therapy since 03/08/23. On 04/10/23 at 2:03 pm, Surveyor requested V7 (Certified Nursing Assistant, CNA) and V8 (CNA) to perform a skin check with R2. V7 stated, Great! It's time for her (R2) to be changed anyway. Surveyor observed V7 and V8 bring R2 to R2's room and place R2's wheelchair next to R2's bed. Surveyor then observed V7 and V8 place a gait belt around R2's waist while R2 was still sitting in R2's wheelchair next to R2's bed. Surveyor observed both V7 and V8 place one of V7's and one of V8's hands on the gait belt around R2's waist while V7's other hand and V8's other hand was observed underneath R2's arms. Surveyor observed V7 and V8 manually transfer R2 to R2's bed without the use of a total body lift. Surveyor observed R2 in bed and R2's wheelchair without a total body lift pad in R2's wheelchair. Surveyor further observed R2's right and left lower legs skin intact. V7 and V8 were asked regarding R2's transfer status. Both V7 and V8 stated, V7 and V8 did not know R2's transfer status. When V7 and V8 was asked regarding how staff is made aware of a residents transfer status both V7 and V8 both stated that the residents have a circle outside of the residents room that tells the residents transfer status. When surveyor, V7 and V8 went to observe R2's transfer status circle outside of R2's door, surveyor, V7 and V8 observed a red circle that showed TBL (Total Body Lift). When V7 and V8 were asked regarding what does the red circle that showed TBL meant, both V7 and V8 both stated, I (V7) and (V8) don't know what TBL means. On 04/10/23 at 2:55 pm, V11 (Restorative Nurse, Wound Care Nurse, Registered Nurse, RN) stated, V12 (Certified Nursing Assistant, CNA) was raising R2's bed to the level of R2's wheelchair and notice a laceration to R2's right lower leg that R2 was holding. V11 stated, an investigation was conducted regarding R2's injury and concluded that R2 had a sharp piece hanging from the side of R2's bed that injured R2 when V12 was transferring R2 to bed from R2's wheelchair. V11 was asked to read R2's progress notes authored by V13 (Registered Nurse, Agency) from the incident dated 02/14/23. V11 stated, Oh the progress notes say the CNA stated R2's injury occurred during V12's transferring of R2's from the wheelchair to the bed. When V11 was asked how staff are made aware of residents transfer status, V11 stated there is a circular sticker outside of each residents door with residents transfer status that is determined by the therapy department and placed outside the residents doors by the restorative department to makes staff aware of a residents transfer status. Surveyor asked V11 R2's current transfer status. V11 stated, R2's current transfer status is a total body lift. V11 was asked what could happen if a residents transfer status is not being followed. V11 stated, the resident can be at risk for injury or fall. V11 was asked how staff are educated regarding a residents transfer status. V11 stated, staff are educated at the facility's daily meetings regarding residents transfer status. On 04/11/23 at 10:00 am, V2 (Director of Nursing, DON) stated R2 sustained a leg injury when V12 (Certified Nursing Assistant, CNA) was transferring R2 from R2's wheelchair to R2's bed a few months ago. V2 stated, R2's bed was examined, and no sharp object was seen coming from R2's bed. V2 stated, there was a metal extension pieced extending from R2's bed that was believed to have injured R2 when V12 was transferring R2 from the wheelchair to the bed. V2 was asked how staff are made aware of a residents transfer status. V2 stated, the circle outside of the residents room indicates that residents current transfer status. V2 was asked regarding TBL on the circle outside of a residents room. V2 stated that TBL means Total Body Lift and that the resident should transfer with a total body lift and two staff members. V2 was asked if a resident is not transferred properly what could happen to the resident. V2 stated, an injury can occur. V2 also stated, the importance of following the indicated transfer status outside of the residents room is to make sure the resident is safe. V2 explained, residents equipment should always be safe to use and that the nurse or the nursing assistant should monitor the patient equipment before use and report if something is wrong. V2 further stated, it is improper for a nurse or CNA to use equipment that is not safe. On 04/11/23 at 12:35 pm, V3 (R2's Physician) was interviewed and stated, V3 was called and informed that R2's leg got injured accidentally while transferring a few months ago. V3 stated, R2 was sent out to the local hospital for the injury to R2's leg (unable to recall which leg) and R2 received sutures to R2's injured leg. V3 further stated, V3 treated R2's injured leg with an antibiotic. Surveyor asked V3 how a residents transfer status is determined. V3 stated, the physical therapist, and the nursing staff determine a residents transfer status. V3 also stated that if a resident is not properly transferred the resident can get hurt or fall. V3 was asked regarding what could happen if staff use equipment for the resident that is not safe. V3 stated, The resident could get harmed or injured. On 04/11/23 1:10 pm, surveyor attempted to contact V12 (Certified Nursing Assistant, CNA, Agency) and was unsuccessful. V2 (Director of Nursing, DON) stated that V12 is an agency CNA and is no longer able to return to the facility. On 04/11/23 1:13 pm, surveyor attempted to contact V13 (Registered Nurse, RN, Agency) and was unsuccessful. V2 (Director of Nursing, DON) stated that V13 is an agency nurse and is no longer able to return to the facility. R2's Facility Reported Incident initial report to state agency dated 02/15/23 at 4:29 pm, documents, in part: When R2 was being assisted to bed, V12 (Certified Nursing Assistant, CNA) noted a large skin tear on R2's left lower leg (area in question is right lower leg) . R2 went out to the hospital for evaluation, skin are with sutures and dressing upon return. R2's Facility Reported Incident final report to state agency dated 02/21/23 at 4:17 pm, documents, in part: R2's was sitting with right leg next to the bed when the bed was raised, the side rail has an extended piece on the outer aspect at the bottom of the rail. It is presumed that the extended piece from the side rail rubbed across the right lower leg when the bed was being raised and caused the skin tear and open area. R2's progress report dated 02/14/23 at 18:35 authored by V13 (Registered Nurse, RN) documents, in part that V13 was called by V12 (Certified Nursing Assistant, CNA) about a laceration on R2's right outer lateral leg (11.5 X 0.5 X 0.4) while V12 was transferring R2 to the bed to change (provide incontinence care) R2 . V12 stated that R2 reached to R2's leg at the injured site after R2 was transferred from R2's wheelchair to the bed . V3 (R2's Physician) was called and informed, order given to send R2 out to the local hospital emergency room for suturing. At 21:04 R2 was picked up by transportation company. R2's progress report dated 02/15/23 at 6:38 am, authored by V15 (Registered Nurse, RN) documents, in part R2 returned to the facility with right lower leg repair . Wound observed with 24 sutures . Tetanus Toxoid inoculation applied during emergency room visit. R2's hospital record dated 02/14/23 documents, in part: Procedure orders: Laceration repair . Physical Exam: . four-inch curvilinear laceration of lateral right shin with exposed but intact fascia and no active bleeding . Repair method: Sutures . Number of sutures: 25. Facility's undated document titled Resident Handling Policy Limited-Lift documents, in part: The Resident handling Policy exist to ensure a safe working environment for resident handlers . The transfer will be designated into one of the following categories . TBL: Total Body Mechanical Lift Transfer with two caregivers . Any transfer with mechanical lift requires two persons assist . The policy is to be followed at all times. Facility's document presented regarding R2's mobility, devices, ambulation documents, in part: Mobility, Devices, Ambulation: Transfer: R2 requires total body lift with transfers. Facility undated document titled Position Description Acceptance and Acknowledgment documents, in part: Position Title: Certified Nursing Assistant (C.N.A.) . When indicated, use mechanical lift with another CNA or nurse and transfer resident.

