Every finding on record at Pearl of Orchard Valley

Based on interview and record review, the facility failed to administer medications, provide nutritional supplements and provide monitoring as ordered by the provider. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for nursing services in the sample of 5. The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic atrial fibrillation, type 2 diabetes mellitus, acute on chronic diastolic (congestive) heart failure, essential hypertension, mood disorder, insomnia, anxiety disorder, and dementia. R1's congestive heart failure care plan dated August 22, 2025, showed [R1] has congestive heart failure. The care plan continued to show multiple interventions dated August 22, 2025, including Give cardiac medications as ordered. R1's August 2026 MAR (Medication Administration Record) showed on August 7, 2026, during the evening shift (3:00 PM to 11:00 PM), R1 did not receive mirtazapine (antidepressant medication) 15 mg (milligram) oral tablet, tamsulosin (prostate medication) 0.4 mg oral capsule, metoprolol succinate (cardiac medication) 50 mg oral tablet, trazodone (antidepressant medication) 100 mg oral tablet, furosemide (diuretic medication) 20 mg oral tablet, glipizide (diabetes medication) 5 mg oral tablet, buspirone (antianxiety medication) 15 mg oral tablet, hydralazine (cardiac medication) 25 mg oral tablet, and diabetic nutritional drink. The MAR continued to show on the evening shift of August 7, 2026, R1 did not receive behavior monitoring, vital signs monitoring, pain assessment, and medication side effect monitoring as ordered by the provider. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, asthma, depression, anxiety disorder, chronic systolic (congestive) heart failure, essential hypertension, atherosclerotic heart disease, and cardiac arrest due to underlying cardiac condition. R2's seizure care plan dated October 14, 2024, showed [R2] uses anticonvulsant/anti-seizure medication related to seizures secondary to left MCA (middle cerebral artery). The care plan continued to show multiple interventions dated October 14, 2024, including Ensure patient takes the correct dose and at the correct time and do not stop taking the medication suddenly. R2's diuretic care plan dated October 14, 2024, showed [R2] is on diuretic therapy related to hypertension, heart failure. The care plan continued to show multiple interventions dated October 14, 2024, including Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness every shift. R2's August 2026 MAR showed during the evening shift on August 7, 2026, R2 did not receive atorvastatin calcium (cholesterol medication) 20 mg oral tablet, chlorhexidine gluconate mouth/throat solution 0.12% (percent), clopidogrel bisulfate (antiplatelet medication) 75 mg oral tablet, insulin glargine (long-acting insulin) 14 unit subcutaneous injection, amantadine (Parkinson's medication) 100 mg oral tablet, budesonide-formoterol fumarate (asthma medication) inhaler, carvedilol (cardiac medication) 25 mg oral tablet, levetiracetam (seizure medication) oral solution 1000 mg, Sacubitril-valsartan (cardiac medication) 14-16 mg oral tablet, ascorbic acid (vitamin) 250 mg oral tablet. The MAR continued to show during the evening shift on August 7, 2026, R2 did not receive blood glucose monitoring, vital sign monitoring, medication side effect monitoring, behavior monitoring, and monitoring for shortness of breath as ordered by the provider. 3. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypercapnia, encephalopathy, chronic obstructive pulmonary disease, type 2 diabetes mellitus, asthma, atherosclerotic heart disease of native coronary artery, acute kidney failure, essential hypertension, and anxiety disorder. R3's coronary artery disease care plan dated February 11, 2026, showed [R3] has coronary artery disease. The care plan continued to show multiple interventions dated February 11, 2026, including Give all cardiac medications as ordered by the physician. Monitor and document side effects. Report adverse reactions to physician as needed. R3's August 2026 MAR showed during the evening shift on August 7, 2026, R3 did not receive atorvastatin calcium 40 mg oral tablet, mirtazapine 7.5 mg oral tablet, fluticasone-Salmeterol (chronic obstructive pulmonary disease medication) inhalation aerosol powder breath activated 250-50 mcg/act, Arformoterol tartrate (chronic obstructive pulmonary disease medication) inhalation nebulization solution 15 mcg (microgram)/2 ml (milliliter), gabapentin (pain medication) 300 mg capsule, metformin (diabetes medication) 500 mg oral tablet, metoprolol (cardiac medication) 25 mg oral tablet, bethanechol chloride (urinary retention medication) 10 mg oral tablet, ropinirole (restless leg syndrome medication) 0.5 mg oral tablet, and diabetic nutritional drink. The MAR continued to show on the evening shift of August 7, 2026, R3 did not receive pain assessment monitoring, medication side effect monitoring, oxygen saturation monitoring, and vital signs monitoring as ordered by the provider. 4. R4's EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including dementia, Alzheimer's disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, essential hypertension, chronic kidney disease, anxiety disorder, and insomnia. R4's cardiac care plan dated April 22, 2025, showed [R4] has potential for altered cardiac function related to diagnosis of hypertension and the use/side effects of medication. The care plan continued to show multiple interventions dated April 22, 2025, including Give antihypertensive medications as ordered. R4's August 2026 MAR showed during the evening shift on August 7, 2026, R4 did not receive atorvastatin calcium 40 mg oral tablet, donepezil (Alzheimer's disease medication) 10 mg oral tablet, mirtazapine 7.5 mg oral tablet, tamsulosin 0.4 mg oral capsule, trazodone 100 mg oral tablet, docusate sodium (stool softener) 100 mg oral tablet, hydroxyzine (mood stabilizer) 10 mg oral tablet, ferrous sulfate (iron supplement) 325 mg tablet, hydralazine 100 mg oral tablet, and high calorie drink 237 ml. The MAR continued to show during the evening shift on August 7, 2026, R4 did not receive pain assessment monitoring, medication side effect monitoring, and behavior monitoring as ordered by the provider. On August 10, 2026, at 3:28 PM, V2 (DON/Director of Nursing) said residents should receive medications as ordered by the provider. The facility's policy titled Medication Administration dated April 5, 2026, showed Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Level of Responsibility: RN, LPN. Guideline: .18. If medication is not given as ordered, document the reason on the MAR. 19. If the medication is given at a time different from the scheduled time, update the MAR to reflect administration time. Scheduled medications will be given within an hour window before and after its scheduled and as preferred by the residents.

Based on interview and record review, the facility failed to administer cardiac medications, diabetes medications, and seizure medications as ordered by the provider. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for nursing services in the sample of 5. The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic atrial fibrillation, type 2 diabetes mellitus, acute on chronic diastolic (congestive) heart failure, essential hypertension, mood disorder, insomnia, anxiety disorder, and dementia. R1's congestive heart failure care plan dated August 22, 2025, showed [R1] has congestive heart failure. The care plan continued to show multiple interventions dated August 22, 2025, including Give cardiac medications as ordered. R1's Order Summary Report dated August 11, 2026, showed orders dated August 19, 2025, for Furosemide (diuretic medication) oral tablet 20 mg (milligram), give one tablet by mouth two times a day for premature ventricular contraction, and glipizide (diabetes medication) oral tablet 5 mg, give one tablet by mouth two times a day for diabetes mellitus. The report continued to show an order dated August 20, 2025, for Metoprolol succinate (cardiac medication) oral tablet extended release 24-hour 50 mg, give one tablet by mouth at bedtime for hypertension. The report showed an order dated March 19, 2026, for hydralazine HCl (hydrochloric acid) (cardiac medication) oral tablet 25 mg, give one tablet by mouth three times a day for hypertension, hold medication if systolic blood pressure less than 120. R1's August 2026 MAR (Medication Administration Record) showed R1 was not administered furosemide 20 mg, glipizide 5 mg, metoprolol succinate 50 mg, and hydralazine 25 mg on August 7, 2026, during the evening shift (3:00 PM to 11:00 PM). The facility does not have documentation to show R1's provider was notified on August 7, 2026, regarding R1 not receiving scheduled medications. On August 11, 2026, at 12:00 PM, V12 (Pharmacist) said furosemide is a diuretic and missing a dose could cause increased blood pressure and heart failure symptoms like increased edema. V12 said metoprolol is a medication used for hypertension and heart failure, and missing a dose could cause increased blood pressure and pulse rate. V12 said glipizide is a diabetes medication and missing a dose could cause an increase in blood sugar. V12 said hydralazine is a medication for hypertension, and a missed dose could cause elevated blood pressure. 2. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, asthma, depression, anxiety disorder, chronic systolic (congestive) heart failure, essential hypertension, atherosclerotic heart disease, and cardiac arrest due to underlying cardiac condition. R2's seizure care plan dated October 14, 2024, showed [R2] uses anticonvulsant/anti-seizure medication related to seizures secondary to left MCA (middle cerebral artery). The care plan continued to show multiple interventions dated October 14, 2024, including Ensure patient takes the correct dose and at the correct dose and do not stop taking the medication suddenly. R2's diuretic care plan dated October 14, 2024, showed [R2] is on diuretic therapy related to hypertension, heart failure. The care plan continued to show multiple interventions dated October 14, 2024, including Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness every shift. R2's Order Summary Report dated August 11, 2026, showed an order dated September 2, 2025, for carvedilol (cardiac medication) oral tablet 25 mg, give one tablet orally two times a day related to essential hypertension. The report showed an order dated January 16, 2026, for Insulin glargine (diabetes medication) subcutaneous solution pen-injector 100 unit/ml, inject 14 unit subcutaneously at bedtime related to type 2 diabetes mellitus with unspecified complications. The EMR showed an order dated October 11, 2024, for levetiracetam (seizure medication) oral solution 500 mg/5 ml, give 10 ml via gastric tube two times a day for seizures. R2's August 2026 MAR showed R2 was not administered carvedilol 25 mg, insulin glargine 14 units, and levetiracetam 1000 mg on August 7, 2026, during the evening shift The facility does not have documentation to show a provider was notified on August 7, 2026, of R2's medications which were not administered. On August 11, 2026, at 12:05 PM, V12 said carvedilol is a cardiac medication for hypertension and heart failure, and a missed dose could cause high blood pressure and pulse rate. V12 said insulin glargine is a long-acting insulin for diabetes management and missing a dose can cause elevated blood sugar levels. V12 said levetiracetam is a medication used to treat seizures, and missing a dose can cause seizure activity. 3. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypercapnia, encephalopathy, chronic obstructive pulmonary disease, type 2 diabetes mellitus, asthma, atherosclerotic heart disease of native coronary artery, acute kidney failure, essential hypertension, and anxiety disorder. R3's MDS dated [DATE], showed R3 had moderate cognitive impairment. R3's coronary artery disease care plan dated February 11, 2026, showed [R3] has coronary artery disease. The care plan continued to show multiple interventions dated February 11, 2026, including Give all cardiac medications as ordered by the physician. Monitor and document side effects. Report adverse reactions to physician as needed. R3's Order Summary Report dated August 11, 2026, showed orders dated May 11, 2026, for metformin (diabetes medication) HCl oral tablet 500 mg, give one tablet by mouth two times a day for type 2 diabetes mellitus and metoprolol tartrate oral tablet 25 mg, give one tablet by mouth every morning and at bedtime for hypertension. R3's August 2026 MAR showed R3 was not administered metformin 500 mg and metoprolol 25 mg on August 7, 2026, during the evening shift. The facility does not have documentation to show a provider was notified on August 7, 2026, of R3 not receiving her scheduled medications. On August 11, 2026, at 12:09 PM, V12 said metformin is a medication for diabetes management and missing a dose can cause elevated blood sugar levels. V12 said metoprolol is a cardiac medication and missing a dose can cause elevated blood pressure and pulse rate. 4. R4's EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including dementia, Alzheimer's disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, essential hypertension, chronic kidney disease, anxiety disorder, and insomnia. R4's cardiac care plan dated April 22, 2025, showed [R4] has potential for altered cardiac function related to diagnosis of hypertension and the use/side effects of medication. The care plan continued to show multiple interventions dated April 22, 2025, including Give antihypertensive medications as ordered. R4's Order Summary Report dated August 11, 2026, showed an order dated August 11, 2025, for hydralazine HCl oral tablet 100 mg, give one tablet by mouth every eight hours related to essential hypertension. R4's August 2026 MAR showed on August 7, 2026, R4 was not administered the 4:00 PM dose of hydralazine 100 mg. The facility does not have documentation to show R4's provider was notified of R4 missing his scheduled medication. On August 11, 2026, at 12:13 PM, V12 said hydralazine is a medication for hypertension and missing a dose can cause increased blood pressure. V12 said residents should receive medications as ordered by the provider and if a dose is missed, the provider should be notified to see if additional orders are needed. On August 10, 2026, at 3:28 PM, V2 (DON/Director of Nursing) said residents should receive medications as ordered by the provider. The facility's policy titled Medication Administration dated April 5, 2026, showed Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Level of Responsibility: RN, LPN. Guideline: .18. If medication is not given as ordered, document the reason on the MAR. 19. If the medication is given at a time different from the scheduled time, update the MAR to reflect administration time. Scheduled medications will be given within an hour window before and after its scheduled and as preferred by the residents.

Based on interview and record review, the facility failed to ensure sufficient nursing staff to meet the care needs of residents. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for nursing services in the sample of 5. The findings include:On August 10, 2026, at 12:15 PM, V6 (RN/Registered Nurse) said she worked day shift (7:00 AM to 3:00 PM) on August 7, 2026. V6 said at the end of her shift, one of the oncoming nurses did not report to work. V6 said she left written report on the desk in case a nurse showed up on the next shift. V6 said a nurse did not show up before she left the facility. On August 10, 2026, at 12:32 PM, V13 (RN) said she worked day shift on August 7, 2026. V13 said V3 (LPN/Licensed Practical Nurse) did not report to work for the evening shift (3:00 PM to 11:00 PM). V3 said she tried to stay as late as she could but could only stay until 4:00 PM or 4:30 PM. V3 said she left written report in case a nurse showed up to work the evening shift. On August 10, 2026, at 12:47 PM, V7 (LPN) said she worked a double shift (7:00 AM to 11:00 PM) on August 7, 2026. V7 said V3 did not show up for the evening shift and V7 and V8 (RN) were the only two nurses on the second shift. V7 said she notified management and was told a nurse would be coming. V7 said no nurse came to work the evening shift with V7 and V8. V7 said her and V8 never sat down the entire evening shift. V7 said she cared for the residents in her assignment and if any of the residents that V3 was supposed to care for asked for medications then she would administer them. V7 said she documented the medications she administered. V7 said she was assigned to care for 27 residents and V7 did not assume care of the residents assigned to the third nurse. On August 10, 2026, at 1:02 PM, V8 said on August 7, 2026, it was just V8 and V7 working on the second floor. V8 said she notified V11 (ADON/Assistant Director of Nursing) when V3 did not report to work. V8 said she was assigned 25 or 26 residents to care for and did not assume care for the residents assigned to the third nurse who was supposed to be working the floor. V8 said if she gave a resident medication then she documented the administration in the medical record. On August 10, 2026, at 2:52 PM, V9 (CNA/Certified Nursing Assistant) said she worked on August 7, 2026, during the evening shift and was assigned to the secured dementia unit. V9 said there were only two nurses working the floor that day. V9 said V7 came into the unit when V9 asked V7 to obtain a blood sugar on a resident. V9 said she did not see V7 or V8 administer medications to the dementia unit residents V9 was assigned to. On August 10, 2026, at 4:32 PM, V11 said she received a call on August 11, 2026, that V3 did not show up for work on the evening shift. V11 said V13 stayed until about 4:30 PM to assist on the unit. V11 said she told V7 and V8 to monitor the residents and to deal with what was going on. V11 said she was at the facility at the beginning of the evening shift and had posted a request for agency staff at 3:54 PM. V11 said she left the facility because she thought the nurses had it handled on the second floor. The facility's daily staffing dated August 7, 2026, showed on August 7, 2026, V3, V7, and V8 were assigned to work as nurses on the second floor, but V3 called off. The document does not show a third nurse working on the evening of August 7, 2026, on the second floor. The facility's Detailed Census Report dated August 11, 2026, showed the census on the second floor on August 7, 2026, was 78 residents. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic atrial fibrillation, type 2 diabetes mellitus, acute on chronic diastolic (congestive) heart failure, essential hypertension, mood disorder, insomnia, anxiety disorder, and dementia. R1's August 2026 MAR (Medication Administration Record) showed R1 was not administered multiple medications and did not receive monitoring as ordered by the provider. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, asthma, depression, anxiety disorder, chronic systolic (congestive) heart failure, essential hypertension, atherosclerotic heart disease, and cardiac arrest due to underlying cardiac condition. R2's August 2026 MAR showed R2 was not administered multiple medications and did not receive monitoring as ordered by the provider. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypercapnia, encephalopathy, chronic obstructive pulmonary disease, type 2 diabetes mellitus, asthma, atherosclerotic heart disease of native coronary artery, acute kidney failure, essential hypertension, and anxiety disorder. R3's August 2026 MAR showed R3 was not administered multiple medications and did not receive monitoring as ordered by the provider. R4's EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including dementia, Alzheimer's disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, essential hypertension, chronic kidney disease, anxiety disorder, and insomnia. R4's August 2026 MAR showed on August 7, 2026, R4 was not administered multiple medications and did not receive monitoring as ordered by the provider. On August 10, 2026, at 3:28 PM, V2 (DON/Director of Nursing) said staffing should be adequate so residents' needs are met, including receiving the ordered medications. V2 said residents should receive medications as ordered by the provider.