Based on interview and record review, the facility failed to use a gait belt and or walker during transfer from wheelchair to bed for one of three (R1) residents reviewed for safe transfers. This failure resulted in R1 falling to the floor during transfer and sustaining an incomplete fracture to the left medial malleolus (broken ankle). Findings include: R1's MDS (Minimum Data Set of 10.18.2022) documents R1 is a cognitively intact [AGE] year-old admitted to the facility on 7.16.2021 with diagnoses including but not limited to Metabolic Encephalopathy, Atrial Fibrillation, Arthritis, Osteoporosis, and Heart Failure. R1 is not steady during surface-to-surface transfer (between bed and wheelchair) and is only able to stabilize with staff assistance. Facility's incident report of 11.1.2022 notes in part, the resident transfers with stand by assist, with walker and can transfer from wheelchair to bed. On 10.21.2022 the nursing assistant was helping the resident into bed, the resident stood up from wheelchair, held onto walker and then started to become weak with legs starting to shake. The nursing assistant felt that the resident was about to fall and assisted with sliding down to the floor. On 1.26.2023 at 1:45 PM. R1 said, I was getting back in bed, I was turning around, apparently I wasn't close enough to the bed, I missed the bed and fell on the floor. On 1.26.2023 at 2:44 PM, V6 (CNA-Certified Nursing Assistant) said, R1 was in R1's wheelchair. V6 said, I put the wheelchair close to R1's bed. R1 didn't have a walker to grab onto. R1 said they (R1 and V6) could do it, so I assumed R1 could. I was standing in front R1, holding on to the back of R1's pants. I told R1 to hold onto the railing. R1 was kind of off balance, looked unsteady when R1 got up from wheelchair and R1 started to fall. I got behind R1. R1 started really sliding. I slid R1 down my leg to the floor. I did not know what R1's transfer status was before I attempted to transfer R1. I didn't use a gait belt. I hold back of their (residents) pants, that's how I secure them. On 1.26.2023 at 4:30 PM, V9 (Director of Rehab/Speech Therapist) said R1's walker should have been used during transfer from wheelchair to bed. Progress note of 10.22.2022 at 12:00 PM notes, (R1) states had a fall 2 days ago when transferring from wheelchair to bed with CNA. R1 states was not ready to transfer, felt pushed, lost balance and landed on the floor bedside. Progress note of 10.22.2022 at 2:00 PM notes, resident said (R1) had fallen on Thursday 10/20/22 around noon. Resident said was in (R1's) wheelchair and was going to be transferred to bed with the help of a CNA. (R1) said they (R1 and V6) stood up but before they could stand up completely, the CNA pulled R1 on to the bed which made R1 lose R1's footing and fall to the floor. R1's at risk for falls care plan (initiated 7.16.2021, revised 10.20.2022) notes, staff to ensure gait belt is used when transferring resident. Left ankle x-ray report of 11.1.2022 notes incomplete fracture of the medial malleolus.

Based on observation, interview and record review the facility failed to protect a resident's right to be free of abuse for one resident (R4) in the sample. This failure affected R4 who asked to have care assessment done after finishing lunch that escalated into verbal and mental abuse. This failure resulted in R4 crying, being upset and feeling hurt. This has the potential to affect all 16 residents residing on the 1st floor of the facility. Findings include: On 6/21/21 at 12:47pm, during lunch time observation, R4 was noted eating lunch in the dining area on the 1st floor. R4 explained to the surveyor that after being admitted to the facility (R4) developed a pressure ulcer to the right buttocks because at the time (R4) was unable to move about freely and had difficulty turning in bed. R4 stated it takes from 20 to 45 minutes before any staff come to help using the call light. R4 stated I developed redness to the back of my thigh from sitting on a commode for a long time. R4 then tried to show the surveyor the pressure site while in the dining room. The surveyor agreed with R4 that after R4 finished eating lunch, the nurse will come with the surveyor to look at the site. The surveyor notified V22 RN (Registered Nurse) in charge of the floor about checking R4's pressure sites after lunch. V22 stated she was supposed to do the treatment to the site and was busy, so she did not know how the site looks. On 6/21/2021 at 1:17pm, V22 came into the dining area, in a loud harsh voice and asked R4 to go into the room so the pressure site can be looked at. R4 was still eating at this time. V22 then in a loud and harsh voice told R4 to get up now and go back to R4's room. R4 tried explaining to V22, that the surveyor agreed to wait till after lunch. V22 said to R4 still in a loud harsh voice that she has no patience for R4's behavior and if R4 did not get up to go in the room now, she will leave and the treatment will not be done. R4 then turn to the surveyor and said, do you see how (V22) is talking to me? and tears began to run down R4's face. R4 stated This is the way they treat me like I don't mean nothing. R4 continued to cry. V22 then replied to R4, I'm sure she (referring to the surveyor) is not hard of hearing, yes she can hear me. V22 then walked away and told R4 and the surveyor I guess she (referring to the surveyor) will not see the sites because this is the time I have for her to see it. V22 then turned and left the dining area. At 1:23pm, the surveyor made this incident known to V1 (Administrator), V3 (Cooperate Director of Nursing), and V17 DON (Director of Nurse's). On 6/21/2021 at 2:13pm, R4 expressed gratitude of thanks to the State Agency stated that I feel better now, that V22 was sent home. R4 told the surveyor you did the right thing. If you are not here (referring to the facility) no-one will do anything about it. They will cover for themselves and that is why I reported to the State Agency because I'm sure they will do something about it. I'm worried about others (referring to peers) who cannot speak for themselves. Thanks, Thanks. The facility policy presented on Resident Rights with revised date November 2020 documented that employees shall treat all residents with kindness, respect and dignity, and will observe and honor the Resident's Bill of Rights in their conduct as an employee. Procedures pointed out that the Federal and State laws guarantee certain basic rights to all residents of the facility and the listed rights include but not limited to residents are fully entitled to exercise their rights and privileges possible. The facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. The facility policy titled Abuse and Neglect Policy and Procedure with revised date 1/17/19 documented that the purpose is to outline guidelines for prevention of resident abuse and measures to be taken in the event any kind of resident abuse is suspected or identified. The policy pointed out in part that all resident have the right to be free from abuse by anyone, including but not limited to facility staff, other resident, consultants, volunteers, staff of other agencies, family members, friends or other individuals. The policy listed out forms of abuse that includes but not limited to mistreatment, mental abuse and verbal abuse. The policy documented in part that mental abuse includes but not limited to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy indicated in part that verbal abuse example includes but not limited to speaking harshly, blaming the resident and making statements that cause a resident to feel intimidated or threatened.

Based on interviews and records reviewed the facility failed to prevent serious injury for one resident (R3) reviewed for unknown injury in a sample of 3 residents. This failure affected R3 who was found with swelling and bluish discoloration of the right lower leg. This failure resulted in R3 being sent to the hospital and suffering pain. R3's hospital X-ray showed [MEDICATION(S)] fracture of the tibia and fracture of the fibular neck. Findings include: R3 is [AGE] year-old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's transfer status prior to 4/24/21 according to her undated care plan states requires 1 staff assistance with transferring. Risk Management forms completed note R3 sustained falls on 2/5/21; 2/25/21; 3/5/21; 3/19/21; and 5/12/21. R3 observed by surveyor on 5/18/21 in her bed with eyes closed covered with blankets. On 5/19/21 R3 observed in her bed with right leg wrapped in soft splint with ace bandage from base of toes to knee. No bruising visible on toes. R3 resting with eyes closed. According to V11(CNA), R3 can talk but is nonsensical. During an interview on 5/18/21 at 12:00PM, V5 (Fall/Restorative Nurse) said before R3's fracture she could stand. During an interview on 5/18/21 at 1:43PM. V4 (Orthopedic Physician) said R3 was seen in his office and has a proximal tibiae fracture and fibulae fracture. V4 stated, This fracture would be caused by force in a person (R3's) age and condition. She would have had to bump her leg hard enough to fracture. In my medical opinion, this would not have occurred unnoticed. In her record, I did not see she has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When I initially saw her (4/30/21) this fracture had been present for 2 to 5 weeks. The facility told me it happened 5 or 6 days ago, that is why she was sent to me. She is now non-weight bearing to that leg. I am concerned that the facility delayed in identifying and treating the fracture. She is having significant pain with this fracture. The resident and her daughter were unable to tell me what happened to cause the fracture. During an interview on 5/19/21, V13 (CNA) said on 4/25/21 at around 4:45AM while doing rounds she heard R3 moaning. V13 said this was the first time on the shift she saw R3's leg. She said she saw R3's bruise on her leg was yellow/greenish in color. V13 said she reported to the nurse immediately. V13 said she was the only CNA assigned to R3 that shift. V13 said she did not see R3 hit her leg. V13 said before the fracture R3 was able to stand with assistance and turn, now she is a mechanical lift for transfers. During an interview on 5/19/21 at 9:45AM, V10 (Registered Nurse) said when she worked with R3 on 4/24/21 she was fine without a bruise. V10 said when she returned to work on 4/25/21 the night nurse told her she found a bruise on R3. V10 said R3 used to wheel herself around in her wheelchair. V10 said she spoke with V11 (CNA), who worked 12 hours on 4/24/21 and asked her what happened to R3. V10 said that V11 told her R3 did not fall while she was working. V10 also said (R3) did not fall while I was working. V10 said she notified the doctor and orders for an X-ray were obtained and completed. V10 said she did not see R3 bump into anything. During an interview on 5/19/21 at 10:30AM, V9 (Assistant Director of Nursing) said on 4/25/21 she was working and assessed R3's leg. She said it was blue and swollen below the knee. V9 said I had seen (R3) on 4/24/21 and she was her normal self, wheeling herself around in her wheelchair. V9 said she spoke with V11 and was told V11 gave R3 a shower on 4/24/21 and she had no bruising on her leg at that time. V9 said in the evening of 4/25/21 x-ray results were received showing a fracture. V9 said she was not able to find a cause of the fracture. V9 said R3 had increased pain on 4/27/21 so she was sent to the hospital for further evaluation. During an interview on 5/19/21 at 11:11AM, V2 (Director of Nursing) said R3 was documented to have been restless and wheeling herself in her wheelchair the day before the bruise was reported (on 4/24/21). During an interview on 5/19/21, V11 (CNA) said I was assigned to (R3) on 4/24/21 and 4/25/21. On 4/24/21 I worked from 7:00AM to 7:00PM. V11 said I gave her bath and she had no bruising on 4/24/21 or I would have reported and documented it. On 4/24/21 we kept her in her wheelchair for dinner to supervise her and then I assisted her into bed between 6:00PM and 6:30PM, there was nothing on her leg at that time. I did not see her bump her leg on anything. When I came in the morning of 4/25/21, the night shift CNA (V13) said R3's leg is swollen. V11 said she looked at R3's leg and it did not look like that when she left her on 4/24/21. V11 said, On 4/25/21 R3 moved a lot and said it hurt when she moved it. During a phone interview on 5/19/21 at 1:40PM, V17 (R3's daughter) said she is the Power of Attorney for health care for R3. V17 said she was told R3 has a bruise on 4/25/21 and an x-ray was being ordered. She said, The nurse in the emergency room told me my mother has a fracture in her leg. V17 said the facility has not told her what caused the fracture in her mother's leg. She said I took my mother to her orthopedic appointment on 4/30/21 and saw her right leg it was red, black, blue, and yellow with several shades of bruising. She was in severe pain. V17 said before the fracture her mother was not able to stand or walk without assistance and cannot recall events. V17 said I am concerned with the number of falls my mother has had at the facility. During an interview on 5/19/21 at 2:54PM, V20 (RN) she said it was usual behavior for R3 to attempt to self-transfer. V20 said she has been assigned to R3 in the past and R3 is familiar with her. V20 said that on 4/24/20 I entered the room on 2 occasions and saw R3 with her legs hanging off the end of the bed. I physically placed her legs back in the bed. V20 said during this shift R3 required much redirection and V11 was supervising and redirecting her. V20 said, I did not see R3 bump her legs on anything. On 4/25/21 when I came to work the off going nurse reported that R3 had bruising on her right leg. I went in to see her right leg it was swollen and bruised dark blue several inches below her knee. V20 said she saw V14 (CNA) go into R3's room the evening of 4/24/21 and then V20 said she went into the next room to assist another resident. V20 said she heard V14 telling R3 to get up and then she heard R3 cry out, like an ahhh,. V20 said she asked V14 what happened to cause R3 to cry out and V14 responded she asked R3 to get up, but she didn't want to. V20 said she did not know how R3 fractured her leg. During an interview on 5/20/21 at 9:44AM, V14 (CNA) said she was assigned to R3 on 4/24/21. V14 said around 5:45PM or 6:00PM she went to check R3 and she would not stand. V14 said (R3) did not have the energy to lift herself. She