Based on observation, interviews, and record review, the facility failed to ensure the use of the appropriate total mechanical lift device and the required two-person assistance when obtaining a resident's weight and performing transfers for one resident (R1) who was totally dependent on staff for transfers. This failure resulted in R1 sustaining a traumatic fracture of the right tibia and fibula after falling during an improper transfer.This applies to 1 of 3 sampled residents (R1) reviewed for falls. The findings include:Review of the Electronic Medical Record (EMR) showed that R1, an [AGE] year-old resident, was admitted to the facility on [DATE]. R1's diagnoses included cerebral infarction, total occlusion of the arteries of the extremities, atherosclerosis of the left lower extremity, end-stage renal disease requiring hemodialysis, muscle disorders, unsteadiness on feet, peripheral vascular disease, dementia, anxiety disorder, neuropathy, and a history of falls (March 15, 2026). The most recent diagnosis, dated July 20, 2026, was a traumatic fracture of the right tibia and fibula.Review of the Minimum Data Set (MDS), dated [DATE], showed R1 was severely cognitively impaired and was totally dependent on staff for transfers between the bed and chair. The MDS further showed R1 required substantial to maximal assistance with other Activities of Daily Living (ADLs) and had impairment of both lower extremities.Review of R1's Special Task History showed that since December 9, 2025, R1 had been assessed to require transfers using a total mechanical lift with the assistance of two staff members.During an interview conducted on July 23, 2026, at 2:30 p.m., R1 was observed lying in bed wearing a right leg immobilizer. R1 was alert and responded appropriately to questions. R1 stated that approximately one to two weeks earlier, she fell while being transferred from her wheelchair to scale before dialysis treatment. R1 stated that her legs became weak, causing her to fall, after which she experienced severe pain and was transported to the hospital. R1 further stated that staff sometimes transferred her manually, sometimes with a mechanical lift, and sometimes with one or two staff members assisting. R1 reported continued right leg pain and rated the pain as 8 out of 10, with 10 representing the worst possible pain.Review of the facility incident report, dated July 9, 2026, documented that at approximately 5:15 a.m., R1 fell while being transferred from a regular wheelchair to a weighing scale. The report documented that only V3 (Certified Nursing Assistant) was performing the transfer. The report further documented that after the fall, V3 and V4 (Nurse) manually lifted R1 from the floor into the wheelchair and returned R1 to her room due to complaints of pain. Because R1 continued to complain of right leg pain, she was transferred to the hospital on July 10, 2026, where she was admitted . Hospital records showed that R1 remained hospitalized for 10 days before returning to the facility on July 20, 2026.Review of hospital records dated July 10, 2026, showed that R1 sustained a mechanical fall resulting in traumatic fractures of the right tibia and fibula.During an interview on July 23, 2026, at 3:00 p.m., V2 (Director of Nursing) stated that the incident report contained a typographical error regarding the date of the incident. V2 confirmed that the fall actually occurred on July 10, 2026, at approximately 5:15 a.m., while R1 was being transferred to a platform weighing scale.During an interview on July 23, 2026, at 5:08 p.m., V3 stated that she had used the total mechanical lift independently to transfer R1 from the bed to the wheelchair. V3 further stated that when attempting to obtain R1's weight, she assisted R1 to stand by holding onto the waistband of R1's pants while R1 grasped the grab bar on the weighing scale. V3 stated that R1's legs suddenly gave way, causing R1 to fall to the floor. V3 stated that she then called V4, and together they manually lifted R1 from the floor back into the wheelchair before returning her to her room. V3 further stated that although she had previously used the total mechanical lift for R1's transfers, V8 (Certified Nursing Assistant) had told her that R1 could be transferred manually without the mechanical lift.During an interview on July 23, 2026, at 5:18 p.m., V8 stated that it had been some time since he had cared for R1. V8 denied instructing V3 to manually transfer R1 and stated that V3 should have reviewed the resident's Special Task documentation to determine the appropriate transfer method.During an interview on July 24, 2026, at 2:00 p.m., V2 stated that residents requiring total mechanical lifts should have their weight obtained using the facility's mechanical lift equipped with an integrated weighing scale. When asked why this equipment was not used for R1, V2 stated there was no explanation. V2 further stated that V3 received disciplinary action for performing an improper transfer and that V4's employment was terminated because R1 should not have been manually lifted from the floor following the fall.During an interview on July 24, 2026, at 12:20 p.m., V5 (Medical Director and R1's attending physician) stated that he was informed R1 had fallen and sustained fractures of the right tibia and fibula.Review of the facility's Safe Transfer Policy, last reviewed in April 2025, required staff to utilize the appropriate mechanical lift device and provide two-person assistance during transfers for residents assessed as requiring total mechanical lift transfers.

Based on observation, interview, record review, the facility failed to provide catheter care in accordance with accepted standards of practice by failing to cleanse the urethral meatus during indwelling urinary catheter care. The facility also failed to follow a physician's order to change an indwelling urinary catheter when a urinary tract infection (UTI) occurred. This applies to 2 of 3 residents (R1 and R3) reviewed for indwelling urinary catheter care.Findings include:The Electronic Medical Record (EMR) showed that R1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her current diagnoses included a right fifth rib fracture and urinary tract infection (UTI). Chronic diagnoses included type 2 diabetes mellitus, hypertension, dementia, abnormalities of gait and mobility, muscle disorder, lack of coordination, muscle weakness, anxiety disorder, senile degeneration of the brain, obstructive and reflux uropathy, chronic kidney disease stage III, history of recurrent UTIs, left femur fracture, left hip joint replacement, and history of subdural hemorrhage.The Minimum Data Set (MDS) assessment dated [DATE], showed that R1 was moderately cognitively impaired and required substantial staff assistance with Activities of Daily Living (ADLs).The EMR showed that R1 had a history of recurrent UTIs. During the four-month period from January 2026 through May 2026, R1 developed three UTIs, with documented occurrences on February 16, 2026, April 27, 2026, and May 18, 2026.Review of R1's Physician Order Sheet (POS) for June 2026 showed a physician's order directing staff to change the indwelling urinary catheter when an infection occurred. Review of the EMR, including treatment records, medication administration records, and progress notes for the previous four months, failed to show documentation that R1's indwelling urinary catheter was changed following any of the documented UTIs. On June 2, 2026, at approximately 1:00 p.m., V2 (Director of Nursing) confirmed that there was no documentation to show the catheter had been changed when R1 experienced the UTIs.On June 1 and June 2, 2026, between approximately 10:30 a.m. and 11:00 a.m., observations were conducted of indwelling urinary catheter care provided to R1 and R3. V8 (Licensed Practical Nurse) and V9 (Certified Nursing Assistant) provided catheter care to R1. V10 (Certified Nursing Assistant) provided catheter care to R3.During the observations, V8, V9, and V10 failed to cleanse the urethral meatus during catheter care. Specifically, V9 failed to separate R1's inner labial folds to ensure cleansing of the urinary meatus. V10 failed to cleanse the tip of R3's penis, including the urinary meatus, during catheter care. The urinary meatus is the entry site for an indwelling urinary catheter and requires routine cleansing to reduce the risk of infection.Additionally, observation of R3 showed an approximately two-inch erosion extending from the penile tip toward the shaft. During interview, R3 stated that he had recently been readmitted to the facility following hospitalization and was currently receiving antibiotics for a urinary tract infection.Review of the EMR showed that R3, a [AGE] year-old male, was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus with diabetic neuropathy, cervical spinal stenosis, arthritis, cervical disc disorder, spondylopathy, spondylosis, neurogenic bladder dysfunction, chronic kidney disease, atherosclerotic heart disease, congestive heart failure, major depressive disorder, morbid obesity, vertebral osteomyelitis, stage IV sacral pressure ulcer, stage III right heel pressure ulcer, paraplegia, colostomy status, chronic pain, sepsis, hematuria, tubulointerstitial nephritis, urogenital candidiasis, and extended-spectrum beta-lactamase (ESBL) infection.The MDS assessment dated [DATE], showed that R3 was cognitively intact and required substantial staff assistance with ADLs.Review of R3's care plan dated June 1, 2026, documented that R3 had been hospitalized in May 2026 with diagnoses that included hematuria and UTI.Review of the facility's Indwelling Catheter Policy, dated June 25, 2020, showed that residents with indwelling urinary catheters should receive catheter care consistent with standards of practice to prevent urinary tract infections. The policy further directed staff to thoroughly cleanse the urethral meatus during catheter care.

Based on observation, interview, and record review, the facility failed to implement the physician-ordered plan of care and follow interventions intended to prevent and manage constipation for a resident with declining renal function and Stage IV chronic kidney disease. The facility failed to ensure the resident received appropriate assessments, dietary interventions, and as-needed constipation treatments despite documented evidence of ongoing bowel elimination concerns. This applies to 1 of 4 residents (R4) reviewed for bowel elimination.The Findings include:Review of the electronic medical record (EMR) showed that R4, a [AGE] year-old resident, was admitted to the facility on [DATE]. Diagnoses included hypertension, type 2 diabetes mellitus, cerebral infarction with right-sided hemiplegia and hemiparesis, peripheral vascular disease, iron deficiency anemia, Stage IV chronic kidney disease (CKD), acute kidney injury, malignant neoplasm of the bladder, and obesity.The Minimum Data Set (MDS) assessment dated [DATE], showed that R4 was cognitively intact and required substantial staff assistance with activities of daily living (ADLs).Review of the Physician Order Sheet (POS) for June 2026 showed an order for a carbohydrate-controlled diet. The POS also included a routine order for Senna-S daily for constipation, initiated on May 3, 2024. Additional as-needed (PRN) constipation medications included Dulcolax suppository 10 mg every 24 hours as needed for constipation, ordered May 1, 2024, and MiraLAX 17 grams every 24 hours as needed for constipation, ordered March 24, 2026.Review of nephrology nurse practitioner (NP-V6) progress notes dated May 21, 2026, documented that R4's renal function was declining and that the resident had elected not to undergo dialysis. The notes identified Stage IV CKD and included interventions to encourage fluid intake, avoid nephrotoxic agents, monitor bilateral nephrolithiasis, and address declining renal function. Documentation further noted a carbon dioxide (CO2) level of 12, consistent with metabolic acidosis likely secondary to CKD. The plan of care was to ensure R4 received a high-fiber diet and to prevent constipation, noting that constipation could contribute to inflammation and toxin accumulation and that bowel management should include increased dietary fiber and appropriate treatment of constipation.Review of the bowel movement monitoring record from May 4, 2026, through June 1, 2026, showed documentation of only one large bowel movement, ten medium bowel movements, five small bowel movements, and twenty-nine entries documented as NA.On June 2, 2026, at 2:30 p.m., V2 (Director of Nursing) and V10 (Certified Nursing Assistant) stated that an NA entry indicated a bowel movement that was too small to measure and consisted only of a smear adhering to the brief.Review of the electronic Medication Administration Record (eMAR) for May 2026 showed that neither the PRN Dulcolax suppository nor the PRN MiraLAX was administered during the month. On June 2, 2026, V2 confirmed that no PRN constipation medications had been provided to R4 during May 2026 despite the bowel movement documentation. Review further showed that the high-fiber dietary intervention ordered by the nephrology provider had not been implemented.On June 1, 2026, at 12:30 p.m., V5 (Registered Dietitian) stated that R4 had not been assessed or evaluated for implementation of a high-fiber diet and had not been placed on a high-fiber diet as recommended by the nephrology provider.On June 1, 2026, at 12:15 p.m., R4 was observed lying in bed, alert and oriented to person, place, time, and situation. R4 stated that she consistently experienced constipation and that when bowel movements occurred, they were very small and almost none. R4 reported informing staff, including nurses, about her constipation concerns but was repeatedly advised only to drink more water. R4 stated that PRN medications for constipation were not provided and that increasing water intake did not resolve the problem. R4 further stated that V3 (Nurse) had been the only staff member who attempted to assist with her constipation concerns, although V3 rarely cared for her.On June 2, 2026, at 1:10 p.m., V3 stated that R4 had complained of constipation to her on the latter part of May 2026.On June 4, 2026, at 11:30 a.m., NP-V6 stated that she evaluated R4 on May 21, 2026, and that the plan of care included a high-fiber diet and prevention of constipation due to the resident's declining renal function. V6 stated that constipation could contribute to toxin accumulation and negatively affect kidney function. V6 further stated that R4 should have received PRN constipation medication based on the documented bowel elimination pattern and that additional interventions, such as a Fleet enema or referral to a gastroenterologist, might be necessary when constipation persists.Review of the facility's Bowel Program Policy, dated August 6, 2020, stated that bowel management interventions are intended to promote regular, voluntary, controlled bowel evacuations of normal consistency and that normal bowel function involves passage of soft, formed stools in adequate volume without straining.

Based on observation, interview, and record review, the facility failed to follow their water management plan for Legionella. The facility also failed to follow their policy for EBP (Enhanced Barrier Precautions). This applies to all 119 residents residing in the facility. The findings include:1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated May 4, 2026, showed the facility census was 119 residents. On May 6, 2026, at 9:25 AM, V15 (Maintenance Director) said for the facility's water management plan for Legionella, V15 checks the hot water tank temperature weekly. The facility's Boiler Temperature Log for the period of January 1, 2026, to present showed V15 checked the boiler temperatures weekly. The facility's Water Management Plan dated August 25, 2025, showed .Hazard Analysis. Processing Step: 2. Hot Water Tank Heater and/or Hot Water Storage, Mixing Valve. Potential Hazard: B = Potential growth of microorganisms in heating system. P = Scalding potential if temperatures are greater than 110 degrees Fahrenheit at the fixture. Risk Significant: Yes. Risk Basis: High Risk: There is potential for microbiological growth at the heating step. This is reduced at temperatures greater than 124 degrees Fahrenheit. Elevated temperature targets also present a noticeable scalding hazard. These factors provide further reason why maintenance of the target temperatures are an essential control measure. Processing Step: Hot Water Storage Tanks: Domestic Hot Water Tanks (5). Critical Control Limit: Hot Water Storage: Domestic Tanks – not less than 140 degrees Fahrenheit. Mixing Valve to precent scalding and to deliver water between 100 degrees Fahrenheit and 110 degrees Fahrenheit. Deliver water to kitchen/laundry – not less than 140 degrees Fahrenheit. Monitoring: Temperature Gauge Check. Frequency: Daily. Limit Deviation Corrective Action: Adjustments in the hot water storage tanks as needed. Verification Procedure: Water Management Team Review. The facility does not have documentation to show the facility's five hot water tanks had their temperature gauge checked daily. On May 6, 2026, at 11:18 AM, V1 (Administrator) said V15 should be following the facility's water management plan for Legionella and be monitoring and documenting the hot water storage tank temperatures daily. The facility's policy titled Policy: Legionella Water Management Plan dated January 13, 2026, showed Policy Statement: Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Procedure: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Preventions and ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers) recommendations for developing a Legionella water management program. 5. The water management program includes the following elements: .c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: 1) Storage tanks; 2) Water heaters. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored. g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. 2. The EMR (Electronic Medical Record) showed R101 was admitted to the facility on [DATE], with multiple diagnoses including nontraumatic subarachnoid hemorrhage, streptococcus group A, type 2 diabetes, asthma, depression, anxiety disorder, major depressive disorder, hypertension. R101's MDS (Minimum Data Set) dated March 27, 2026, showed R101 was cognitively impaired and dependent on staff for dressing, bathing and toileting assistance. R101's care plan dated March 29, 2026, showed impaired cognitive function or impaired thought process, on Enhanced Barrier Precautions related to g-tube, and impaired mobility, weakness and physical limitations related to stroke. Care plan continued to show that R101 requires maximal assistance with hygiene, bathing and total assistance with dressing. Staff to wash hands, including before entering and when leaving the room. Wear gloves and gown for high contact resident care activities: dressing, bathing, providing hygiene care and changing briefs or assisting with toileting. On May 5, 2026, at 9:52 AM, V5 (CNA/Certified Nurse Assistant) walked into room of R101 did not apply PPE (Personal Protective Equipment) gloves or gown or perform hand hygiene. V5 put on gloves inside the room raised bed of R101 to appropriate height. V5 opened R101's brief and used a disposable cleaning wipe to wipe front of perineal area. V5 disposed of the wipe in the garbage. V5 removed R101's brief. V5 did not remove gloves and did not perform hand hygiene. V5 used a cleaning wipe to clean resident's buttock area and then put it in the garbage V5 did not change gloves and did not perform hand hygiene. V5 applied new brief and put on R101's pants. V5 did not change gloves and did not perform hand hygiene. V5 removed R101 soiled gown and put her on a shirt that was hanging over wheelchair and put on R101's gym shoes. V5 did not remove gloves and did not perform hand hygiene. V5 pulled wheelchair to the bedside. V5 stood R101 up and transferred her into wheelchair. V5 removed gloves but did not perform hand hygiene before leaving R101's room. On May 5, 2026, 10:49 AM, V2 (DON/Director of Nursing) said an EBP (Enhanced Barrier Precaution) sign hangs on the outside of the door with instructions for staff and visitors before entering. V2 said before entering the room the CNA (Certified Nurse Assistant) should preform hand hygiene and put on PPE (Personal Protective Equipment) when providing direct care for residents. V2 said it is her expectation for CNAs to remove soiled gloves and perform hand hygiene before putting on new gloves when moving from dirty to clean. V2 said the reason CNAs should perform hand hygiene after removing gloves is to minimize the risk for infection. V2 said CNAs should remove PPE inside of room and perform hand hygiene before coming out. Facility policy titled Enhanced Barrier Precautions dated March 28, 2024, showed enhanced barrier precautions is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission. Facility policy continued to show examples of high contact resident care activities providing hygiene, changing briefs or assisting with toileting, dressing and bathing. Guideline showed when a resident is placed in Enhanced Barrier Precautions gown and gloves will be used in high-contact resident care activities.