wasn't talking but when she talked, she was confused and she seemed out of it. V14 said it was unusual that R3 was acting this way. V14 said she does not recall that R3 cried out when she was in the room with her on 4/24/21. During an interview on 5/20/21 at 10:31AM, V15 (RN) said V13 (CNA) reported to her around 5:00AM on 4/25/21 that R3's leg was red and swollen. V15 said R3 had slept well and had no attempts to get out of bed. V15 said when she looked at R3's leg the bruise was about the size of my hand. V15 said V13 said she was not aware of what happened to cause the bruise. During an interview on 5/20/21 at 11:59PM, V18 (Assistant Administrator) said the unit [where R3 resides] has 2 cameras facing the hallway. V18 said we have access to review the camera footage. V18 said, I or (V1) would have been notified if we need to review the camera footage. The nurses do not have access to review the camera footage. V18 said he was not asked to review the footage from 4/24/21 into 4/25/21 morning hours. V1 (Administrator) said she did not review the footage from 4/24/21 into 4/25/21 morning hours to investigate the cause of R3's fracture. During an interview on 5/20/21 at 12:45PM, V2 (Director of Nursing) said before her fracture R3 was a 1 person assist for transfers and currently R3 is a mechanical lift for transfers. Review of Skin Event dated 4/25/21 completed by V15, notes leg below the knee is swollen with slight bluish discoloration about 10x6 cm, painful to touch. It is unknown how it happened. Review of Progress Note dated 4/25/21, notes R3 seen with bruise with swelling on the right lower leg. Unknown cause. Resident unable to state what happened due to confusion and forgetfulness. [MEDICATION(S)] given with minimal relief. Review of Progress Notes on 4/27/21 states R3 transferred to hospital at 1:31PM. Returned to facility at 7:27PM. Review of Progress Notes on 4/28/21 notes R3 screams with pain with slight movement. Review of Progress Notes on 4/30/21 note. R3 was seen by V4 with orders for non-weight bearing and a long leg splint to be worn at all times. Review of R3's X-ray of the right tibia and fibula report dated 4/27/21 states: Findings: Subacute appearing [MEDICATION(S)] fracture of the tibial diametaphysis with disassociation of the metaphysis from the diaphysis with minimal displacement. Nondisplaced fracture of the fibular neck. Chronic healed fractures of the distal tibial and fibular diaphysis. Impression: 1. Subacute fracture of the proximal tibial diametaphysis 2. Nondisplaced fracture of the fibular neck. On 5/19/21 at 11:11AM and 2:00PM surveyor requested the written witness statements used in the investigation for review. The facility did not provide the statements. At 2:45PM the facility provided a typed document Investigation Summary. There is no cause of the fracture listed on this document. Review of the facility's undated Final Report provided to IDPH on 4/30/21 notes upon investigation [R3] propels wheelchair herself around and bumps her legs into different objects which probably may cause this issue. No document reviewed for 4/24/21 indicated R3 had bumped her leg. No staff reported R3 seeing R3 bump her leg on 4/24/21. V11 said R3 did not have a bruise on her leg when she put her to bed on 4/24/21. Review of the facility Abuse and Neglect Policy last update: 10/24/19 notes Injuries of unknown origin: an injury of should be classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. 2. The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. The facility policy for Accident and Incident - Investigating and Reporting revised 2/2016 states Investigation information is documented for follow up care, any required reporting, corrective action and/or education needs.

Based on interview and record review the facility failed to identify and remove the risk of injury while transferring R1 from the wheelchair to the bed. This failure resulted in R1 sustaining a laceration to the left lower extremity Findings Include: R1 has [DIAGNOSES REDACTED]. R1 was admitted to the facility 12/14/19. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 06 indicating severe cognitive impact. On 07/19/20 R1 was transferred to the hospital due to the laceration to the Left Lower Extremity. On 07/24/20 at 11:17 AM V5 (Certified Nurse Assistant) stated 'I am not aware of any open wounds to R1's leg prior to 07/19/20. On 07/24/20 at 11:23 AM V4 (Registered Nurse) stated on 07/19/20 there was an open laceration to the left leg that was wrapped with a gauze. On 07/18/20 R1 did not have any open wounds on his legs. On 07/24/20 at 11:33 AM V6 (Certified Nurse Assistant) stated on 07/18/20 no open wounds were seen on R1's legs. On 07/24/20 at 11:45 AM V7 (Registered Nurse) stated I took care of R1 once and he did not have any wounds on his body. On 07/24/20 at 12:06 PM V3 (Director of Nursing) stated R1 had no evidence or documented wounds to the left lower extremity. The staff noticed an opening to the left leg over the weekend. Based on the investigation, before transfer to bed his skin was intact and after the transfer he had a wound to his leg. On 07/24/20 at 12:18 PM V8 (Certified Nurse Assistant) stated me and another CNA(Certified Nurse Assistant) and nurse transferred R1 to bed. Me and the nurse lifted his legs into the bed and that is when we saw the blood coming from his leg. The wound looked pretty deep. I cleaned the blood from the floor then left the room. Prior to that I do not know if he had any wounds. Prior to 07/18/20 he did not have any dressings on his legs. On 07/24/20 at 12:29 PM V9 (Licensed Practical Nurse) stated I did not see any open areas to R1 legs. When I came to work 07/18/20 R1 was up in a wheelchair. We pushed him to his room. Me and 2 CNA's transferred him to bed. I was on the right side of him, one CNA was on his left and the other CNA was holding his wheelchair. We helped him stand up and pivot to the bed. He sat on the bed, V8 (Certified Nurse Assistant) and I lifted his legs to put them in the bed. I saw red blood. It might have been 30 cc. Some of it squirted out of the wound. There was an opening at the top of his leg near the calf. There was a thin area 3 cm opening in width. The length went all the way down his leg near his foot. He did not have any wounds to his leg prior, not to my knowledge. It was a gash. There was some blood on the floor next to the bed. On 07/24/20 at 12:48 PM V10 (Medical Director) stated R1 has a vertical skin laceration to lower left leg with exposed muscle. It is a new laceration. Most likely from something pulling up on his leg and tearing his skin. It is 25 cm in length and 1/2 cm in width. It appears something had to be sharp. On 07/24/20 at 12:56 PM V11 (Certified Nurse Assistant) stated R1 was wheeling himself with the rails in the halls. There was no blood on the floor near or around him. He was wheeled into his room, his wheelchair was positioned beside his bed. I was behind the wheelchair. The transfer happened and they put his legs on the bed. There was a pool of blood on the floor. There was a laceration on his leg. On 07/24/20 at 01:38 PM V12 (Assistant Director of Nursing) stated, I worked with R1 Thursday 07/16/20 and Friday 07/17/20. He did not have any wounds to his legs. The laceration to R1 LLE (Left Lower Extremity) measurements 11 cm x 3 cm. There was a long laceration on left lateral side. The lower extremity, in the middle, it was whiter and irregular shaped. It was deep about 1 cm. On 07/24/20 at 02:42 PM V6 (Certified Nurse Assistant) stated on 07/17/20, R1 was given shower and he did not have any open areas on his legs. On 07/24/20 at 02:48 PM V13 (Registered Nurse) stated on 07/18/20 R1's left leg was clearly visible, with no injuries. On 07/28/20 at 08:40 AM V15 (Licensed Practical Nurse) stated I had R1 as a patient on 07/16/20. I do not remember R1 having any open areas to his leg On 07/28/20 at 09:08 AM V2 (Administrator) stated I did the initial investigation. I was on site Sunday 07/19/20 and the ADON told me R1 had a skin tear of unknown origin. He was not aware of how it got there. During my investigation we looked at the wheelchair and bed to see how it transpired. The wheelchair did not have leg rest and the C-shaped part that holds the leg rest is kind of sharp and was exposed. We looked at the bed and there is nothing sharp on it. The wheelchair was right next to the bed. He could have bumped his leg. On 07/28/20 Record review of Progress Note dated 07/18/20 at 2300 reads in part resident skin noted as intact. Progress Note dated 07/19/20 at 02:54 reads in part resident assisted to bed. Resident noted with left lower leg ulcer. Left lower lateral leg with moderate amount of blood. Progress Note dated 07/19/20 at 10:27 reads in part noted open skin area to left lateral lower leg 18 cm x 4 cm with small amount of blood, irregular shape, skin around laceration pinkish/purple in color and hard to touch. Progress note dated 07/19/20 at 19:40 reads in part has a vertical laceration on lateral lower 2/3rd (Two third) of leg with bleeding, wound gaped 1 - 1.5 inch, exposing underlying muscle. Record review of hospital medical records indicate [DIAGNOSES REDACTED]. Wound is deep exposing muscle. Patients' lower leg skin is grayish in color. Left lower extremity to the leg region has a significant laceration from the knee to the ankle exposed with mild bloody oozing likely of lack all the way to the muscle. Patient presents with approximately 14-inch laceration on LLE (Left Lower Extremity). Record review of Treatment Result Report reads in part on 07/18/20 R1 has skin tear/open area to lateral site on left lower leg. R1 was being transferred to bed. The Nurse and CNA (Certified Nurse Assistant) assisted R1 to stand and Pivot from the wheelchair to the bed. After transfer was complete fluid, blood, and skin tear/open area were observed. Records were reviewed and staff were interviewed and there is no evidence of any bruising, skin tear, wounds, etc. (Etcetera) to LLE (Left Lower Extremity) until the identified incident on July 18th. Staff interviews lead to the conclusion that resident sustained [REDACTED]. Policy: Abuse and Neglect Policy and Procedure Reviewed 2019 reads in part an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. The injury is suspicious because of the extent of the injury or the location of the injury.

1. Based on observation, interview and record review, the facility failed to ensure that the proper disinfecting agents were used to sanitize a Clostridium difficile (C-diff) room, failed to ensure that housekeeping personnel used proper procedure when cleaning a[DIAGNOSES REDACTED] isolation room, failed to ensure proper use of personal protective equipment (PPE) when cleaning a[DIAGNOSES REDACTED] isolation room, failed to follow facility policies regarding[DIAGNOSES REDACTED] infections, failed to develop a comprehensive care plan addressing[DIAGNOSES REDACTED] infection, failed to ensure that resident education regarding[DIAGNOSES REDACTED] infection/isolation was documented and ongoing, failed to reassess resident's knowledge regarding[DIAGNOSES REDACTED] infection and failed to ensure that resident was educated regarding hand washing with[DIAGNOSES REDACTED] infection. This deficient practice affected one resident (R15) of two residents reviewed for infection control in a sample of 14. These failures have the potential to affect all 54 residents in the facility. The facility's failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was determined to have begun on 4/11/15 when R15 was diagnosed with [REDACTED]. On 5/20/15 at 2:05pm, E1 (Administrator) was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 5/21/15 at 10:15am when the second abatement plan was accepted. While the immediacy was removed, the facility remains out of compliance at severity level two. 2. Based on observation and record review the facility also failed to follow its policy for infection control related to hand hygiene and glove changes. These failures affected one resident (R3) out of two resident reviewed during wound care in the sample of 14. In addition, the failure affected two out of seven residents (R6,R14), observed during medication pass, in the sample of 14 and one resident (R22) in the supplemental sample. Findings include: 1. R15's Order Summary Report documents that she was sent to a local acute care hospital on [DATE]. R15 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The onset date of the infection is documented as 4/11/15. R15's Order Summary Report dated 4/11/15 documents: Contact Isolation for[DIAGNOSES REDACTED]. On 4/13/15 at 11:29am, E10 (RN-Registered Nurse) documented in R15's Progress Notes: Resident is on contact precautions for[DIAGNOSES REDACTED]. Transferred to a private room (on the West Wing) so resident does not share a bathroom. Housekeeping completed breakdown cleaning of previous room along with roommates room and shared bathroom completed. On 5/20/15 at 11:00am, E10 stated, We moved (R15) to a private room on 4/13/15 because (R15) shared a bathroom. On 5/20/15 at 10:45am, E3 (DON-Director of Nursing) stated, (R15) was a resident on the (North Wing) and then sent out to the hospital, came back to the (North Wing) on 4/11/15 which is when we found out was positive for[DIAGNOSES REDACTED]. (R15) was moved to another room, a private room , on the West Wing on 4/13/15. E3 was asked about the 2 day lapse from when the facility was aware of R15's[DIAGNOSES REDACTED] infection to isolating (R15) on 4/13/15. E3 stated, The culture results were back on 4/11/15. A comprehensive care plan for R15's [DIAGNOSES REDACTED]. On 5/21/15 at 2:45pm, R15 stated, They never told me about infection in my stomach. Never taught me about