Based on interview and record review, the facility failed to employe a full time qualified Food Service Manager/Director to manage resident food and nutrition service operations at the facility. This applies to all 119 residents residing in the facility. The findings include:On May 4, 2026 at 9:45 AM, V14 (Food Service Director) stated he had not passed a Dietary Manager's course and was not enrolled to begin the Dietary Manager's course. On May 6, 2026 at 11:18 AM, V26 (Food Service Consultant) and V14 failed to provide documentation that V14 met state requirements for a qualified food service director. On May 5, 2026 at 11:39 AM, V25 (Registered Dietitian) stated she consulted with the facility one day a week. V25 stated she and V14 spoke about V14 signing up to take the Dietary Managers course and V25 was available to precept V14 when he enrolled in the course. On May 6, 2026 at 10:42 AM, V1(Administrator) stated the Food Service Managers at the facility were required to have passed the Certified Dietary Managers' course. Review of State of Illinois Administrative Code Part 300 Skilled Nursing and Intermediate Care Facilities Code, section 300.2010 Director of Food Services, shows the Food Service Director will either be a full-time dietitian or a full-time dietetic service supervisor. Section 300.330 Definitions, shows Dietetic Service Supervisor a person who: is a dietitian; is a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Clinical Board of Nutrition; is a graduate, prior to July 1, 1990, of a Department-approved course that provided 90 or more hours of classroom instruction in food service supervision and has had experience as a supervisor in a health care institution which included consultation from a dietitian; has successfully completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course; is certified as a Certified Dietary Manager or Certified Food Protection Professional by the Association of Nutrition & Foodservice Professionals; or has training and experience in food service supervision and management in a military service equivalent in content to the programs in the second, third or fourth paragraph of this definition. Facility Job Description - Food Service Director, undated, fails to show the Food Service Director was required to meet any of the state requirements for Food Service Director qualifications. The job description shows the Food Service Director is responsible for directly and indirectly managing all culinary and nutritional services department staff, ensures menus are followed, and ensuring nutrition care for residents is developed and carried through by ensuring new patient assessments medical records charting, resident care conference attendance, diet order auditing, and food intake monitoring take place.

Based on observation, interview and record review, the facility failed to provide palatable meals at acceptable service temperatures per facility policy. This applies to all 116 residents receiving oral diets in the facility. The findings include:Facility Long Term Care Facility Application for Medicare / Medicare, dated May 4, 2026, shows there were 119 residents residing in the facility. Facility memo, dated May 6, 2026, shows three residents had physician orders for NPO (Nothing By Mouth). 1. On May 4, 2026 at 12:09 PM, a lunch test tray was conducted. The test tray was placed on an uninsulated bun rack which was used to serve resident room trays. The plate of food had a lid but no warmed pellet under the plate. At 12:40 PM, the last lunch meal on the bun rack was served and the temperatures of the hot foods on the test tray were measured. The pork temperature was measured at 116 degrees Fahrenheit, the potato measured 117 degrees F, and the vegetable was measured at 113 degrees F. The food was tasted and tasted luke warm and not hot. The temperature of the pork on the hot holding on the steamtable in the kitchen was measure and was 170 degrees F. Facility policy/procedure Food Temperature Management at Bedside/Table-Side Service, undated, shows, Food served at bedside or table-side must be palatable and maintained at safe temperatures in accordance with the latest CMS requirements and the Food Code In addition to meeting specific temperature targets, all hot food must be prepared and served in a manner that remains palatable If any hot food item drops below 125 degrees Fahrenheit at bedside/table, it must be reheated promptly to reach at least 165 degrees Fahrenheit before serving to the patient On May 4, 2026 at 12:32 PM, R86 stated the food was served hotter at lunch and if the residents were served hot foods at the temperature served during the survey, she would not complain. V24 (Family) was feeding R86 and stated he fed R86 every day at the facility. V24 stated if the state was in the building, the food was served hot. On May 4, 2026 at 12:37 PM, R74 stated the food was never served hot like it was served at lunch that day. R74 stated the hot food at the facility was always served cold. On May 4, 2026 at 12:37 PM, R97 stated that day the food was served hot but sometimes the hot food was served cold and the temperatures seemed dependent on who was cooking. R97 stated he typically ate meals in his room. 2. On May 4, 2026 at 10:30 AM during initial tour of the facility, the following residents expressed concerns regarding cold food served at meals: R21 stated the hot food was served cold.R26 stated the eggs are served cold and the food is not consistently served hotR83 stated the hot food is served cold at times even if eating in the dining roomR106 stated she typically ate in her rom and the hot food was not served hotR86 stated the food was very seldom hot R128 stated the hot food is not served hot even in the dining room On May 5, 2026 at 10:23AM, during resident council meeting, R86 stated dinner the night prior was served cold and that morning they were serve cold eggs for breakfast. R86 stated she didn't think enough CNAs (Certified Nursing Assistants) pass out food. On May 5, 2026 at 11:20 AM, R111 stated the hot food was served cold, including when served in the dining room, during all three meals each day. On May 5, 2026 at 12:02 PM, R90 stated the hot food served during all three meals was always cold. On May 5, 2026 at 12:05 PM, R122 stated the hot food was served cold at every meal. On May 4, 2026, at 11:22 AM, R100 stated the food is always cold, so R100 doesn't like to eat the food. On May 5, 2026 at 11:39 AM, V25 (Registered Dietitian) stated when she visits the facility she receives some food temperature complaints.

Based on observation, interview and record review, the facility failed to provide positioning assistance and grooming/hygiene for residents who required assistance for ADL (Activities of Daily Living) care.This applies to 4 of 6 residents (R63, R69, R82, R140) reviewed for ADL care in the sample of 25. The findings include:1. On May 4, 2026, at 11:47 AM, R82 was in her room, lying in bed. R82's fingernails were long and had black substances underneath the left-hand fingernails. On May 5 at 12:50 PM, R82 was in her room. R82's nails had black substances underneath all the fingernails of her left hand. V22 (Certified Nursing Assistant/CNA) said R82's left hand fingernails were long, and the left-hand fingernails were dirty and had black substances underneath. R82 said she probably had dirt under her fingernails from gardening. V22 said R82 requires staff assistance for showers and the CNAs are responsible for assisting the residents with trimming and cleaning of nails during showers and as needed. According to the EMR (Electronic Medical Records), R82 had multiple diagnoses including dementia, unspecified severity, psychotic disturbance, disorder of muscle, polyneuropathy, and type 2 diabetes mellitus. R82's care plan initiated on February 18, 2025, showed R82 had an ADL self-care performance deficit due to weakness, confusion, fatigue, activity intolerance, and limited mobility. R82's care plan interventions included CNAs and nurses to, check nail length and trim and clean on bath day and as needed. 2. According to the EMR, R69 had multiple diagnoses including, Parkinson's disease with dyskinesia, unspecified lack of coordination, disorder of muscle, and unspecified dementia. R69's care plan showed R69 had care plan initiated on February 26, 2026, showed R69 had ADL self-care deficit due to generalized, fatigue, and activity intolerance. On May 4, 2026, at R69 lying in bed, and awake. R69 had lots of curly black and grey thick facial hair under her chin. When asked if she wanted her facial hair shaved, R69 said she had been waiting to have a staff help her and it had not been done since last week. On May 5, 2026, at 12:06 PM, R69 said she had asked a staff to assist her with shaving and was still waiting, maybe it would get done later in the afternoon. R69 stated, I would try to do it myself, but I need some help and don't have a razor. On May 6, 2026, at 8:45 AM, R69 was in her room and still had lots of curly black and grey thick facial hair under her chin. V2 (Director of Nursing/DON) was also in R69's room and said R69's facial hair should have been shaved. On May 6, 2026, at 8:50 AM, V2 said the CNAs are responsible for assisting the residents with shaving, trimming, and cutting nails during showers and as needed. V2 said the residents' fingernails should not be dirty, should be clean, and facial hair should be shaved for dignity and infection prevention. 3.The Electronic Medical Record (EMR) showed that R140 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses documented for R140 include spondylosis with myelopathy of the thoracic spine, spondylopathy, lumbar spinal stenosis, cervical disc disorder of the cervical spine, post-procedural spinal conditions, Type 2 diabetes mellitus, and major depressive disorder. The Minimum Data Set (MDS), dated [DATE], showed that R140 was cognitively intact. The care plan, initiated on April 26, 2026, documented that R140 was experiencing declining health related to significant medical conditions and compromised Activities of Daily Living (ADLs). The care plan further documented that R140 required staff assistance with ADLs and that the facility was responsible for providing care and support services to meet R140's needs. On May 4, 2026, at approximately 10:15 a.m., R140 was lying in bed. Observation showed that R140's left hand was contracted. The fingernails on the left hand were noted to be long, jagged, and contained black debris underneath the nails. Due to the excessive nail length, the fingernails were observed pressing into and embedding against the inner palm of the contracted left hand. During interview, R140 stated that he wanted his fingernails trimmed and filed. V11, (Social Services Director), was immediately informed of R140's request for nail care. 4. The Electronic Medical Record (EMR) showed that R63 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses documented for R63 include cerebral palsy, paraplegia, left-sided hemiplegia, dementia, functional quadriplegia, peripheral neuropathy, polyneuropathy, and peripheral vascular disease. The Minimum Data Set (MDS), dated [DATE], indicated that R63 was moderately cognitively impaired. The MDS further documented that R63 required extensive assistance to total dependence on staff for ADLs. The care plan, initiated July 14, 2023, documented that R63 required staff assistance with ADLs and personal hygiene needs. On May 4, 2026, at 10:00 a.m., R63 was seated in a reclining wheelchair in the second-floor lounge area. R63's upper torso was slouched and leaning beyond the wheelchair armrest in an awkward position. R63's left hand was contracted, and the fingernails on the left hand were observed to be long, jagged, and contained black debris underneath the nails. The fingernails were noted to be embedded into the inner palm of the contracted left hand. Further observation showed that R63 was unshaven, unkempt, and appeared disheveled. [NAME] flaky debris was observed on the front of the resident's dark-colored shirt. The shirt did not fully cover the resident's abdominal area, and the incontinence brief was exposed. During interview, R63 stated that he was experiencing shoulder pain and requested assistance with repositioning. Following the request, V17, (CNA), V18, (Nurse), and V20, (CNA), assisted R63 by repositioning him upright in the wheelchair from the slouched and awkward position. Review of the facility policy dated October 29, 2021, regarding Activities of Daily Living (ADLs), showed that residents are to be provided with the care, treatment, and services necessary to maintain or improve their ability to perform ADLs. The policy further stated that the facility is responsible for providing appropriate care and services to residents who are unable to independently perform ADLs, including assistance with hygiene, grooming, nail care, dressing, mobility, and repositioning, in order to maintain or restore functional abilities.

Based on interview and record review, the facility failed to offer and administer influenza and pneumococcal vaccines to residents. The facility also failed to follow their policy to document residents' immunization status in the medical record. This applies to 5 of 5 residents (R11, R35, R66, R79, and R90) reviewed for immunizations in the sample of 25. The findings include:1. The EMR (Electronic Medical Record) showed R11 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including stroke, hypertension, and malignant neoplasm of the skin. R11's Immunization Report dated May 6, 2026, showed R11 did not receive the 2025-2026 influenza vaccine. The report continued to show R11 received the PCV13 (Pneumococcal Conjugate Vaccine-13) on November 8, 2024. R11's undated Annual Influenza Vaccine Consent Form showed I give consent. The form continued to show Missed was written in the corner of the form. R11's Consent/Education Flu Vaccine dated May 23, 2025, showed A. Educational Outcome: 1. Consent to immunization. The facility does not have documentation to show R11 was administered the influenza vaccine for the 2025-2026 influenza season. R11's Consent for Pneumonia Vaccine PPSV 20 (Pneumococcal 20-valent Conjugate Vaccine) dated May 23, 2025, showed .1. Consent Decision: a. Consent to vaccination. The facility did not have documentation to show R11 received the pneumococcal vaccine once R11 became eligible for the vaccine. 2. The EMR showed R35 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, psychosis, and moderate protein-calorie malnutrition. R35's Immunization Report dated May 5, 2026, at 2:54 PM, did not show R35 was offered, refused, or was administered a pneumococcal vaccine and the 2025-2026 influenza season vaccine. On May 5, 2026, at 2:07 PM, V4 (IP/Infection Preventionist) said when a resident is admitted to the facility. V4 said she reviews their vaccine history to see which vaccines they are eligible for. V4 said she is behind in reviewing resident vaccine histories and documenting in the medical record. On May 5, 2026, at 5:05 PM, V4 said she was still reviewing R35's vaccine history. On May 6, 2026, at 10:53 AM, V13 (Regional Nurse Consultant) said residents should be assessed for their vaccination status during their admission to the facility. V13 said the Infection Preventionist should be reviewing resident vaccination statuses and entering them into the medical record. V13 said resident vaccination information should be entered into the medical record as close to the real time as possible. 3. The EMR showed R66 was an [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hyperlipidemia. R66's Immunization Report dated May 5, 2026, at 2:57 PM, did not show R66 had received any pneumococcal vaccines. On May 5, 2026, at 5:05 PM, V4 said she was still reviewing R66's vaccine history. 4. The EMR showed R79 was a [AGE] year-old admitted to the facility on [DATE], with multiple diagnoses including encephalopathy, hyperlipidemia, and alcohol abuse. R79's Immunization Report dated May 5, 2026, showed R79 has only received the pneumococcal vaccine. R79's Annual Influenza Vaccine Consent Form dated October 11, 2025, showed R79's power of attorney gave consent for R79 to receive the influenza vaccine. The facility does not have documentation to show R79 received the influenza vaccine. 5. The EMR showed R90 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including hypertension, hyperlipidemia, alcohol abuse, and nicotine dependence. R90's Immunization Report dated May 5, 2026, at 2:57 PM, did not show R90 had received any vaccines. On May 5, 2026, at 5:05 PM, V4 said she was still reviewing R90's vaccine history. R90's Consent/Education Flu Vaccine dated October 10, 2025, was incomplete and did not show if R90's representative consented or refused the influenza vaccine for R90. On May 6, 2026, at 10:53 AM, V13 said residents should be offered the influenza vaccine each influenza season. V13 said the facility follows CDC (Centers for Disease Prevention and Control) guidelines for pneumococcal vaccine timing. V13 said residents should be screened for vaccine eligibility, educated, and offered the vaccines. V13 said documentation should be completed in the immunizations portion of the medical record. The facility's policy title Policy: Infection Control - Influenza and Pneumococcal Immunizations for Residents dated January 14, 2026, showed Intent: It is the policy of the facility to ensure that the resident receives Influenza and Pneumococcal immunizations, in accordance with State and Federal Regulations, and national guidelines. Procedure: Influenza Immunization: 1. Before offering the influenza immunization, each resident and or the resident representative receives education regarding the benefits and potential side effects of the immunization; 2. Each resident is offered an influenza immunization October 1 through March 31 annually (unless CDC changed its recommendation), unless the immunization is medically contraindicated or the resident has already been immunized during this time period; 3. The resident and or representative has the opportunity to refuse immunization; and 4. The resident's medical record includes documentation that indicated, at a minimum, the following: i. That the resident or resident representative was provided education regarding the benefits and potential side effects of influenza immunization; and ii. That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications. Pneumococcal Immunization: 1. Before offering the pneumococcal immunization, each resident and or the resident representative receives education regarding the benefits and potential side effects of the immunization; 2. Each resident is offered pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; 3. The resident and or representative has the opportunity to refuse immunization; and 4. The resident's medical record includes documentation that indicated, at a minimum, the following: i. That the resident or resident representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and ii. That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications. 5. Pneumococcal immunization will be offered in accordance with CDC immunization algorithm. Pneumococcal Vaccine Timing for Adults. Adults greater than or equal to [AGE] years old, Complete pneumococcal vaccine schedule. Prior vaccines: none. Option A, PCV20 or PCV21; Option B PCV15 then greater than or equal to one year after PPSV23. Prior Vaccine: PCV12 only at any age: Option A, greater than or equal to one year later, PCV20 or PCV21; No option B.

Based on interview and record review, the facility failed to offer the 2025-2026 COVID-19 immunization to residents. This applies to 3 of 5 residents (R66, R79, and R90) reviewed for immunizations in the sample of 25. The findings include:1. The EMR (Electronic Medical Record) showed R66 was an [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hyperlipidemia. R66's Immunization Report dated May 6, 2026, did not show R66 was offered, administered, or refused the 2025-2026 COVID-19 Vaccine. The facility does not have documentation to show R66 was offered and provided education regarding the 2025-2026 COVID-19 immunization. 2. The EMR showed R79 was a [AGE] year-old admitted to the facility on [DATE], with multiple diagnoses including encephalopathy, hyperlipidemia, and alcohol abuse. R79's Immunization Report dated May 6, 2026, did not show R79 was administered or refused the 2025-2026 COVID-19 vaccine. R79's Consent for Covid Vaccine dated August 2, 2025, did not show if R79 or R79's representative consented or refused for R79 to receive the 2025-2026 COVID-19 Vaccine. 3. The EMR showed R90 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including hypertension, hyperlipidemia, alcohol abuse, and nicotine dependence. R90's Immunization Report dated May 6, 2026, did not show R90 was administered or refused the 2025-2026 COVID-19 vaccine. R90's Consent Covid Vaccine dated October 10, 2025, did not show if R90 or R90's representative consented or refused for R90 to receive the 20252026 COVID-19 vaccine. On May 6, 2026, at 10:53 AM, V13 (Regional Nurse Consultant) said residents in the facility are offered the most up to date version of the COVID-19 vaccine when they become available and the administration or refusal of the vaccine should be documented in the medical record. The facility's policy titled Policy: Acute Respiratory Illness dated January 14, 2026, showed Policy Statement: The focus remains on minimizing the impact of Acute Respiratory Illnesses on the residents in the facility who are at higher risks of severe outcomes due to respiratory viral infections. Procedure: .Vaccinations: The facility will recommend and encourage all residents and healthcare personnel to receive all recommended vaccines in a timely manner. The facility will provide education to all residents and healthcare personnel about recommended vaccinations.