loose stools and that it could be a stomach infection. They never taught me that I need to wash my hands for 20 seconds with soap and water. Am I supposed to? If I don't know that I have an infection, how do I know that I'm supposed to wash my hands after I go to the bathroom? Sometimes I call for help, sometimes I go by myself. It depends. I always use my own washroom. Sometimes, I can't reach the soap dispenser. Sometimes, they tell me I can use the hand gel-the foamy stuff in the hallway. There were multiple hand gel sanitizers affixed to the wall in the hallway. R15 continued, I never just stay in my room. I don't know why people wear gowns or why I have red bins. Or why the cart is outside my room. This conversation was witnessed by E10 (RN). R15 was asked questions to gauge cognition at present time. R15 was asked when originally admitted to the facility. R15 stated, 2007, May. R15's Admission Record documents an Initial admission date of [DATE]. R15 was asked doctor's name and answered correctly. This interaction took place with R15 after the Immediate Jeopardy was identified. On 5/20/15 at 2:50pm, E3 (DON) stated, Policy, can leave room if don't pose a community threat. (R15) has not been diarrhea free for 72 hours, that's why we haven't taken (R15) out of isolation, still on contact precautions and still potentially infectious. I'm not willing to say that[DIAGNOSES REDACTED] is gone. Education, washing hands with soap and water is important. Otherwise, (R15) is a community risk. We don't equate loose stools with[DIAGNOSES REDACTED]. A facility policy with a revision date of 9/2014 and titled, Clostridium Difficile documents: When residents have symptoms of diarrhea (i.e. three (3) loose stools in a twenty four (24) hour period, Clostridium difficile should be considered as a cause. On 5/19/15 at 9:03am, E11 (LPN-Licensed Practical Nurse) stated, This weekend (R15) had multiple watery BM (bowel movement) Saturday afternoon into Sunday morning, so, had to continue isolation. (R15) had consecutive watery BM's on Sunday. R15's Bowel Continence log documentation is inconsistent. On 5/20/15 at 11:00am, E10 (RN) stated, Since the time (R15) was diagnosed with [REDACTED]. (R15) continues to have loose BM's(bowel movements) on/off. (R15) has had periods of formed stool. But policy is no diarrhea for 72 hours. And (R15) hasn't met that goal yet. E10 was identified by staff as the nurse that cares for R15 on a consistent basis. R15's Minimum Data Set ((MDS) dated [DATE], the time of transfer to a local hospital, documented a Brief Interview of Mental Status (BIMS) score of 13 out of 15. R15's MDS dated [DATE], one week after readmission to facility, documents a BIMS score of 8 out of 15. The decrease in BIMS score indicates a decrease in her level of cognition upon readmission. On 5/21/15 at 4:30pm, E3 (DON) stated, I know (R15) was educated about[DIAGNOSES REDACTED] infection when moved into the isolation room. There was no documentation regarding the education that was provided for R15 related to her[DIAGNOSES REDACTED] infection. There is no documentation in R15's Progress Notes dated 4/12/15 through 5/16/15 regarding[DIAGNOSES REDACTED] education. R15's Progress Notes document that she was confused with periods of forgetfulness from 4/15/15 through 4/17/15. On 4/26/15, R15's Progress Notes document a change in behavior accompanied with increased confusion. There is no documentation regarding reassessment of R15's knowledge base related to isolation precautions or infectious disease process. On 5/1/15, the following is documented in R15's Progress Notes: Did know that (R15) had been hospitalized for [REDACTED]. There is no documentation regarding reassessment of R15's knowledge base related to her isolation precautions or infectious disease process. On 5/21/15 at 2:55pm, E10 (RN) stated, No education is formally documented. On 5/21/15 at 4:00pm, E4 (ADON-Assistant Director of Nursing) stated, I didn't provide[DIAGNOSES REDACTED] education to (R15) today regarding handwashing. I thought it was communicated already. I thought maybe days/nights would have taught (R15) We (staff) all know the plan. But, I'm not sure what (R15) knows. When identified concern yesterday, everyone knows the plan for[DIAGNOSES REDACTED]. If difficulty using soap dispenser, then we put a bar of soap in there. (R15's) able to use the soap dispenser, and stands. Sometimes, helps self in the bathroom. I did not know that (R15) was not aware of the plan. (R15) was not re-educated today regarding[DIAGNOSES REDACTED]. In the very beginning, education was provided. When first isolated. (R15) is alert now. Maybe we need to re-educate (R15) regarding the importance of washing hands. On 5/21/15 at 10:50am, Z1 (Medical Director) stated, Behavior and hygiene have a lot to do with transmission. Follow ordinary precautions, may not cause a risk if staff is using proper precautions.[DIAGNOSES REDACTED] is a spore transmission. Don't know exact duration, but long time because it's a spore. If improper cleaning, it does pose a higher risk for residents in the facility. Becomes a training opportunity. R15's lack of knowledge regarding her[DIAGNOSES REDACTED] infection/isolation and lack of knowledge regarding the importance of handwashing after using the bathroom poses an increased risk for the community. On 5/21/15 at 2:45pm, R15 indicated does not stay in room. During the course of the survey, 5/18/15 through 5/21/15, R15 was usually in activities. On 5/19/15 at 1:30pm, R15 attended the group interview with State. On 5/20/15 at 1:30pm, E27 (Director of Life Enrichment) stated, Resident on isolation can come to activities depending on isolation.[DIAGNOSES REDACTED]? They can come to activities. Only communicable diseases can't come to activities. E27 continued, (R15) has always been very active in coming to activities. In the last three weeks, comes regularly, went to the opera about a month ago. R15's Activity Calendar for April 2015 and May 2015 indicates that (R15) consistently attends activities. On 5/20/15 at 1:35pm, E30 indicated that she performs a lot of the facility activities. (Life Enrichment Coordinator) stated, (R15) is always at activities. On 5/20/15 at 10:20am, E7 (RN-Registered Nurse Infection Control) stated, They stay in their room if they have active symptoms, diarrhea, more than three loose stools within a 24 hour period and a positive stool culture. They can be on Contact Precautions and still come out of room. Safely, meaning they can maintain a clean area around them. E27 continued, If still active diarrhea, whether contained in an incontinence brief or not, they are not allowed out in community. Active diarrhea-then all activity (nursing care, dietary, activities, life enrichment) has to take place in resident room. Potential harm? If actively having diarrhea and out in the community, can infect other residents.