Based on interview and record review, the facility failed to ensure a resident was free from unnecessary medications. This applies to 1 of 2 residents (R1) reviewed for antibiotic use in the sample of 25. The findings include:The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including sepsis, pneumonia, and dehydration. R1's Order Audit Report dated May 6, 2026, showed an order dated April 16, 2026, for Ciprofloxacin oral tablet 250 mg (milligrams), give one tablet by mouth two times a day for UTI (Urinary Tract Infection) for five days. The documentation showed R1 completed her order of ciprofloxacin for five days. R1's McGeer Criteria for Infection Surveillance Checklist dated April 16, 2026, completed by V18 (RN/Registered Nurse) showed .B. Urinary Tract Infection Without Indwelling Catheter, UTI Without Indwelling Catheter. Must Fulfill both 1 and 2. 1. At least one of the following sign and symptoms: Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate. c. If no fever or leukocytosis, then greater than or equal to two of the following: 1. Suprapubic pain; 2. Gross hematuria; 3. New or marked increase incontinence; 4. New or marked increase in frequency; 5. New or marked increase in urgency. Selected Comments: the following two comments apply to both UTI with or without catheter: 1A. The following UTI can be diagnosed without localizing symptoms if a blood isolate is the same as the organism isolated from urine and there is no alternate site of infection. In the absence of a clear alternate source of infection, fever or rigors with a positive urine culture result in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as UTI. However, evidence suggests most of these episodes are likely not due to infection of a urinary source. 2. At least one of the following microbiologic criteria: a. greater than or equal to 105 cfu (colony forming unit)/mL (milliliter) or no more than two species of organisms in a voided urine sample; b. greater than or equal to 102 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter. B1. Criteria: a. UTI criteria met; b. UTI criteria not met. The documentation showed the only symptom marked in section one was If no fever or leukocytosis, then greater than or equal to two of the following: 3. New or marked increase in incontinence. The documentation did not show R1 had the adequate number of symptoms. The documentation did not have a selection for R1's microbiologic criteria, and the documentation did not show if R1 met or did not meet criteria for a UTI. V18 continued to document Additional Comments: Increase confusion/hallucinations. See urinalysis result. R1's Laboratory Results Report showed the laboratory results were received on April 11, 2026. The report continued to show Culture, Urine- Second Preliminary report: No growth. Final Culture Report- No growth. R1's Laboratory Results Report showed the laboratory results were received on April 17, 2026. The report continued to show Urine, Bacterial Culture- 60,000 to 100,000 cfu/mL, multiple organisms isolated with no predominant type, consistent with contamination. Consider recollection. The facility does not have documentation to show a urine culture was recollected. A progress note dated April 21, 2026, at 10:57 AM, by V18 showed [Physician] here earlier and made aware that resident is having visual hallucinations and more confused. Last day of antibiotic therapy for UTI. [Physician] saw resident. No new order. Said to continue to monitor resident. On May 6, 2026, at 10:53 AM, V13 (Regional Nurse Consultant) said a resident receiving an antibiotic should have laboratory results reviewed to ensure there is an active infection, and the antibiotic is the correct antibiotic for the organism. V13 said R1's McGeer's Criteria was incomplete and R1 did not meet criteria for an infection. V13 said confusion and hallucinations are not symptoms of a UTI per the McGeer's criteria. V13 said since R1's urine cultures did not show growth of a specific organism or organisms, R1 should not have received the antibiotic. The facility's policy titled Policy: Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes dated January 14, 2026, showed Policy Statement: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Procedure: As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. The IP (Infection Preventionist), or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. A. Therapy may require further review and possible changes if: .Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics.

Based on interview and record review the facility failed to ensure that medication regimen recommendations were addressed by the physician in a timely manner. This failure applies to 1 of 5 residents (R79) reviewed for medication regimen review in a sample of 25 The findings include: The EMR (Electronic Medical Record) showed R79 was admitted to the facility on [DATE], with multiple diagnoses encephalopathy, cerebrovascular disease, anemia, hyperlipidemia, psychosis, dementia, anxiety disorder and depression.R79's MDS (Minimum Data Set) dated February 9, 2026, showed R79 was cognitively impaired and requires assistance with toileting, dressing and bathing.Care plan dated February 15, 2026, showed R79 impaired functional mobility related to weakness and decreased activity tolerance, secondary to dementia with behavioral disturbance, altered mental status. Care plan continued to show uses antipsychotic medications related to diagnosis of psychosis. Interventions showed administer antipsychotic medications as ordered by physician and consult pharmacy, medical doctor to consider dose reduction when clinically appropriate at least quarterly.R79's Medication Regimen Review dated February 28, 2026, showed to see report of pharmacist recommendation to nursing. The pharmacy recommendation dated February 28, 2026 showed to Please confirm there is clinical contraindication available in medical record if this patient is not a candidate for GRD at this time.R79's Pharmacist recommendation to nursing dated February 28, 2026, showed no physician recommendations till April 7, 2026. The physician made the following response and signed the Medication Regimen Review form on April 8, 2026, reduce Seroquel to 25 milligrams three times a day per GDR (Gradual Dose Reduction).On May 6, 2026, 9:36 AM, V2 (Director of Nursing) stated she and V4 (Assistant Director of Nursing) are responsible for making sure the recommendations are complete. V2 said she is not sure if V16 went on vacation in the month of March or what happened and why the recommendations from pharmacy were not followed up on in the absence of V16.Facility policy titled Monthly Medication Regimen Review dated November 1, 2022, showed 5. If the attending physician does not respond to the consult pharmacist's recommendation in a timely manner, the irregularity will be referred to the medical director.6. Urgent irregularities that are not responded to responded to during the consultation visit will be escalated to the medical director.

Based on observation, interview, and record review, the facility failed to ensure the use of adaptive devices for residents with contracted hands to prevent further decline in range of motion and promote comfort related to contractures. This applies to 2 of 4 residents (R63 and R140) reviewed for contractures in a sample of 25 residents. The findings include: 1. The Electronic Medical Record (EMR) showed that R140 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses documented for R140 include spondylosis with myelopathy of the thoracic spine, spondylopathy, lumbar spinal stenosis, cervical disc disorder of the cervical spine, post-procedural spinal conditions, Type 2 diabetes mellitus, and major depressive disorder. The Minimum Data Set (MDS), dated [DATE], showed R140 was cognitively intact.The care plan, initiated on April 26, 2026, documented that R140 was experiencing declining health related to significant medical conditions and compromised Activities of Daily Living (ADLs). The care plan further documented that R140 required staff assistance with ADLs and that the facility was responsible for providing care and support services to meet R140's identified needs.On May 4, 2026, at approximately 10:15 a.m., R140 was lying in bed. R140's left hand was contracted. The fingernails on the left hand were noted to be long and jagged. Due to the excessive nail length, the fingernails were observed pressing into and embedding against the inner palm of the contracted left hand. No splint or adaptive device was observed in use to assist with positioning and promote comfort. The Physician Order Summary (POS) for May 2026 showed a physician order dated April 23, 2026, for Physical Therapy (PT) and Occupational Therapy (OT) evaluation and treatment. Review of the EMR showed no documentation that R140 had been screened or evaluated by PT or OT for adaptive devices related to the contracted hand following admission.On May 5, 2026, at approximately 2:17 p.m., V9, (Occupational Therapist/OT), stated that a splint or adaptive device would benefit R140's contracted left hand by preventing further decline in range of motion and promoting comfort. 2. The Electronic Medical Record (EMR) showed that R63 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses documented for R63 include cerebral palsy, paraplegia, left-sided hemiplegia, dementia, functional quadriplegia, peripheral neuropathy, polyneuropathy, and peripheral vascular disease. The Minimum Data Set (MDS), dated [DATE], showed that R63 was moderately cognitively impaired. The MDS further documented that R63 required extensive assistance to total dependence on staff for ADLs (Activities of Daily Living).The care plan, initiated July 14, 2023, documented that R63 required staff assistance with ADLs. Review further of the care plan showed no interventions related to the use of splints or alternative adaptive devices for the contracted left hand to promote comfort or prevent worsening of the contracture.On May 4, 2026, at 10:00 a.m., R63 was seated in a reclining wheelchair in the second-floor lounge area. R63's upper torso was slouched and leaning beyond the wheelchair armrest in an awkward position. R63's left hand was contracted, and the fingernails on the left hand were observed to be long and jagged. The fingernails were embedded into the inner palm of the contracted hand. No splint or adaptive device was observed in place to promote comfort or maintain hand positioning.On May 5, 2026, at approximately 2:14 p.m., V9 stated that there was no alternate adaptive device that was explored and implemented after R63 reportedly refused the hand splint on January 27, 2026, due to the splint being too heavy.Review of the facility policy dated June 20, 2020, regarding management of residents with impaired physical mobility, showed treatment for contractures is to be assessed by PT/OT and may include the application of splints to stretch affected tissues and encourage the use of assistive devices.Review of the facility policy dated October 29, 2021, regarding Activities of Daily Living (ADLs), indicated that residents are to be provided with the care, treatment, and services necessary to maintain or improve their ability to perform ADLs.

Based on observation, interview, and record review, the facility failed to ensure that accepted standards of quality care and safe medication administration practices were followed during medication administration.This applies to 1 of 6 residents (R62) reviewed for medication administration. The findings include:The Electronic Medical Record (EMR) showed that R62 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses documented for R62 include multiple sclerosis, muscle spasm, depression, nicotine dependence, psychosis, and anxiety disorder.The Minimum Data Set (MDS), dated [DATE], indicated that R62 was cognitively intact.The care plan, initiated on June 4, 2024, documented that R62 was experiencing declining health related to significant medical conditions and compromised Activities of Daily Living (ADLs). The care plan further documented that R62 required staff assistance with ADLs and that the facility was responsible for providing care and support services to meet R62's identified needs.On May 5, 2026, at 9:43 a.m., V12, (Licensed Practical Nurse/LPN), prepared and poured R62's scheduled morning medications into a medication cup. During medication preparation, V12 stood at the medication cart reconciling the medication supply labels with the physician orders documented in the EMAR (Electronic Medication Administration Record).At that time, V4, (Assistant Director of Nursing/ADON), was standing approximately three to four feet away from the medication cart and was not within visual range of either the eMAR or the medication supply labels being reconciled by V12. During the preparation process, V12 identified that Vitamin D was not available in the medication cart. V4 then left the area of the medication cart, walked to the medication storage room located beyond the nurses' station, and during that time had no visual oversight of the medications previously prepared by V12.Upon returning, V4 provided the Vitamin D medication supply to V12. V12 then added one tablet of Vitamin D to the previously prepared medications. V4 subsequently took the prepared medications and administered them to R62. V12 later signed the eMAR indicating that she had administered the medications; however, observation confirmed that V4 was the individual who administered the medications.Observation further showed that prior to administration, V4 did not verify the medications against the physician orders, medication labels, or the eMAR to confirm the accuracy of the medications being administered. As a result, the medications were administered without V4's independent verification process to ensure the right medication, right dose, right resident, right route, and right time, thereby creating the potential for medication error.When questioned regarding the medication administration practice observed and the potential for medication error, V4 stated that she was attempting to assist V12 because V12 was behind schedule with medication administration.On May 5, 2026, at 3:50 p.m., V2, (Director of Nursing/DON), stated that facility practice required the nurse who prepared and reconciled the medications with the physician orders and medication labels to also administer the medications to the resident.On May 5, 2026, at approximately 3:52 p.m., V4 acknowledged that she did not independently check the medication labels or verify the medications prior to administration and instead assumed that V12 and the surveyor had already verified the medications that had been prepared.Review of the facility policy regarding medication administration, dated March 20, 2020, indicated that medications are to be administered safely and appropriately. The policy further required staff to review the Medication Administration Record (MAR) prior to administration to ensure the right dose, right medication, right route, right resident, and right time; verify discrepancies between the eMAR and medication labels; review physician orders before administration; and document medications in the eMAR as each medication is prepared and administered.

Based on observation, interview, and record review, the facility failed to provide a wheelchair to accommodate a resident's assessed needs. This applies to 1 of 1 resident (R140) reviewed for accommodation of needs in a sample of 25. The findings include:The Electronic Medical Record (EMR) showed that R140 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses include spondylosis with myelopathy of the thoracic spine, spondylopathy, lumbar spinal stenosis, cervical disc disorder of the cervical spine, post-procedural spinal conditions, Type 2 diabetes mellitus, and major depressive disorder.The care plan, initiated on April 26, 2026, documented that R140 was coping with declining health related to significant medical conditions and compromised Activities of Daily Living (ADLs), necessitating long-term care placement for rehabilitation and restorative care. The care plan further documented that R140 required staff assistance with ADLs and that the facility was to provide care and support to enable R140 to function at the highest practicable level.The Physician Order Summary (POS) for May 2026 included a physician's order dated April 23, 2026, for Physical Therapy (PT) and Occupational Therapy (OT) evaluation and treatment. Review of the EMR revealed no documentation that R140 had been screened or evaluated by PT or OT for functional or adaptive equipment needs, including wheelchair assessment, upon admission.On May 4, 2026, at approximately 10:15 a.m., R140 was lying in bed. During interview, R140 stated that he had remained in bed for more than one week because he had not been provided with a wheelchair to enable him to get out of bed. R140 stated that he wished to leave his room during mealtimes to dine in the dining room and interact with other residents rather than remain isolated in his room. R140 further explained that he became paralyzed from the chest down following spinal surgery involving the cervical, thoracic, and lumbar regions of his spine. During the interview, R140 became tearful while discussing his declining medical condition and expressed that being able to get out of bed and socialize with others would help him feel less isolated.V11, Social Services Director, was immediately informed of R140's concerns and request for a wheelchair. V11 stated that this was the first time she had been made aware of the issue and indicated that she would refer R140 to the therapy department for evaluation.On May 4, 2026, at approximately 12:50 p.m., R140 was again observed lying in bed while eating lunch. R140 stated that he had not yet been able to get out of bed because the wheelchair initially provided this morning was not appropriate for his condition and did not provide adequate back support. R140 stated that, due to paralysis affecting his neck and lower body, he required a wheelchair capable of supporting his neck and back.On May 5, 2026, at approximately 9:30 a.m., V8, (Restorative Certified Nursing Assistant), delivered a high-back reclining wheelchair to R140's room.On May 5, 2026, at 11:30 a.m., R140 was assisted out of bed by V5 and V6, (Certified Nursing Assistants/CNAs), utilizing a mechanical lift transfer device and the newly provided high-back reclining wheelchair. R140 was smiling and stated, Finally, I can go to the dining room for lunch and not just look at my bedroom walls.On May 5, 2026, at 1:45 p.m., V10, Physical Therapist (PT), stated that the therapy referral for R140 was not received until May 4, 2026, and that the evaluation was completed later that same day. V10 stated that R140 was totally dependent on staff for mobility and transfers and required a high-back reclining wheelchair and mechanical lift transfers due to paralysis. V10 further stated that the high-back reclining wheelchair was medically appropriate to support R140's spinal condition and to meet R140's functional seating and mobility needs.Review of PT documentation dated May 4, 2026, completed by V10, confirmed that R140 was evaluated and that a high-back reclining wheelchair was recommended and indicated for the R140's condition.Review of the facility policy regarding ADLs and impaired physical mobility dated October 29, 2021, showed that residents are to be provided care, treatment, and services necessary to maintain or improve their ability to perform Activities of Daily Living (ADLs). The policy further stated that the facility is responsible for providing appropriate care and services to residents who are unable to independently perform ADLs and for maintaining or restoring functional abilities.

Based on interview and record review, the facility failed to follow their policy for Antibiotic Stewardship. This applies to 1 of 2 residents (R1) reviewed for antibiotic use in the sample of 25. The findings include:The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including sepsis, pneumonia, and dehydration. R1's Order Audit Report dated May 6, 2026, showed an order dated April 16, 2026, for Ciprofloxacin oral tablet 250 mg (milligrams), give one tablet by mouth two times a day for UTI (Urinary Tract Infection) for five days. The documentation showed R1 completed her order of ciprofloxacin for five days. R1's McGeer Criteria for Infection Surveillance Checklist dated April 16, 2026, completed by V18 (RN/Registered Nurse) showed .B. Urinary Tract Infection Without Indwelling Catheter, UTI Without Indwelling Catheter. Must Fulfill both 1 and 2. 1. At least one of the following sign and symptoms: Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate. c. If no fever or leukocytosis, then greater than or equal to two of the following: 1. Suprapubic pain; 2. Gross hematuria; 3. New or marked increase incontinence; 4. New or marked increase in frequency; 5. New or marked increase in urgency. Selected Comments: the following two comments apply to both UTI with or without catheter: 1A. The following UTI can be diagnosed without localizing symptoms if a blood isolate is the same as the organism isolated from urine and there is no alternate site of infection. In the absence of a clear alternate source of infection, fever or rigors with a positive urine culture result in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as UTI. However, evidence suggests most of these episodes are likely not due to infection of a urinary source. 2. At least one of the following microbiologic criteria: a. greater than or equal to 105 cfu (colony forming unit)/mL (milliliter) or no more than two species of organisms in a voided urine sample; b. greater than or equal to 102 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter. B1. Criteria: a. UTI criteria met; b. UTI criteria not met. The documentation showed the only symptom marked in section one was If no fever or leukocytosis, then greater than or equal to two pf the following: 3. New or marked increase in incontinence. The documentation did not show R1 had the adequate number of symptoms. The documentation did not have a selection for R1's microbiologic criteria, and the documentation did not show if R1 met or did not meet criteria for a UTI. V18 continued to document Additional Comments: Increase confusion/hallucinations. See urinalysis result. R1's Laboratory Results Report showed the laboratory results were received on April 11, 2026. The report continued to show Culture, Urine- Second Preliminary report: No growth. Final Culture Report- No growth. R1's Laboratory Results Report showed the laboratory results were received on April 17, 2026. The report continued to show Urine, Bacterial Culture- 60,000 to 100,000 cfu/mL, multiple organisms isolated with no predominant type, consistent with contamination. Consider recollection. The facility does not have documentation to show a urine culture was recollected. R1's Antibiotic Timeout dated April 17, 2026, by V4 (IP/Infection Preventionist) did not show V4 discussed R1's urine culture results with the provider. R1's progress notes for the period of April 15, 2026, to April 21, 2026, did not show a provider was notified of R1's urine culture results. On May 6, 2026, at 10:53 AM, V13 (Regional Nurse Consultant) said the antibiotic timeout assessment should be completed 72 hours after an antibiotic has been started to review any adverse reactions from the antibiotic and the culture results with the provider. V13 said R1's McGeer's Criteria was incomplete and R1 did not meet criteria for an infection. V13 said confusion and hallucinations are not symptoms of a UTI per the McGeer's criteria. V13 said V4 (Infection Preventionist) did not complete R1's antibiotic timeout completely. V13 said since R1's urine cultures did not show growth of a specific organism or organisms, R1 should not have received the antibiotic. The facility's policy titled Policy: Antibiotic Stewardship dated January 14, 2026, showed Policy Statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Procedure: 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 11. When a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on observation, interview and record review, the facility failed to maintain facility roof, kitchen ceiling, and kitchen flooring in good repair per facility policy. This applies to all 119 residents residing in the facility. The findings include:Facility Long Term Care Facility Application for Medicare / Medicare, dated May 4, 2026, shows there were 119 residents residing in the facility. On May 4, 2026 at 9:45 AM with V14 (Food Service Manager), the flooring in front of the cooking area was bulging up and had missing tiles replaced with mismatching and unfitting tiles leaving large gaps in the tiles where dirt/debris collected. There were also several broken tiles requiring repair/replacement. In the dry storage room, the reach in freezer had a bucket on top of the freezer. V14 stated the bucket was there to catch water that was leaking through the ceiling from the roof on to the freezer. Wall to the right of the freezer unit had peeled paint and stain which V14 stated was caused by water running down the wall from the ceiling. In the dish machine room there were also several missing and broken floor tiles that required repair/replacement. On May 5, 2026 at 1:05 PM, the white bucket remained on top of the reach in freezer unit and the freezer was plugged into the electrical outlet on the wall. V14 moved the freezer out from under the opening in the ceiling created by the leaking water to the extent the electrical cord would reach. The electrical cord extended directly under the area of the leak in the ceiling and V14 stated he would speak to V15 (Maintenance) about moving the freezer out from under the ceiling leak. In the cooks area there were approximately 70 broken/misaligned tiles that required repair/replacement and the floor remained bowed up from the surrounding floor. In the dish room there were approximately 45 broken/misaligned tiles that required repair/replacement. On May 5, 2026 at 12:30 PM, V15 (Maintenance) stated the roof above the reach in freezer in the dry storage room began leaking in the winter and was an ongoing concern since. On May 4, 2026 at 2:33 PM, V1 stated the facility was investigating the need for repairs of the kitchen floor and roof area. On May 5, 2026 at 10:48 AM, V1 provided a repair estimate, dated May 4, 2026, to remove buckled tiles in cooking and dishwasher area and replace the tiles with new tiles. At 1:05 PM, V1 provided a repair estimate dated May 5, 2026 for silicone coating the roof. Facility Policy /Procedure, reviewed 1/7/26, shows, The facility will be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel, and the public The facility will provide a safe, functional, sanitary and comfortable environment for residents, staff and the public The facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner

Based on interview and record review, the facility failed to keep residents free from sexual abuse when R3 sucked on R2's breast. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on February 9, 2026, at 11:30 AM, when R2, a female dementia resident with known inappropriate sexual behaviors was left unsupervised in the dining room with R3, a male dementia resident, and R2 waved R3 over, lifted her shirt, and R3 sucked on R2's breast. This applies to 2 of 4 residents (R2 and R3) reviewed for sexual abuse in the sample of 6. V3 (Assistant Administrator), V17 (Senior Administrator), and V18 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on March 10, 2026, at 11:47 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on March 10, 2026, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include:The facility's State Report dated February 13, 2026, by V15 (Previous Administrator) showed Incident Date: February 9, 2026. Time: 11:30 AM. [R3] is an [AGE] year-old male long-term care resident. [R3] has diagnosis of psychotic disturbance, diabetes mellitus, arteriosclerotic heart disease, dementia, major depressive disorder, anxiety, and myelopathy. R2 is an [AGE] year-old female long-term care resident. R2 has diagnosis of dementia, chronic obstructive pulmonary disease, diabetes mellitus, altered mental status, and bipolar disorder. At approximately 11:30 AM, it was reported to the abuse coordinator that R2 was noted to have her shirt raised, and [R3] was noted to have his face on her chest. Staff immediately separated [R3] from R2 and took [R3] to his room and kept him on one on one with a staff person until EMS (Emergency Medical Services) transferred to the ER (Emergency Room). Nurse assessed R2 for any signs of injury and none were noted. The police were notified and they interviewed [R3]. R2 told the officer that nothing happened that she didn't want to happen. R2 was sent to the ER for evaluation and returned with no new orders. [R3] was placed on the men's secure unit upon return from the hospital and R2 was moved to the women's secure unit. IDT (Interdisciplinary Team) conducted a thorough investigation that included staff and residents. Staff state that [R3] and R2 were last seen sitting at separate tables after eating lunch in the dining room. An interview with residents on the same unit revealed that no one has been touched inappropriately, and all feel safe at the facility. The interview of R2, who scores a 15 on her BIMS (Brief Interview for Mental Status) reveals that she called [R3] over and lifted her shirt for him, but the next day didn't recall anything happening. The interaction occurred briefly in a supervised area and was immediately addressed by staff that were present and supervising the dining room. No abuse was substantiated, and safeguards were implemented to protect both residents. Care plan will be updated with appropriate interventions for both [R3] and R2. Residents are doing well on their new units. Family was notified and satisfied with the outcome of the investigation. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including atherosclerotic heart disease, dementia, anxiety, and bipolar disorder. R2's MDS (Minimum Data Set) dated December 1, 2025, showed R2 was cognitively intact. The MDS continued to show R2 has one to three days of physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). R2's behavior care plan dated July 13, 2015, showed I, [R2], have a history of socially inappropriate behavior and display a lack of boundaries. I am noted to objectify males through sexually oriented behavior/comments. When my behavior is addressed, I minimize how my actions may be interpreted or impact others. As evidenced by: I have made crude, sexually oriented, profane and suggestive remarks (i.e. statements to male staff members about 'taking care of her' and 'get on top of me'). I over-step personal boundaries by getting too close to others, initiating sexually related behavior, making sexually oriented gestures and behaving in an uninvited and flirtatious manner. The care plan continued to show multiple interventions dated July 13, 2015, including Unsupervised visiting with male residents should be discouraged and prevented when possible. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including dementia, major depressive disorder, and anxiety disorder. R3's MDS dated [DATE], showed R3 had moderate cognitive impairment. The MDS continued to show R3 exhibited wandering behavior for one to three days of the assessment period. R3's behavior care plan dated July 15, 2024, showed Resident displays socially inappropriate behavior related to: diagnosis of unspecified dementia, major depressive disorder, anxiety disorder. As evidenced by: voicing inappropriate behavior toward a peer including getting close and behaving in a flirtatious manner. The care plan continued to show multiple interventions dated February 9, 2026, including, Administer medication and monitor for effectiveness. As indicated, discuss [R3]'s situation with the physician, licensed clinical social worker, family or psychiatrist. Discourage inappropriate remarks, behaviors toward female staff and peers. Notify family of any instances of behaviors. Communicate assertively that resident exercise control over impulses and behavior. On March 9, 2026, at 12:18 PM, R2 said R3 sucked on her breasts. R2 said it was a freak accident. R2 said she wanted R3 to suck on her breast. R2 said she didn't know today's date, but it was September of 2026. On March 9, 2026, at 12:22 PM, R3 said he does not remember the incident. R3 said R2 and him were friends and spent a lot of time together. On March 9, 2026, at 12:39 PM, V5 (Dietary Aide) said she was setting up for lunch on February 9, 2026, when she walked into the dining room and saw R3 sucking on R2's breast. V5 said she told the residents to stop and went to get nursing staff at the nursing station. V5 said she immediately told the administrator. V5 said no other staff members were present in the dining when R2 and R3 were making inappropriate contact. V5 said she watched the security footage of the dining room with administration and the video showed R2 and R3 were making inappropriate contact whenever staff would leave the dining room and then stop when someone would enter. V5 said she guesses she walked in too fast for the residents to notice and she caught them. V5 showed the surveyor the residents were seated at a table at the center of the dining room. On March 9, 2026, at 1:53 PM, V8 (CNA/Certified Nursing Assistant) said she had put drinks in the dining room and saw R2 and R3 sitting together at a dining room table. V8 said the food hadn't arrived yet so V8 left the dining room, and no other staff were in the dining room. V8 said V5 alerted staff and V8 ran into the dining room and separated R2 and R3. V8 said R2 has been verbally inappropriate with other residents by talking to them about her private areas. V8 said R2 would ask the residents to do something sexual to her private areas. V8 said if she heard an inappropriate comment, she would separate R2 and report it. V8 said the nurse would talk with R2 and tell R2 it was inappropriate. On March 9, 2026, at 1:43 PM, V6 (CNA) said R2 can be sexual at times, it depends on R2's mood. V6 said she was unaware R2 had any special interventions in place for her sexual behavior. V6 said staff only do continuous monitoring of the dining room once meals have been served and residents are eating. On March 9, 2026, at 1:48 PM, V7 (CNA) said she is caring for R2 today, and there is no additional monitoring required for R2. On March 9, 2026, at 3:46 PM, V14 (RN/Registered Nurse) said R2 has sexual behaviors and says sexually inappropriate comments to males. V14 said R2 is not able to give informed consent. V14 said if consent is required for R2, R2's family is called. V14 said R2 thought some male residents liked her, and when R2 would see these residents, she would make inappropriate sexual comments. V14 said staff would try to separate her and put her with female residents. V14 said R2 used to reside in the co-ed dementia unit. V14 said the intervention in place for R2's inappropriate sexual behavior was when R2 would say something inappropriate, staff would separate R2 from the other resident. On March 9, 2026, at 3:01 PM, V10 (Social Services Director) said R2 can be flirtatious. V10 said when she interviewed R2 after the incident, R2 told V10, R2 waved R3 over and lifted her shirt and R3 was kissing R2's chest. V10 said when she interviewed R3, R3 said he could recall the incident and R2 waved R3 over, R3 went up to R2, R2 lifted her shirt, and R3 kissed R2's chest. V10 said she calls sexually inappropriate behavior flirtatious behavior. V10 said R2 has said to V10, Ooooh baby, come over here. V10 said R3 is also flirtatious with her. V10 said she contacted V11 (Psychiatric Nurse Practitioner) and V12 (LCSW/Licensed Clinical Social Worker) regarding the incident with R2 and R3. On March 9, at 4:05 PM, V12 (LCSW) said he met with R3 on February 12, 2026, following the incident but was unable to meet with R2 on February 12 because she refused to speak with V12. V12 said he has not attempted to see R2 again after she refused. V12 said he comes to the facility to see residents five days a week, Monday through Friday. V12 said he should have attempted to see R2 again since that day. V12 said R3 is not cognitively intact and cannot make his own decisions. V12 said R2 is not able to make informed decisions. V12 said he was aware R2 had inappropriate sexual behaviors and V12 thinks staff were just used to it by now because R2 was flirtatious with staff and residents. V12 said all they could do was document R2's behaviors and attempt to redirect R2. On March 9, 2026, at 6:13 PM, V11 (Psychiatric Nurse Practitioner) said R2 has a diagnosis of dementia does not have the decision-making capacity to consent to sexual activity/contact. V11 said he was not given all the details regarding R2 and R3. V11 said he was told there was an allegation but V11 was unaware contact was made between the residents. V11 said R2 could not be deemed decisional without further testing by a neuropsychologist due to R2's dementia diagnosis. R2's Psychiatric progress note dated January 20, 2026, at 9:59 AM, by V11 showed Visited January 19, 2026. MSE (Mental Status Examination): This patient was personally examined by the writer. Speech: The patient's speech exhibited an impaired rate, rhythm, low volume, and altered prosody, with noticeable latency in responses. Mood: The examination revealed a labile mood with a congruent affect. Thought Processes and Associations: the patient's thought processes displayed abnormal associations and impairments in processing and abstraction. Thought Content: The patient did not report any suicidal ideation, homicidal ideation, violent thoughts, auditory or visual hallucinations, or delusions. Insight/Judgement: The patient's insight and judgment are considered poor. Cognitive: the patient is alert and oriented to person only, with significant deficits in both short and long-term memory, as well as impaired attention and concentration; however, language skills and general knowledge are appropriate for their cognitive status. R3's psychiatric progress note dated December 26, 2025, at 12:02 PM, by V11 showed Visited on: December 22, 2025. MSE: The patient was personally examined by the writer.Thought Processes and Associations: The patient's thought processes displayed abnormal associations and impairments in processing and abstraction. Thought Content: The patient did not report any suicidal ideation, homicidal ideation, violent thoughts, auditory or visual hallucinations, or delusions. Insight/Judgment: The patient's insight and judgment are considered poor. Cognitive: The patient is alert and oriented to person only, with significant deficits in both short and long-term memory, as well as impaired attention and concentration; however, language skills and general knowledge are appropriate for their cognitive status. R2's EMR showed a progress note dated February 10, 2026, at 4:07 PM, by V23 (R2's Doctor), including Patient being seen for general follow up. Patient was seen while in her room. Patient had an incident yesterday, when she provoked another resident to suckle on her bosom. [Emergency Medical Services] was called, and police came to investigate. Patient does not seem to recall the events when asked about it. On March 10, 2026, at 11:47 AM, V18 said she thought sexual abuse was unsubstantiated because both residents enjoyed the act. On March 12, 2026, at 12:32 PM, V7 said she was caring for R2 in the female secured dementia unit. V7 said when she entered R2's room this morning, R2 said to V7 I want to f*** you. V7 said she left R2's room and when she returned, R2 said the same thing about another male resident outside of the dementia unit. V7 said she redirected R2 and said she can't speak like that and reported the behavior to the nurse. The facility's policy title Abuse Policy and Procedure dated October 24, 2022, showed Policy Statement: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Purpose: The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. The facility prohibits abuse, neglect, misappropriation of property, and exploitation of residents, including verbal, mental, sexual, or physical abuse; corporal punishment; and involuntary seclusion. The facility has a 'no tolerance' philosophy; persons found to have engaged in such conduct will be terminated. Definitions: . Sexual Abuse is non-consensual sexual contact of any type with a resident. Protocol: Objective of Abuse Policy: the objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention. The Abuse Prevention Program will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance And Performance Improvement (QAPI) program. V. Reporting and Response. E. Final Report and Follow Up. Within five days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken to respond to the to the allegation, will be sent to the Department of Public Health. i. Report contents. The final report shall include the following, as appropriate: name, age, diagnosis and metal status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated; the original allegation (note day, time, location, the specific allegation, he alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries); a summary of facts determined during the process of the investigation, review of medical record and interview of witnesses; and conclusion of the investigation based on known facts. iii. Corrective Actions. The administrator shall take appropriate corrective action and disciplinary action, if deemed appropriate and necessary. F. Quality Management Review. Any investigation that concluded that abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred shall be reviewed by the facility Quality Management committee for possible changes in facility practices to ensure that similar events do not occur again. The investigation shall be reviewed at the next quarterly Quality Management committee meeting, or sooner if possible. The facility's policy titled Policy and Procedure: Sexual Abuse Prevention, Reporting, and Response dated February 18, 2025, showed Policy Statement: It is the policy of this facility to maintain a zero-tolerance stance toward sexual abuse, sexual assault, sexual harassment, or any form of non-consensual sexual contact involving residents. All staff, contractors, volunteers, and visitors must comply with federal and state regulations to protect residents' rights to dignity, privacy, and safety. The facility will ensure immediate protection of residents, prompt reporting to proper authorities, thorough investigation, and corrective actions in compliance with IDPH (Illinois Department of Public Health) and CMS (Centers for Medicare and Medicaid Services) requirements. Definitions: Sexual abuse: Non-consensual sexual contact of any type with a resident. Includes sexual assault, harassment, coerced nudity, inappropriate touching, photographing, or exposing residents without consent. Perpetrator: May include staff, other residents, volunteers, visitors, or contractors. Consent: The resident's ability and right to make an informed, voluntary decision. Consent cannot be given if the resident is cognitively impaired or under duress. The facility's policy titled Policy: Management of Sexual Behaviors dated September 18, 2025, showed Policy Statement: This long-term care facility affirms and respects the rights of consenting adults to privately engage in a private intimate relationship and pursue a meaningful quality of life. The facility emphasizes care in a manner and environment that enhances dignity and respect with full recognition of each person's individuality. The health care team recognizes the need to intervene when questions regarding informed consent and/or decisional capacity arise. It is the objective of this policy to clarify the issue of informed consent and the facility's potential role in educating individuals about appropriate sexual expression and safe practices. In-service education will address the content of his policy, as appropriate. Addressing questions of informed consent: 1. Definition: Informed Consent is defined as having the capacity to understand the outcome and consequences of one's actions. A person who does not understand, nor cannot explain the consequences of his/her decisions will be considered clinically incompetent. A specific diagnosis does not automatically imply a person can or cannot give informed consent. A person with dementia or severe mental illness may meet the legal and clinical standard defined above and therefore be capable of giving informed consent. As appropriate the organization may utilize a mental health practitioner, such as a psychiatrist, clinical social worker and/or clinical psychologist to help in the evaluation and determination of the individual's ability to provide informed consent. 2. The facility will not intervene in situations in which two consenting adults are privately engaging in intimate behavior. The facility will be responsible for intervening in situations in which one or both individuals lack the ability to provide informed consent. Interventions may include, but are not limited to, verbal guidance, re-direction, firm limit setting, separation, escorting one or both individuals to a more closely supervised area, notification of appropriate responsible parties, notification of the attending physician and psychiatrist, counseling, reality orientation and appropriate distraction. 3. The facility respects privacy and encourages residents to appropriately pull privacy curtains and close doors when engaging in behavior of a sexual nature. Evaluation and education of residents: 1. In situations in which it is difficult to assess a resident's ability to give informed consent the facility may request further assessment from professionals such as the attending physician, attending psychiatrist and licensed clinical social worker. Special interventions may be implemented based on recommendations from the above professionals. The Immediate Jeopardy that began on February 9, 2026, was removed on March 10, 2026, when the facility took the following actions to remove the immediacy: 1. Corrective Actions Takena. R2 continues to reside in the facility with no further incidents and suffered no negatives effects.b. R2's physician and responsible party were notified on February 9, 2026; responsible party had no concerns.c. R2 was sent to the hospital on February 9, 2026; no new findings and no new orders were received.d. R2 was moved to the secured female unit on February 11, 2026e. R3 continues to reside in the facility with no further incidents and suffered no negative effects.f. R3's physician and daughter were notified on February 9, 2026; daughter voiced no concerns.g. R3 was sent to the hospital on February 9, 2026; no new findings and no new orders were received. R3 was on a 1:1 with staff until R3 left for the hospitalh. R3 was moved to the secured male unit on February 9, 2026.i. Law Enforcement was notified on February 9, 2026, and concluded investigation with no findings. Report #AUP260-16372.j. Social Services completed assessments on behavior, potential abuse and trauma on February 9, 2026, for R2 and R3. Care plans were reviewed and updated as indicated on potential for abuse, behavior and trauma. Assessments and care plans will completed per assessment schedule and as needed. Goal: completedk. On March 10, 2026, Social Services completed and reviewed assessments on residents identified with sexually inappropriate behaviors. Care plans were reviewed and updated as needed. DON (Director of Nursing), ADON (Assistant Director of Nursing) and/or designee communicated plan of care to staff. On March 10, 2026, a behavior monitoring binder was created and placed at the nurses' station that shows residents with behaviors and their plan of care and will be reviewed and updated by DON, ADON, Social Services, and/or designee weekly and as needed. Goal: ongoingl. For identified residents with sexually inappropriate behaviors, behavior monitoring started every 2 hours times 2 weeks and every shift thereafter while awake by nursing staff and will be documented on behavior monitoring log. Findings will be escalated to abuse officer and ADON for protocol implementation immediately. Start: March 10, 2026; goal: March 24, 2026/ongoing.2. Identification of Other Residents at [NAME]. All residents in the facility are considered potentially affected.3. Systemic Measures to Prevent Recurrencea. Resident Interviews of approximately 105 residents was conducted by Social Service and/or designee on March 10, 2026; Residents feel safe and with no concern on any potential and actual abuse.b. Daily Huddles with nursing staff and facility IDT (Social Service, Admin, MDS, Therapy, Activity): DON/ADON/Charge Nurse initiated review on new behaviors, interventions, and reports of suspected abuse daily. Behavior monitoring binder at the nurses' station with residents with sexually inappropriate behaviors with appropriate and updated plan of care. Start date: March 10, 2026; goal: ongoing.c. Staff Education: Facility-wide training on sexual abuse policy and behavior management for sexually inappropriate behaviors including following care plan interventions. Training was conducted by DON, ADON, MDS Director. Agency staff were included with training. This training began on March 10, 2026, and will be ongoing. Facility staff who didn't receive training will not be allowed to start their shift unless training has been completed including agency staff. DON, ADON, MDS Director, and/or Charge nurse were assigned to complete training for new agency staff and for facility staff (all departments) who haven't received the training after work hours. Re-education will be conducted quarterly and as issue on any type of abuse would arise. Goal: ongoing.d. On March 10, 2026, Administrator and Consultants reviewed abuse policy that includes sexual abuse:i. Residents will be assessed upon admission for potential for abuse/trauma and behaviors such as sexual inappropriateness. This will be followed by an assessment quarterly, annually and as neededii. Residents will be screened and assessed by Social Services to identify any inappropriate behaviors. Care plans, interventions, and targeted inappropriate behavior monitoring orders will be added by a nurse as indicated.iii. Any new behaviors will be discussed by the IDT with Administrator, DON, Assistant Director of Nursing and/or consultant daily to coordinate plan of care. DON, Assistant Director of Nursing will communicate any new identified behaviors as well as interventions and orders with staff during daily huddle; staff will also be encouraged to report any new or unusual resident behaviors. Nursing managers will monitor daily for compliance. A reference behavior binder will be kept at the nurses' stations that contains identified residents sexually inappropriate behaviors. Care plans and interventions will be included. DON, ADON, Social Service and designee will maintain, and update binder as needed.iv. For residents with sexually inappropriate behaviors, behavior monitoring will continue every 2 hours times 2 weeks and every shift thereafter while awake by nursing staff and will be documented on behavior monitoring log. Findings will be escalated to abuse officer and DON for protocol implementation immediately.v. QAPI with the QA Committee and Medical Director was held on March 10, 2026, to discuss the plan of removal, Sexual Abuse policy the Management of Sexual Behaviors, this includes monitoring of behaviors such as sexual comments, sexual gestures, flirtatious behaviors, excessive friendly touching and/or directed infatuation of another resident; implementing interventions such as re-direction, firm limit setting, separation, escorting residents to a more closely supervised area, reality orientation, notification of appropriate responsible party/provider, and to ensure that all corrective actions and safety measures are consistently implemented.vi. Human Resources and Director of Nursing initiated a staff in-service and will continue to conduct ongoing in-services on Management of Sexual Behaviors, this includes monitoring of behaviors such as sexual comments, sexual gestures, flirtatious behaviors, excessive friendly touching and/or directed infatuation of another resident; implementing interventions such as re-direction, firm limit setting, separation, escorting residents to a more closely supervised area, reality orientation, notification of appropriate responsible party/provider. Staff to include dietary, housekeeping, therapy, nursing and administrative departments. Any agency staff will be educated prior to the start of their first work shift; education will be provided by the Charge Nurse and/or manager designee.4. Monitoring of Corrective Actionsa. A tool has been created in which the Administrator and/or designee will select 5 random residents weekly x 4 weeks to ensure that residents are free from abuse. Start: March 10, 2026; goal: April 7, 2026.b. Any quality assurance issue/s and progress will be reported to facility's monthly QAPI meeting for three months by the Administrator and recommendations given to assist in ensuring that the facility stay in compliance and if concerns are identified the Quality Assurance Committee will add on additional months until Compliance is sustained.c. Administrator and/or Director of Nursing will complete monthly in-servicing on the facility's sexual abuse policy and sexual behavior management for three months and quarterly thereafter. Start: April 1, 2026.

Based on interview, and record review, the facility failed to assess a resident after an unwitnessed fall. This failure resulted in a delay of treatment for R1 who sustained subdural hematoma after a fall incident. This applies to 1 of 3 residents (R1) reviewed for assessments in the sample of 3. The findings include:R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, delirium due to known physiological condition, unsteadiness on feet, unspecified lack of coordination, unspecified abnormal gait and mobility, muscle weakness, cognitive communicative deficit, and vascular dementia moderate without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R1's MDS (Minimum Data Set) dated September 11, 2025, shows R1 had severely impaired cognition and required partial/moderate staff assistance to go from sitting to standing, from chair to bed, and getting on and off toilet. R1's care plan shows R1 had impaired cognition and thought process related to his diagnosis of dementia as evidenced by poor temporal orientation, difficulty with recall and confusion. R1's cognitive assessment shows he had severe cognitive impairment. Interventions included monitor, document, and report to physician any changes in cognitive function, specifically changes in decision making, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status.R1's progress notes and EMR (Electronic Medical Record) were reviewed for nursing assessments and documentation post fall. The following were identified as the only documentation completed: On September 11, 2025, V9 (RN/Registered Nurse) was the nurse on duty when R1 fell. V9 completed a Fall Event, a progress note about the fall, and a fall assessment. The fall event dated September 11, 2025, at 7:02 PM showed the location of the fall, what resident was doing prior to the fall, when resident was last observed, when resident was last toileted, resident's statement, resident's mental status prior to fall, any deviation from resident's usual mental status, did the resident hit his head, have resident smile to assess facial muscle, extremity grasp, pupil response, ability to respond to name, ambulatory status, footwear, pain assessment, range of motion in extremities, and full body observation.On September 12, 2025, at 6:01 AM, The V18 (LPN/Licensed Practical Nurse) was the night shift nurse, and she documented a skilled charting note. Skilled charting included vital signs, orientation, recent change in disorientation, recent change in confusion, functional status, bladder function, bowel function, skin assessment, respiratory, cardiovascular, edema, pain, new orders, medication orders, and skilled services.On September 13, 2025, at 7:31 AM, a nurse completed the Follow up Documentation Falls form in the EMR. The Follow up documentation falls shows R1's temperature, heart rate, blood pressure, oxygenation, injury, function, cognitive status, and orders.On September 14, 15, and 16, 2025, there were no progress notes and no documentation of any assessment done on R1. The next progress note was written on September 17, 2025 at 10:40 AM, and it showed R1 was fatigued that morning and required more staff assistance for transfers and ambulation.On November 18, 2025, at 8:55 AM, V2 (DON/Director of Nursing) was unable to provide any neuro assessments done on R1 after September 11, 2025.On November 17, 2025, at 2:49 PM, V7 (R1's POA/Power of Attorney) said she was notified by the nurse on September 11, 2025, that R1 had an unwitnessed fall. V7 said she specifically asked the nurse if R1 hit his head, and the nurse told her he had asked R1, and he said no. V7 was concerned that R1 was confused and may not have been able to say if he hit his head or not. V7 said she told the nurse she wanted R1 sent to the hospital for evaluation which the facility did not do. V7 said on September 17, 2025, R1 was not able to talk and was barely able to move. At this point, V7 said she told V11 (Previous DON/Director) that she wanted R1 sent out because she was concerned that R1 hit his head when he fell, and this was the result of that fall. V11 responded saying she had done a neuro (Neurological) assessment and based on that assessment R1 was fine. V7 questioned her and asked what did her neuro assessment consist of? V11 said, she checked R1's pupils and said she felt R1's current status was most likely because he had a UTI (Urinary Tract Infection). The next day (September 18), V7 said another family member went to check on R1 at the facility and called her to let her know R1 was still not able to talk or even able to move in the bed. V7 spoke to V11 and told her she wanted R1 sent out. V11 called V8 (Physician) and placed V8 on speaker phone, so V7 and family member could hear that conversation. V8 told V11 send (R1) to the hospital now. V7 said they called 911 to have R1 sent to the ER. V7 said she was later called by the ambulance staff, and they made her aware that due to R1's condition, they could not take R1 to the requested hospital but took him to the closest hospital to the facility due to his current condition. R1 had a CT scan (Computerized Tomography) in the ER that showed he had major brain bleed on both sides of his head and was transferred to another hospital where he had surgery the next day.R1's Emergency Department Physician report dated September 18, 2025 at 4:44 PM shows R1 presented with altered mental status following a likely fall one week prior. Head CT revealed acute on chronic bilateral subdural hematomas (12 mm right, 20 mm left) and bilateral subdural hygromas with significant mass effect and effacement of cerebral sulci and ventricles. Trauma surgery and neurosurgery were consulted R1 was accepted for transfer to another hospital for definitive trauma and neurosurgical management. The report also shows currently R1 was nonverbal. The report further shows R1's daughters reported a fall last week followed by a change from his baseline mental status.On November 18, 2025, at 10:37 AM, V8 (Physician) stated when there is an unwitnessed fall and staff are not sure if resident hit their head or not, he would send the resident to the hospital for an evaluation. If there were any changes in their mental status, they should send the resident out for an evaluation immediately. V8 also stated R1 was on Aspirin 325 mg (milligrams) daily, and at that dose it would be considered an anticoagulant, and anyone taking an anticoagulant, needs to be sent out immediately. Knowing R1 was on the memory care unit with impaired cognition and on Aspirin, he would have sent R1 to the ER for evaluation right away, but the facility contacted V12 (NP/Nurse Practitioner) on the day of the fall. V8 said he saw R1 on the day he was sent out to the local hospital. It was reported to him by the nursing staff and the family that R1 had a change of condition and had been more lethargic since the day before, and the staff also stated they were having trouble transferring him. V8 said based on what he was told, he spoke with V11 (Previous DON/Director of Nursing) and told her to send R1 to the ER immediately. V8 said he called the facility approximately 3 hours later to follow up and found out that V11 had not sent R1 to the ER. V8 said he was really upset. V8 said V11 tried to refute what he said, claiming that V8 had told her to just order some labs. V8 said he did not and told her to send R1 to the ER where they could evaluate him and run test if necessary. V8 told V11 to start the process and get R1 transferred to the hospital immediately. V8 said he was later made aware that due to R1's condition the paramedics rerouted R1 to the closest hospital and not the hospital requested by the family. R1 was later transferred to another hospital due to a brain bleed. V8 said he was not aware that the facility was not doing neuro (neurological) assessments on R1 and if they would have done the assessments after the fall, they may have caught the brain bleed earlier.On November 11, 2025, at 10:54 AM, V12 (Nurse Practitioner) said she was unsure if the nurse who called her to report R1's fall told her if it was a witnessed or unwitnessed fall. V12 said she saw R1 the next day and he denied having had a fall the day before. V12 said if it was an unwitnessed fall, the staff should be doing neuro checks for 72 hours post fall. V12 said she saw R1 on September 17, 2025, and R1 was more fatigued, staff were having difficulty transferring R1. V12 said she thought R1 might have a UTI (Urinary Tract Infection), so she ordered labs and an UA C&S (Urinalysis Culture and Sensitivity). The preliminary urinalysis was negative for UTI. R1 was sent out to the ER the next day by V8 (Physician).On November 18, 2025, at 8:21 AM, V2 (DON/Director of Nursing) said after a fall, we call a fall huddle where everyone gets together to determine how and why this fall happened. The nurse should do a head-to-toe assessment, if the resident hit their head or if they are not sure about the resident hitting their head then they should do neuro assessments and call the physician. The nurse needs to provide the physician or Nurse Practitioner with the fall assessments to determine if the resident should be sent out to the hospital. The nurse should report to the oncoming nurse the information about the fall, and they should continue to assess the resident by documenting in a progress note, fall assessment under the assessment tab in the EMR (electronic medical record). V2 said she was unsure how long the assessments should continue, because she is new to this facility and is not sure of their policy but said neuro assessment needs to be done for 72 hours post fall. V2 said if a resident is confused and the nurse is unsure if resident hit their head, and is on an anticoagulant, then the resident needs to be sent out immediately to the ER or evaluation.On November 19, 2025, at 2:35 PM, followed V20 (CNA/Certified Nursing Assistant) into the dining room where R1 fell. In the back right corner of the dining room, there was a large wooden stand with cabinet doors that held a large fish tank. Along the same wall on the left-hand corner, V20 said they had an activity table with activity sheets and magazines the residents could read. That table was not there during this investigation. V20 said she was cleaning a table on the right-hand side of the dining room in front of the fish tank and R1 was standing few feet away behind her and suddenly she heard a noise and turned around and saw R1 sitting on the floor with his head against the wooden cabinet holding the fish tank and his feet to the left of the fish tank in front of the activity table. V20 called for the nurse who came and assessed R1. V20 could not say if R1 hit his head or not.On November 18, 2025, at 3:11 PM, V9 (RN/Registered Nurse) said he was the nurse on duty when R1 fell. He was passing medications when the CNA (Certified Nursing Assistant) called out to him to let him know R1 had fallen in the dining room. V9 said he went to the dining room and saw R1 on the floor. R1 was ambulatory at the time of the fall but was not able to say what happened due to his confusion which was his baseline. V9 said he did a head-to-toe assessment, checked ROM (Range of motion) in all four extremities, and did a neuro assessment. V9 said there were no concerns. R1 was assisted by two staff to a chair. V9 said he notified V12 (NP/Nurse Practitioner) told her R1 had an unwitnessed fall in the dining room, gave her results of his assessment, and there were no new orders. V9 said a head-to-toe assessment was done initially, and neuro assessment as per the paper (every 15 minutes x 1 hour, 30 minutes x whatever the neuro assessment paper says to do). V9 said the nurse should document a progress note every 8 hours or once every shift unless something changes then the doctor or NP should be notified. V9 said he was off the next four days after R1's fall, when he returned, he was told they might be sending R1 out to the hospital for a change in condition. V9 could not remember if it was V10 (dayshift nurse) or V11 (Previous DON) that told him that about R1's change of condition. On November 19, 2025, at 11:22 AM, V15 (LPN) said when there is an unwitnessed fall, she would do a head-to-toe assessment and she would also do the neuro checks (assessment) as per schedule (every 15 minutes x 4, every 30 minutes x2, .).On November 19, 2025, at 12:26 PM, V17 (LPN/Licensed Practical Nurse) said when there is an unwitnessed fall, he would first assess the resident by doing a head-to-toe assessment and then do a neuro assessment according to the schedule on the sheet (15 minutes x how many ever times.).On November 19, 2025, at 12:35 PM, V18 (LPN) said when a resident falls, we do a head-to-toe assessment, if they hit their head, we do a neuro assessment, and they are automatically sent out to the ER for evaluation. If we are not sure if the resident hit their head, we start the neuro assessment and call the physician. Neuro assessments are documented on a paper form. V18 said she thinks they must chart on the resident for three days after the fall. Facility provided their 72-hour Neurological Flow Sheet. The form showed neuro checks are to be done every 15 minutes times 4, 30 minutes times 2, every hour times 6, and every 8 hours times 8.Facility provided their incident report for R1. Facility started an investigation on September 19, 2025, for R1's fall on September 11, 2025. The report was sent to IDPH (Illinois Department of Public Health). The final report was faxed to IDPH on September 24, 2025. The investigation showed neuro checks were initiated and completed. The supporting documents the facility presented did not include any documented neuro checks after September 11, 2025. The investigation showed R1 had a change in condition on September 18, 2025, but the progress note dated September 17, 2025, showed a nurse reached out the Nurse Practitioner due to increased fatigue and change in R1's transfer and mobility status.Facility provided their policy, titled, Fall Prevention and Management dated October 29, 2021. The policy identified. #3 Procedure for Post-Fall Management. c. perform physical assessments including: i. head to toe assessment, ii. Vital signs, pulse, respiratory rate, pulse ox, blood pressure, and pain, iii. Range of motion, iv. Neurological Assessment as indicated.