[DIAGNOSES REDACTED] stays on surfaces for a long period of time. E7 indicated that she trains housekeeping personnel regarding handwashing and PPE usage. On 5/19/15 at 8:40am, E31 (Housekeeper) prepared to clean R15's[DIAGNOSES REDACTED] room. E31 donned a yellow gown and gloves. E31 cleaned the high touch areas with disinfectant bleach wipes. Some surfaces did not have the required contact time. -Side table wiped down at 8:44am and dried at 8:47am -Dresser wiped down at 8:48am and dried at 8:50am At 8:49am, E31 stepped out of the door to access her housekeeping cart. E31 still had her yellow gown and gloves on. E31 used her keys to open her cart and retrieve a bottle of toilet bowl cleaner. There was no bleach noted in the bottom of her cart. E31 indicated that all bottles are kept in the bottom compartment. E31 then used a toilet brush and a non bleach disinfectant cleaner to clean the toilet bowl. At 8:51am, E31 first cleaned the interior of the toilet with the brush then moved to the exterior of the toilet bowl. At 8:52am, E31 dried off the toilet seat with paper towel. At 8:52am, E31 stepped back out into hallway with PPE (personal protective equipment) on. E31 used her keys to open the cart to return the toilet bowl cleaner. E31 did not wipe the bottle down with bleach prior to returning it to her cart. At 8:55am, E31 stepped into hallway to access the isolation cart to retrieve a red isolation bag. E31 still had her yellow gown and gloves on and was coming into contact with the items on the isolation cart. -Bathroom sink wiped down at 8:56am and dried at 8:59am -Door knobs to bathroom and exterior door wiped down at 8:57am and dried at 9:00am At 8:56am, E31 stepped out into hallway with PPE on to retrieve the mop. E31 cleaned the floors in the room and the bathroom with a disinfectant cleaner. E31 indicated that it was a premeasured solution. At 9:06am, E31 left the room without washing her hands to show the surveyor the product that she used to clean the floors. E31 discarded the mop head but placed the mop handle back on the isolation cart without wiping it down with bleach. E31 continued to clean rooms on 3 West. On 5/20/15 at 12:25pm, E1 (Administrator) stated, Housekeepers rotate through all units. They're not on any set unit. E1 submitted a housekeeping schedule for May 2015. On 5/19/15 at 2:30pm, E9 (Maintenance Director) stated, Staff not allowed to come out of isolation room with yellow gowns (isolation gowns) and gloves on.[DIAGNOSES REDACTED] is only killed by bleach. On 5/20/15 at 10:50am, E9 stated, No bleach in house. As long as I have been here, I haven't had any training on how to clean[DIAGNOSES REDACTED] rooms. On 5/20/15 at 11:05am, E9 stated, Other than the (bleach wipes), there is no other bleach in the house. On 5/21/15 at 8;00am, E9 stated, It's unfortunate that (E31) did not have bleach on the cart. We have to clean the[DIAGNOSES REDACTED] rooms with bleach. Only solvent that kills[DIAGNOSES REDACTED]. The policy for cleaning[DIAGNOSES REDACTED] rooms was requested on three occasions: 5/19/15 at 9:30am, 5/20/15 at 1:00pm and 5/20/15 at 3:10pm. The policy was not presented until 5/21/15 at 4:00pm. On 5/26/15 at 9:00am, vendor receipts were requested for the purchase/delivery of all bleach products. At 9:30am, E3 (DON) presented two receipts dated 1/27/15 and 3/17/15. E3 indicated that the only bleach products purchased and delivered were the bleach wipes. There is no invoice for the bottles of bleach. The specifications for the bleach disinfectant wipes documents: Kills Clostridium difficile spores in 5 minutes. Special Instructions for Cleaning Prior to disinfection against Clostridium difficile spores: Disinfection Procedures: Wipe surface with towel until completely wet. Let stand for 5 minutes. Wipe dry or allow to air dry. The specifications for the toilet bowl cleaner does not indicate that it is effective against[DIAGNOSES REDACTED]. The specifications for the quaternary disinfectant that was used to clean the floors does not indicate that it is effective against[DIAGNOSES REDACTED]. A facility policy with a revision date of 9/2014 and titled, Clostridium Difficile documents: Handwashing Requirements: When caring for residents with diarrhea or fecal incontinence, staff will maintain hand hygiene with soap and water, rather than alcohol-based hand rubs, for the mechanical removal of Clostridium difficile spores from hands. A facility policy with a revision date of 9/2014 and titled, Clostridium Difficile documents, in part: Residents pose a community risk in the following situations and should remain in their rooms for dining and social activities in the following situations: When the resident is noncompliant with basic personal hygiene and handwashing and uses community shared bathrooms. A facility policy dated 9/2014 and titled, Initiating and Discontinuing Transmission-Based Precautions documents, in part: Policy Interpretation and Implementation: Explain to the resident(or representative) the reason(s) for the Precautions. A facility policy dated 9/2014 and titled, Infection Control: Standard Precautions/General Guidelines documents, in part: Hand Hygiene: In the following situations employees must wash their hands using antimicrobial or non-antimicrobial soap and water: After handling items potentially contaminated with blood, body fluids, or secretions; After removing gloves; When there is likely exposure to spores (e.g., [DIAGNOSES REDACTED]icile) A facility policy dated 9/2014 and titled, Transmission-Based Precautions documents, in part: Remove gown and gloves before leaving the room; wash hands. Ambulation and/or socialization are restricted for the following individuals: Residents with poor compliance with standard practices for personal hygiene, especially handwashing. Abatement Plan- Infection Control Procedures for[DIAGNOSES REDACTED] (The facility) realizes the importance of establishing and maintaining an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. We have taken immediate actions in response to the concerns addressed today by the survey team. An immediate plan of correction has been established and will be completed no later than 3:00pm on May 21, 2015. Specific Findings: A housekeeper was observed not following the correct procedures for disinfecting a resident's room with[DIAGNOSES REDACTED]. Specific Corrective Action: 1. The housekeeper was suspended and will be terminated from employment based on her failure to follow the procedures in place and on which she was trained. 2. All rooms on the third floor will be re-cleaned and properly disinfected by 3:00pm 5/21/15 to ensure that residents are not placed at risk. 3. Procedures have been put into place regarding the resident in question and handwashing. Prior to the resident leaving room, and, after every bathroom episode, a licensed nurse will visually supervise (R15) handwashing to ensure proper techniques are employed. General Corrective Measures: 1. The procedure for disinfecting[DIAGNOSES REDACTED] rooms have been revised. 