Based on observations, interviews, and record reviews, the facility failed to ensure the safety and protection of R1, a female resident with severe cognitive impairment, from R2, a male resident with a documented history of wandering and entering other residents' rooms within the secured dementia care unit.This failure resulted in an incident on August 29, 2025, in which R2 entered R1's room without staff awareness. R2 had remained in the room with the door closed for approximately eight minutes. Staff later discovered R2 near R1, with his genitals exposed and near R1's face. This incident was a significant breakdown in supervision necessary to protect vulnerable residents from harm including sexual abuse.This applies to 1 of 2 residents (R1) reviewed for abuse, from a total sample of 11 residents.The facility's failure to supervise and protect R1 from sexual abuse constituted an Immediate Jeopardy to resident health and safety. The Immediate Jeopardy began on August 29, 2025, when staff member V4 (Restorative Aide) entered R1's room and observed R2 standing at the head of R1's bed. R2's sweatpants were lowered to his knee level, his genitals were exposed, and R1, who was asleep in a side-lying position, was facing R2.The facility administrator (V1) was notified of the Immediate Jeopardy on September 17, 2025 at 12:21 P.M.Through subsequent observations, staff interviews, and record reviews, the surveyor verified that the Immediate Jeopardy was removed on September 18, 2025. However, the facility remains in non-compliance at Severity Level 2 due to the need for additional time to evaluate the implementation and effectiveness of the corrective actions, including in-service training provided to staff.The findings include:The Electronic Medical Record (EMR) shows R1 is a [AGE] year-old female resident admitted to the facility on [DATE]. R1 has multiple diagnoses including dementia, cerebral atherosclerosis, unspecified psychosis, psychotic disorder, anxiety disorder and a recipient of hospice care. The most recent Minimum Data Set (MDS) dated [DATE] shows R1 has severe cognitive impairment, not able to recall her location, person, and place. R1 also showed no signs of psychosis including hallucination, delusion, and no negative behavior such as rejection of care and wandering. R1 is dependent on facility staff for ADLs (Activities of Daily Living). R1 also has limited range of motion to upper and lower extremities, with contractures to lower extremities. On September 9, 2025 at 12:15 P.M., R1 was observed in the secured dementia unit' dining room. V7 (CNA/Certified Nurse Assistant) was feeding R1 for lunch. R1 was confused and not able to carry a conversation, and not able to verbalize needs. V7 said that R1 was totally dependent from staff with all aspects of ADLs (Activities of Daily Living). V7 also said that R1 was not able to verbalize her needs and just utter incoherent words. The Electronic Medical Record (EMR) shows R2 is a [AGE] year-old male resident admitted to the facility on [DATE]. R2 has multiple diagnoses including unspecified dementia, bipolar disorder, alcoholic cirrhosis, alcohol abuse with intoxication, hepatic encephalopathy, malignant neoplasm of right kidney, and adjustment disorder. The most recent Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact with BIMS (Brief Interview Mental Status) score of 14/15. R2's temporal orientation shows he can recall correct month and year, able to correctly repeat words with no cues required for the words repetition. The assessment also showed that R2 had no signs of delirium, inattention, disorganized thinking, and no altered level of consciousness. The mood assessment showed R2 was feeling down, depressed, trouble falling asleep, and feeling tired. R2 was assessed with no indicators of psychosis including hallucination, delusion, and misconception of belief. R2 was identified with behavioral symptoms such as exhibited physically pacing, rummaging, public sexual acts, disrobing in public and wandering that occurred 1-3 days in a period of 7 days. R2 has no impairment for upper and lower extremities, is ambulatory, and required only set up, and supervision for ADLs. On September 9, 2025 at 12:35 P.M., R2 was observed in the dining eating his lunch. R2 was aware of his location, his name and reason why he was at the facility. R2 said he was admitted to the facility after a hospitalization due to his kidney and liver condition. However, when surveyor asked regarding his wandering and what was he doing entering other residents' room he replied nothing. On September 9, 2025 at around 2:30 P.M., R2 was again observed. R2 was ambulatory, was found by the entrance of the 700 unit. V10 (CNA/Certified Nurse Assistant) who was supposed to be providing direct supervision to R2, was at the nurse's station, and had her back from R2, with no visual control and V10 was providing hair care to another resident. The facility's incident report dated September 4, 2025 showed an event investigation of sexual abuse dated August 29,2025 at 11:30 A.M. The incident report showed that staff had expressed concern of R2 standing at the head of R1's bed with R2's pants lowered. During the discovery of this situation, R1 was asleep. V4 (Restorative Aide) was the one who discovered this incident. The report showed that V4 asked R2 what he was doing, and that R2 immediately pulled his pants up, turned around and replied nothing. On September 9, 2025 at 12:12 P.M., V4 was asked about the incident. V4 also demonstrated in R1's actual room how she saw R2 in R1's room. V4 started by saying that she went to the designated dementia unit around 11:00 A.M. to take R1's weight. V4 said that she went directly to R1's room, in which the door was closed. V4 said that she opens the door and saw R2 standing next to R1's head of bed. V4 said that from the entrance door, R1's bed was approximately 10 feet away. V4 said that R2's sweatpants were lowered to the knee level, and R2's buttocks were exposed. V4 said that during that time, R1's bed was positioned low, close to floor level, so it was approximately the height of bed was knee level of R2's. V4 added that R1 was lying sideways facing the door and this meant R1 was facing R2. V4 said that she only saw R2 from behind, however, R2 pants was lowered all the way to his knee level and saw his bare buttocks. V4 added that R2's position was standing to the level of R1's head level. V4 further said that since R2 was standing to R1's head level and that R1 was facing R2, it was just few inches that R2's genitals were closed to R1's face. The facility's video surveillance footage was reviewed on September 10, 2025 at 9:29 A.M. for the date August 29,2025 regarding R1 and R2's incident report. V1 (Administrator) and V14 (Human Resources) were present during this review of surveillance footage. The surveillance footage showed the following:-at 10:46:00 A.M., R2, came from the designated dining room in the dementia unit, was ambulatory, no assistive devices.-at 10:46:39 A.M., R2 directly headed to R1's room, passing 3 residents' rooms. R2, opened R1's closed door, entered R1's room, then closed the door. -at 10:54: 03 A.M., V4 entered the designated dementia unit, went directly to R1's room. -at 10:54:20 A.M., R2 was walking out from R1's room, with his sweatpants not totally pulled up since R2's lower abdominal area was still exposed. R2 went directly to his room. The video surveillance footage confirmed that R2 was alone in R1's room for 8 minutes, with door closed. There was also no staff present in the hallway during this period. R2 exited R1's room with his pants still not fully pulled up. Multiple separate interviews held with direct staff V7 and V8, V10, V13, (CNAs), V9 (Nurse), and V15 (Social Service Director) on September 9 and 10, 2025. They say that R2 was known to be a wanderer, going into each residents' rooms, rummaging into residents' closets, and sometimes taking other residents belongings. V7, V8, have said (R2) is sneaky, when he knows no staff was around him, or was not looking, (R1) goes to residents' rooms. They have expressed concerns that this incident may not have been the first of its kind, only the first caught. They all said that R2 can be confused or forgets but knows what he was doing. They also said that (R2) makes sound conversations, knows his family members, was sneaky, look at staff, and when staff was not looking, (R2) goes to other residents' rooms, taking their stuff. We take care of approximately 13 residents per CNA, cannot watch everything, by the time something happened, it was already too late. V15 said that R2 was cognitively intact, reminded of boundaries and understood the reminders but remained wandering around other residents' rooms. V15 confirmed that the secured unit housed 19 residents, 8 female and 11 males, with moderate to severe cognitive impairment. V15 said there was no individualized plan addressing R2's inappropriate wandering behaviors, going to other residents' rooms, going through their closets, and taking their belongings aside from the standards 2-hour monitoring. They all said they do not know when that 1:1 staff supervision started but that it was started few days after the incident with R1 on August 29, 2025. On September 9, 2025, V1 validated that 1:1 supervision for R2 was initiated on September 8, 2025 at 6:00 A.M. This was 10 days later after the sexual incident that occurred on August 29, 2025. V1 also verified that 1:1 monitoring meant that staff had the visual control of R1 during the supervision. On September 9, 2025 at 2:10 P.M., V2 (Director of Nursing) said that staff providing 1:1 monitoring to R1 should have been documenting in a binder what was R1's specific behaviors and what interventions was implemented. Together with V2, the binder that was mentioned cannot be found. As confirmed with V10, CNA/sitter (on September 9, 2025 at 12:35 P.M.) and V13, CNA/sitter (on September 10, 2025 at 10:00 A.M.), they have stated that there was no binder that they were supposed to document, nor they were told what specific behavior and implementation they were supposed to do with R1. They said that we just watch him. R2 was lying in bed with door closed when V13 was watching R2. V13 said the door was closed for privacy. On September 9, 2025 at 3:19 P.M., V3 (Assistant Director of Nursing) stated that R2 was placed on 1: 1 supervision last winter due to an elopement incident. V3 also said that the 1:1 monitoring was discontinued and does not remember when, but R1 was placed on the secured alarmed floor designated as the dementia unit. The care plan that was initiated August 31, 2024, showed R1's wandering behavior, standing by hallways, exit doors and interventions were for elopement. The intervention was revised on September 4, 2025, after the incident of August 29, 2025, which showed a non-specific intervention such as increased rounding should resident's (R2) displays increased wandering behavior. On September 10, 2025 at 1:10 P.M., V16 (R1's family) said that she had received notification from V1 on September 5, 2025, regarding sexual abuse investigation that involved R1 and R2. V16 was dissatisfied why the facility did not notify her timely. V16 also said that facility only called the police 10 days after the alleged sexual abuse, and that possible evidence and securing perimeters for the alleged sexual abuse was already non-existent. On September 10, 2025 at 2:20 P.M., V19 (Clinical Manager for Hospice Care) said that based on R1's medical record for hospice care, the facility had not notified the hospice clinic, the hospice physician, hospice nurse, otherwise a hospice nurse could have visited and evaluated R1 immediately. The hospice record showed that R1 was seen by hospice nurse on August 28, 2025, September 4 and 8, of 2025 and there was no documentation existed regarding the sexual abuse allegation. On September 10,2025 at 2:31 P.M., V18 (Hospice Physician) validated that neither him, nor the alternating physician were not notified regarding the sexual allegation that involved R1. V18 added that if they would have known, they would have sent a hospice nurse immediately to assess, evaluate and provide treatments as indicated. On September 10, 2025 at 2:59 P.M., V22 (R1 and R2's Primary Physician) said that he was not notified of this sexual allegation that occurred and involved R1 and R2. V22 said that if he would have been notified, he would have sent R1 to the hospital for evaluation and determine any trauma, STI (sexually transmitted infections) and should have sent R2 to the psychiatric hospital for psychiatric assessments, evaluations, and treatment. The facility's abuse policy dated October 24,2022 showed that Residents have the right to be free from abuse. Abuse means any physical or mental or sexual assault inflicted upon resident other than by accidental means. sexual abuse in non-consensual contact of any type with a resident. The facility prohibits abuse, neglect, exploitation of its residents including verbal, mental, sexual abuse. The facility presented an abatement plan to remove the immediacy on September 17, 2025 at 3:01 P.M. The surveyor was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. Multiple revisions made by the facility and abatement accepted on September 18, 11:37 A.M. The Immediate Jeopardy that began on August 29,2025 at 10:46 A.M. was removed on September 18, 2025 at 11:37 A.M., when the facility took the following actions to remove the immediacy: 1. Corrective Actions Takena. R2 discharge: R2 (alleged perpetrator) was discharged from the facility on September 15,2025.b. R2's physician notified on September 5, 2025; responsible party notified on September 12, 2025.c. On 9.17.2025, R1 was started on enhanced supervision by nursing staff every 30 minutes for 7 days, then every 2 hours thereafter, documented on Monitoring Log. No signs of abuse noted and R1 is not in any form of emotional, mental, and physical distress. Goal: 30 min checks end on 9.24.2025; 2hr checks begin on September 25, 2025 and will be ongoing.d. Residents on the secured unit will have daily skin checks performed by nursing staff for 4 weeks; checks will be tracked using the Skin Monitoring: Daily Skin Check form; Wound Care and/or Charge Nurse will review sheets daily and report any abnormalities to the appropriate parties. Start date: September 17, 2025; goal: 4 weeks (October 15,2025).e. On September 17, 2025, 8 Female Residents at Risk: Nursing staff started enhanced supervision Q30 mins x 7 days, then Q2H. Safety and wellness check Q2H while awake by Nursing and Social Service Department; Social Services completed assessments for potential abuse, behavior, and trauma on September 17, 2025. Any findings will be reported immediately to the abuse officer and communicated to DON. Goal: ongoingf. 11 Other Residents in Secured Unit: Social Services completed assessments on behavior, potential abuse, and trauma on September 17,2025. Care plans were reviewed and updated as indicated on potential for abuse, behavior, and trauma. Goal: ongoing.g. Social Service completed review and assessments on wanderers on the secured unit. Based on assessment, there were 10 residents identified. Care plans were reviewed and updated on location monitoring and staff supervision. ADON and designee communicated plan of care to staff. On September 17, 2025, a behavior monitoring binder located at the nurses' station that will show residents with behaviors and their plan of care and will be reviewed updated by ADON, Social Service, and or designee weekly. Goal: ongoing.h. On September 17, 2025, Social Service completed review and assessments on residents on the secured unit with sexually inappropriate behaviors. There was a total of 2 residents identified. Upon identification, care plans were updated. Social Service communicated to ADON and designee and was communicated to staff for plan of care. On 9.17.2025, behavior monitoring binder with list of residents with sexually inappropriate behavior and their plan of care was updated and communicated to staff. Review and update will be completed by ADON, Social Service and designee weekly with a start date of September 24, 2025. Goal: ongoing.i. For identified wanderers and residents with sexually inappropriate behaviors, behavior monitoring started Q1H while awake by nursing staff and will be documented on behavior monitoring log. Findings will be escalated to abuse officer and ADON for protocol implementation immediately. Start: September 18, 2025. Goal: ongoing.j. Staff Accountability: V1 suspended September 15 ,2025; in-serviced on September 5, 2025 and September 16, 2025.k. Law Enforcement: Notified September 9 ,2025; investigation initiated.2. Identification of Other Residents at [NAME]. All residents in the facility are considered potentially affected.3. Systemic Measures to Prevent Recurrencea. Resident Interviews, total of 128 participated that were able to participate: Conducted by Social Service on September 17, 2025; Residents feel safe and with no concern on any potential and actual abuse. This will repeat quarterly by Social Service and or designee.b. Daily Huddles with nursing staff and facility IDT (Social Service, Admin, MDS, Therapy, Activity): ADON/Charge Nurse initiated review on new behaviors, interventions, and reports of suspected abuse daily. Behavior monitoring binder at the nurses' station with residents with behaviors including wanderers and sexually inappropriate behaviors with appropriate and updated plan of care. Start date: September 17, 2025; Goal: ongoing.c. Staff Education: Facility-wide training on abuse prevention, trauma-informed care, potential for abuse and neglect observation, sexual abuse policy and behavior management for sexually inappropriate behaviors, immediate reporting chain, and environmental/evidence preservation when abuse has been observed. Training was conducted by ADON, MDS Director and Consultants. Agency staff were included with training. This training began on September 5, 2025 and will be ongoing. Facility staff who didn't receive training will not be allowed to start their shift unless training has been completed including agency staff. ADON, MDS Director, and or Charge nurse were assigned to complete training for new agency staff and for facility staff (all departments) who haven't received the training after work hours. Re-education will be conducted quarterly and as issue on any type of abuse would arise. Goal: ongoing.d. Supervision & Rounding: On September 18, 2025, hourly rounds were started on hallways, common areas, and rooms. Administrator developed an hourly rounding assignment schedule. Facility staff will be assigned every hour and will continue and document on Rounding Sheets; closed doors checked Q30 mins until resident exits room. If resident/s prefer/s their door closed, care plan will be updated and communicated to staff. Any abuse and or behavior observed will be escalated immediately to abuse officer and DON for abuse/behavior management protocol implementation immediately. Goal: ongoing.e. On September 17, 2025: Administrator and Consultants reviewed abuse policy that includes sexual abuse and revised to include:i. Residents will be assessed upon admission for potential for abuse/trauma and behaviors such as wandering and sexual inappropriateness. This will be followed by an assessment quarterly, annually, and as needed.ii. Residents will be screened and assessed by Social Services to identify any inappropriate behaviors. Care plans, interventions, and targeted inappropriate behavior monitoring orders will be added by a nurse as indicated.iii. Any new behaviors, abuse incidents reported will be discussed by the IDT with Administrator, DON, Assistant Director of Nursing and/or consultant daily to coordinate plan of care. DON, Assistant Director of Nursing will communicate any new identified behaviors as well as interventions and orders with staff during daily huddle; staff will also be encouraged to report any new or unusual resident behaviors. Nursing managers will monitor daily for compliance. A reference behavior binder will be kept at the nurses' station that contains identified residents on the secured unit with wandering and/or sexually inappropriate behaviors. Care plans and interventions will be included. ADON, Social Service and designee will maintain, and update binder as needed.iv. The secured unit will continue to conduct hourly rounds on hallways, dining rooms and on areas by assigned facility staff using rounding sheet log. Administrator will update daily and weekly schedules.v. For identified wanderers and with sexually inappropriate behaviors, behavior monitoring will continue Q1H while awake by nursing staff and will be documented on behavior monitoring log. Findings will be escalated to abuse officer and ADON for protocol implementation immediately.vi. QAPI with the QA Committee and Medical Director was held on September 17, 2025 to discuss the plan of removal, revisions to Sexual Abuse policy including environmental observations, visual signs of abuse, and preservation of physical evidence, the Management of Sexual Behaviors, this includes monitoring of behaviors such as sexual comments, sexual gestures, flirtatious behaviors, excessive friendly touching and/or directed infatuation of another resident; implementing interventions such as re-direction, firm limit setting, separation, escorting residents to a more closely supervised area, reality orientation, notification of appropriate responsible party/provider, and to ensure that all corrective actions and safety measures are consistently implemented.vii. Human Resources, and Director of Nursing initiated a staff in-service and will continue to conduct ongoing in-services on Management of Sexual Behaviors, this includes monitoring of behaviors such as sexual comments, sexual gestures, flirtatious behaviors, excessive friendly touching and/or directed infatuation of another resident; implementing interventions such as re-direction, firm limit setting, separation, escorting residents to a more closely supervised area, reality orientation, notification of appropriate responsible party/provider. Staff to include dietary, housekeeping, therapy, nursing, and administrative departments. Any agency staff will be educated prior to the start of their first work shift; education will be provided by the Charge Nurse and/or manager designee.4. Monitoring of Corrective Actionsa. A tool has been created in which the Administrator and/or designee will select 5 random residents weekly x 4 weeks to ensure that residents are free from abuse. Start: September 10, 2025; goal: October 8, 2025.b. A tool has been created in which the DON and/or designee will select 5 random residents on the secured unit weekly x 4 weeks to ensure that residents are monitored for inappropriate sexual behaviors and wandering. Start: September 18, 2025; goal: October 16, 2025.c. A tool has been created in which the Administrator and/or designee will conduct video surveillance review twice a day x 4 weeks to observe for any inappropriate wandering behaviors. Start: September 18, 2025; goal: October 16, 2025.d. Any quality assurance issue/s and progress will be reported to facility's monthly QAPI meeting for three months by the Administrator and recommendations given to assist in ensuring that the facility stay in compliance and if concerns are identified the Quality Assurance Committee will add on additional months until Compliance is sustained.e. Administrator and/or Director of Nursing will complete monthly in-servicing on the facility's sexual abuse policy and sexual behavior management for three months and quarterly thereafter. Start: October 1, 2025.Date of Completion: September 18, 2025