2. Structured education about the cleaning policy and procedures for[DIAGNOSES REDACTED] will be provided to all current Environmental Services (ES) staff members by the Director of ES by 5/21/15. The same structured education will be provided to all newly hired ES staff members at hire by the director of ES (Exhibit 1). 3. The education will include written materials, demonstration and return demonstration. 4. A step-by-step instruction for[DIAGNOSES REDACTED] cleaning will be kept on the housekeeping cart for immediate reference by the housekeeper. This instruction will include the required PPE for[DIAGNOSES REDACTED] contact precaution, solutions to have on their cart for[DIAGNOSES REDACTED] cleaning. (Exhibit 2). 5. The CDC Environmental Checklist will be used to document that all high touch room surfaces are cleaned. The checklist will be signed and returned to the ES director for review after each cleaning. (Exhibit 3). 6. A terminal cleaning team will be created to minimize variability in compliance with policy and procedure. This team will be identified and established by 5/21/15. In addition, a terminal cleaning cart will be created for use specifically by the terminal cleaning team. On-going Corrective Measures and Quality Assurance Plan: 1. Quarterly inservice reviews of[DIAGNOSES REDACTED] cleaning policy and procedures will be conducted by the Director of ES. The Infection Prevention Nurse will provide quarterly inservice education about infection control policies generally and how they apply to ES. 2. Monitoring of adherence to cleaning policy and procedures will be documented by random observation of at least two ES staff members each month. If there are no rooms with[DIAGNOSES REDACTED] precautions in place, an empty room will be used for demonstration of the procedures by the staff being monitored. 3. Weekly checks of housekeeping carts will review proper inventory on the cart of all necessary PPE, equipment and cleaning solutions for[DIAGNOSES REDACTED] cleaning. Those checks will be documented and logged by the ES director. 4. Random observations and weekly checks of housekeeping carts will be tracked to determine ongoing quality of cleaning and are expected to be 90% successful in all aspects of policy and procedure compliance. Date of Correction: May 21, 2015 Addendum to Plan of Correction (The facility) was informed by the survey team that upon interviewing resident in question (R15) was unable to articulate the circumstances around the need for isolation. Based on this new information, (the facility) has determined that it is necessary for the resident to return to full isolation until we can be sure once again that resident is able to understand and retain the information. Resident was counseled today at approximately 4:00pm and informed of this change in condition by (E4-ADON). The care plan for R15 has been updated accordingly, and (R15) has been provided with written instructions, as a visual reminder regarding the isolation and procedures. (Exhibit 4). In addition, (the facility) has added to the General Corrective Measures our intent to create process and procedure formalizes our assessment of residents regarding their understanding of isolation procedures, and risk factors associated with permitting intermittent departures from their room. This procedure will be developed no later than Tuesday May 26, 2015, and will be executed by the Infection Prevention Nurse. 2. On 5/19/15 at 8:55 AM, E10 (Registered Nurse) prepared to administer medications to R6. E10 placed multiple pairs of gloves into her uniform pocket, then washed her hands for 18 seconds. E10 then moved R6's floor mat, washed her hands for 10 seconds and pulled gloves from her pocket to put on. E10 then removed R6's nasal cannula, picked up R6's bed control to raise the head of the bed with her gloved hand, removed the gloves, washed her hands for eight seconds and regloved with gloves from her pocket. At 8:58 AM, E10 applied pressure to E10's lacrimal duct after attempting to administer eye drops, first to the left eye, then to the right eye, without hand hygiene and glove change. Additional hand hygiene observations were of five seconds duration at 9:03 AM and 10 second duration at 9:16 AM. On 5/19/15 during medication administration to R14, E8 (Licensed Practical Nurse) performed hand hygiene for 10 seconds at 10:20 AM, donned gloves and administered nasal spray and then removed her gloves and performed hand hygiene for five seconds at 10:25 AM. On 5/19/15 at 1:27 PM, E11 (Licensed Practical Nurse) prepared to administer a nebulizer treatment to R22. E11 did not perform hand hygiene prior to donning gloves and then proceeded to rinse R22's nebulizer medication chamber. R22 asked to see oxygen concentrator, so E11 moved the unit around to the front of R22's wheelchair, picking up the power cord from the floor to allow the machine to roll. No glove change and hand hygiene was performed. E11 then touched R22's hands to admire (R22's) manicure. At 1:40 PM, E11 again picked up the concentrator power cord from the floor to move the unit back behind R22's wheelchair, did not change gloves or perform hand hygiene and then removed R22's nebulizer mask, rinsed it, stored it and gave R22 eyeglasses. Then E11 removed her gloves and used hand gel before leaving R22's room. On 5/21/15 at 8:35 AM during wound care observation for R3, E10 (Registered Nurse) prepared for the treatment and placed multiple pairs of gloves into her uniform pocket. E10 washed her hands, but then moved R3's call light and handled treatment notes, then put on gloves taken from her pocket without additional hand hygiene. After removing R3's right heel dressing, E10 removed her gloves, washed her hands and pulled another pair of gloves from her pocket. E10 then assembled dressing supplies, touching the dressing packaging, scissor handles, and moved R3's tray table into position. E10 then proceeded to cleanse R3's wound without first changing gloves and performing hand hygiene. The facility policy, Infection Control: Standard Precautions/General Guidelines, dated 9/2014, reads in part: Hand Hygiene - If hands are not visibly soiled, employees may use either an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or isoproponal or wash with antimicrobial or non-antimicrobial soap and water for fifteen to twenty seconds for the following situations: before and after direct contact with residents; before preparing and handling medications; before moving from a contaminated body site to a clean body site during resident care; before handling clean or soiled dressings, gauze pads, etc.; after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; and after removing gloves.