Based on observation, interview, and record review, the facility failed to monitor a resident's skin for breakdown. This failure resulted in a pressure injury not being identified until it was a stage 3, which delayed treatment, and the wound became infected. The facility also failed to implement pressure ulcer care plan interventions. This applies to 1 of 3 residents (R108) reviewed for pressure injury in a sample of 32. The findings include: On 03/18/2025, observations made at 10:18 AM, 11:01 AM, 12:17 PM, 1:04 PM, and 2:35 PM, showed R108 was visible from his doorway and was lying in bed on his back on a regular mattress. R108 appeared frail and lethargic. The sign on R108's door showed he was on contact and droplet isolation precautions. R108's 3/17/2025 antibiotic care plan showed he was on the antibiotic because of a MRSA (multi-drug resistant organism)/Strep A infection in his wound. On 03/19/2025, observations made at 10:02 AM, 10:58 AM, 12:53 PM, and 2:06 PM again showed R108 lying on his back on a regular mattress. R108's 3/12/2025 Weekly Skin Assessment Tool (effective 10:54 PM) showed R108 had no skin concerns and no new skin issues were noted. R108's 3/17/2025 Wound Assessment Detail report showed his sacral pressure ulcer was a facility-acquired stage 3 pressure ulcer, and it had been identified on 3/13/2025 as a stage 3. The report showed the wound presented with 30% white fibrinous slough, and it measured (in centimeters) 1.5 x 0.5 x 0.1 cm (for length x width x depth). The report showed R108's Braden scale showed he was only at mild risk for skin breakdown. On 3/19/2025 at 3:20 PM, V6 LPN (Licensed Practical Nurse, Wound Care Nurse) measured R108's pressure ulcer. The wound measurements showed the size of R108's sacral ulcer had deteriorated to 1.8 x 0.9 with an unknown depth due to slough. On 3/18/2025 at 2:00 PM, V6 (LPN- Wound Care Nurse) was asked why R108 was on a regular mattress and why he had not been turned or why pressure had not been offloaded from his wound site. V6 stated R108 did not have a stage 3 pressure ulcer and instead it was a stage 2 pressure ulcer, and a low air-loss mattress was not required. V6 stated positions should be changed as frequently as possible or at least every two hours, and pressure areas should be offloaded. On 03/21/2025 at 9:28 AM, V15 (Nurse Practitioner- Wound Care) said his expectations of the facility are to implement all preventative measures to prevent acquired pressure injuries. V15 stated he recommended using an air-loss mattress, even if a pressure injury is stage 2, shifting weight as frequently as possible but at least every two hours, and offloading pressure areas to prevent facility-acquired pressure injuries. V15 stated regular skin inspections help to identify skin problems earlier in their development. On 03/18/2025 at 2:30 PM, V21 (Certified Nursing Assistant) said they should reposition residents at least every two hours and offload the pressure. V21 stated he elevated R108's head for the meal but then did not change his positions. On 03/20/2025 at 2:50 PM, V2 (Director of Nursing) said she expects nursing staff to check residents' skin daily and follow the facility's skin prevention process of assessing residents' skin and reporting to nurses. V2 said nurses are responsible to assess and contact the physician and initiating wound care immediately. R108's Face Sheet showed his diagnoses include dementia, anemia, and weight loss. R108's 1/6/2025 MDS (Minimum Data Set) showed R108 was severely cognitively impaired and showed he used pressure-reducing devices in bed and was on a turning/repositioning program. R108's 4/22/2024 care plan from admission showed he was incontinent of both bowel and bladder, and he was unable to use a call light for his needs. R108's 3/16/2025 pressure ulcer care plan showed he had a pressure ulcer development related to immobility. Site: Sacrum. Interventions created on 3/16/2025 on this care plan include to avoid positioning the resident on (SPECIFY location), The resident requires the bed as flat as possible to reduce shear, and The resident requires (SPECIFY: Pressure relieving/reducing device) on (SPECIFY: chair.) R108's care plan also showed a 3/16/2025 intervention of follow the facility policies/protocols for the prevention/treatment of skin breakdown. Section 1 of the facility's policy Wound Prevention and Healing policy (revised 06/01/2024) was titled Risk Assessment and Prevention and included guidance for when the Braden Scale should be completed and why, and when skin inspections should be completed. Sections 2-13 (the rest of the policy) showed guidance for wound treatments and did not provide policy guidance or protocols or information for other interventions for wound Prevention, such as when to place specialty mattresses, repositioning to offload pressure, eliminating moisture, or providing assistance with turning because of resident immobility.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent a resident from acquiring a pressure ulcer. This failure resulted in R2 developing a stage 2 pressure ulcer on the left ischium. This applies to 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 6. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including acute cystitis, acute respiratory failure, sepsis, bacteremia, heart failure, and acute kidney failure. R2's MDS (Minimum Data Set) dated December 27, 2024, showed R2 has moderate cognitive impairment. The MDS continued to show R2 required maximal assistance from facility staff for rolling left to right in bed and was dependent on facility staff for toileting hygiene. R2's skin care plan dated December 24, 2024, showed [R2] has potential impairment to skin integrity related to fragile skin, limited mobility, morbid obesity. The care plan continued to show multiple interventions dated December 24, 2024, including Assist with turning and repositioning frequently and as tolerated/needed. Keep skin clean and [NAME]. Use lotion on dry skin. R2's ADLs (Activities of Daily Living) care plan dated December 24, 2024, showed [R2] has an ADL self-care performance deficit related to activity intolerance, fatigue, limited mobility, weakness, low activity tolerance related to acute cystitis, atrial fibrillation, congestive heart failure, and morbid obesity. The care plan continued to show multiple interventions dated December 24, 2024, including Resident will be turned regularly while in bed. The care plan showed an intervention dated December 26, 2024, including Bed mobility: [R2] is totally dependent/extensive assistance on two staff for repositioning and turning in bed every routine round and as necessary. Low air loss mattress in use. R2's Nursing Admission/Re Admission Evaluation dated December 23, 2024, showed R2's Braden Scale for Predicting Pressure Risk was a 10, indicating R2 was at high risk for developing a pressure ulcer. The facility's Wound Report dated February 10, 2025, showed R2 had a facility acquired stage to pressure ulcer on the left ischium. On February 10, 2025, at 10:00 AM, R2 was lying in bed, with the head of the bed elevated. R2's call light was activated. R2 said he activated his call light at 8:30 AM, and it was now 10:00 AM, and R2 was waiting for his soiled incontinence brief to be changed. R2 said on February 1, 2025, R2 waited three hours for his soiled incontinence brief to be changed. R2 continued to say on multiple evenings, R2 has had to wait over three hours for his soiled incontinence brief to be changed. On February 10, 2025, at 10:23 AM, V8 (RN/Registered Nurse) said she provided incontinence care to R2 with the assistance of V9 (CNA/Certified Nursing Assistant). V8 said R2 had stool in his incontinence brief. On February 10, 2025, at 10:25 AM, V9 said the last time she checked on R2 was when she delivered his breakfast tray before 8:30 AM. On February 10, 2025, at 1:39 PM, R2 said when he had his call light on earlier, he was waiting for his soiled incontinence brief to be changed. R2 said he waited until after breakfast to activate his call light to be changed. R2 said he had been sitting in stool from when he turned his call light on at 8:30 AM, until the staff came in to change him around 10:15 AM. R2 continued to say the only time R2 gets out of bed is when physical therapy is working with him for 30 minutes five times a week. On February 10, 2025, at 4:34 PM, R2 was lying in bed. R2 said facility staff do not turn him side to side, the only repositioning the facility does for R2 is pulling him up in bed. R2 said after staff pull him up in bed, staff leave R2 lying on his back with the head of his bead elevated. On February 11, 2025, at 9:23 AM, R2 was lying in bed. R2 was positioned on his back with his head of the bed elevated. R2 said he had not been turned to either side by facility staff overnight. On February 11, 2025, at 9:31 AM, V10 (CNA) said R2 does not get out of bed unless R2 is working with physical therapy. V10 said she does not get R2 out of bed. On February 11, 2025, at 9:33 AM, V8 said R2 only gets out of bed when he is working with physical therapy. On February 11, 2025, at 9:58 AM, V11 (Physical Therapy Assistant) said R2 gets five days of physical therapy a week. V11 said he works regularly with R2. V11 said every time V11 works with R2 for physical therapy, R2 is lying in the bed and V11 gets R2 out of bed, then returns R2 to bed at the end of the session. On February 11, 2025, at 10:12 AM, V12 (Director of Rehab) said R2 receives physical therapy five times a week, Monday through Friday. V12 said she assisted with R2's physical therapy. V12 said when R2 is provided physical therapy, R2 is in bed and then returned to bed at the end of therapy. V12 said facility staff can safely sit R2 at the edge of the bed. Continuous observations were done on February 11, 2025, from 10:36 AM, to 12:29 PM, R2 was not repositioned or turned during that time. R2 remained in bed, on his back, with the head of the bed elevated. Intermittent observations were done on February 11, 2025, from 9:23 AM, to 11:58 AM. On February 11, 2025, at 11:56 AM, R2 said no facility staff had turned or repositioned him in bed. On February 11, 2025, at 1:42 PM, V10 said routine checks on residents are every two hours to see if they need their incontinence brief changed. V10 said she repositions R2 when she changes his incontinence brief. V10 said she will move him side to side in bed while changing him and then returns him to his back when completed. V10 said she had changed R2's incontinence brief one time since 7:00 AM, and that was the only time she repositioned R2 in bed. R2's Documentation Survey Report dated February 11, 2025, for the period of December 24, 2024, to February 10, 2025, showed R2 was not repositioned in bed every shift as needed. The facility does not have documentation to show R2 was repositioned and/or turned in bed frequently or with routine checks. On February 10, 2025, at 4:15 PM, V6 (Wound Nurse Practitioner) said V6 assessed and evaluated R2 on February 6, 2025, for a new stage 2 pressure ulcer of the left ischium. V6 said he reviewed the etiology of R2's wound and R2 had been sitting in bed for quite a while. V6 said R2's prolonged sitting is what caused the ulceration. V6 said the ischium is also called the sit bone. V6 said prolonged exposure to stool could also be a contributing factor to R2 developing a pressure ulcer. V6 said his expectation is for facility staff to assist R2 with turning in bed and offloading R2's wound. V6 said proper repositioning of R2 could have prevented R2 from developing a pressure ulcer. V6 continued to say if facility staff followed preventative measures, it should prevent a wound from developing. V6 said he documented in his progress note for R2 to avoid direct pressure to the wound site. V6 continued to say V6's expectation is for facility staff to off-load R2's wound by turning in bed. A wound care note dated February 6, 2025, by V6 showed Wound Assessments: Wound number one, left ischial is a stage 2 pressure injury pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 8.5 cm (centimeters) length by 7.5 cm width by 0.1 cm depth, with an area of 63.75 sq cm (square centimeter) and a volume of 6.375 cubic cm . Additional Orders: . Off-Loading: Facility Injury Prevention Protocol; Wheelchair Pressure Redistribution Cushion per Facility Protocol; Avoid direct pressure to wound site . The facility's policy titled Policy: Wound Prevention and Healing dated June 1, 2024, showed Policy Statement: To provide wound care treatments/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician. 1. Risk Assessment and Prevention: a. Braden Scale will be completed upon admission, readmission, quarterly, and when there is a change in condition by a licensed or registered professional nurse. b. 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 policy titled Policy: Supportive Activities of Daily Living (ADL) dated November 7, 2024, showed Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: . b. Mobility (turning, re-positioning, transfers and ambulation, including walking); c. Elimination (toileting) .

Based on interview and record review, the facility failed to successfully notify the physician of a significant change in condition in a timely manner and failed to notify administration when the physician's answering service did not respond. As a result of this failure, there was a delay in obtaining treatment and pain relief for R1 for 2 days after swelling and pain was noted. R1's radiology revealed a supracondylar fracture with anterior angulation of the fracture site and a supracondylar fracture of the distal femur with anterior angulation at the fracture site. This applies to 1 of 3 residents (R1) reviewed for pain and injuries of unknown origin. The findings include: The EMR (Electronic Medical Record) shows R1, was a [AGE] year-old, admitted to the facility on [DATE]. The EMR also shows R1's diagnosis that included heart failure, other disorders of psychological development, cardiomyopathy, restlessness and agitation, encounter for palliative care, underweight, personal history of Covid-19, osteoarthritis, fracture right femur (5/10/2024), and mild protein calorie malnutrition. The most recent MDS (Minimum Data Set) dated 12/15/2023 showed R1's ADL's (Activities of Daily Living) regarding functional level. The MDS showed that R1 required extensive assistance for bed mobility, transfer, dressing and toileting. R1 was also assessed as severely impaired with decision making. The nurses' notes dated 5/9/2024 at 3:40 A.M. showed that R1 was noted yelling and was guarding her right leg. The documentation also showed that V3(Registered Nurse/RN) had called V18 (R1's Attending Physician) for 4 times regarding R1's pain but there was no response from V18. On 5/29/2024 at 7:30 P.M., V4 (Certified Nurse Assistant/CNA) said that on 5/9/2024 at around 3:30 A.M., R1 was yelling I am wet!!. V4 said she assisted R1 out of bed, transferred to wheelchair and to the toilet seat. V4 added that she then assisted R1 back to the wheelchair nearby the toilet seat using a pivot transfer. V4 added that she then propelled R1 next to the bed. V4 added that immediately after she propelled R1 next to bed, R1 complained of pain and saying non-stop my leg, my leg, it hurts. V4 said it was unusual of (R1), so I informed (V3 Registered Nurse) immediately. On 5/29/2024 at 8:30 A.M., V3 (RN) stated said that she placed a call to V18's (Attending Physician) answering service when R1 had a significant change regarding the pain to the right leg and that it needed medical attention. V3 also added that she had not received a return call from V18 nor any on call physician. V18 said she did not call administration for further directives when V18 had not returned the call. On 5/30/2024 at 1:00 P.M., V12 (Licensed Practical Nurse) said she took care of R1 the evening of 5/8/2024. V12 said that R1 was at her baseline, no complaints of pain, or swelling of the right leg, no bruises to the leg and left arm. On 5/28/2024 at 9:25 P.M. V6 (CNA) said that she took care of R1 on 5/8/2024 during the dinner time. V6 said that R1 did not complained of right leg pain, no swelling on the right leg, no bruise to the left arm, no skin tear to the left arm. V6 added that on 5/9/2024 around 8:00 A.M., she heard R1 yelling of right leg pain. V6 said she saw R1's right leg that was swollen from right mid-thigh through the mid leg area. V6 also noted a reddish-purplish discoloration of the right leg, and on R1's left arm that had extended from the armpit through the elbow. V6 also said that she called V13 (Licensed Practical Nurse/LPN/Wound Treatment Nurse) to have a look at R1 on 5/9/2024 around 8:00 A.M. V6 added that she saw R1 again on 5/10/2024 around 8:00 A.M. and at this time, R1 was sitting in her wheelchair in her room. V6 said that R1 was still yelling of right leg pain. V6 said she again told V13, and both informed V9 (Registered Nurse). On 5/28/2024 at 1:16 P.M., V13 said that on 5/9/2024 at around 8:00 A.M., V6 called her because R1 was having any pain of the right leg. V6 said that together with V6, they both went to see R1. At that time, R1 was in her room. R1 was sitting in her wheelchair. V13 said that R1 continuously yelling my leg my leg. V13 said she saw R1's right leg that was swollen and described it double the size of the left leg. V13 also said that the swollen area was from mid-thigh down to mid lower leg. V13 also said that the swollen right leg was discolored, bruised with reddish purplish discoloration. On 5/28/2024 at 1:40 P.M., V9 said had not report from the outgoing nurse regarding R1's swollen right leg/pain and bruises. V9 said it was V6 and V13 that had informed her regarding R1. V9 then immediately informed V2 (Director of Nursing), V17 (Physician Assistant of V18) regarding R1's injury. V9 said that R1's face sheet/profile sheet was up to date with contact number of providers including V17 and V18. V9 added that when she called V17 at 8:29 A.M. on 5/10/2024, V9 had responded at once. The incident report dated 5/10/2024 at 3:55 P.M. showed that incident report made regarding R1's swollen bruised knee. The incident also showed that it was only on 5/10/2024 that the following were notified: -R1's POA (Power of Attorney) was notified at 10:46 A.M. -V2 (Director of Nursing) at 8:29 A.M. -V17 (V18's Physician Assistant) at 8:29 A.M. The x-ray of the knee was done on 5/10/2024 with result as follows: -right knee: supracondylar fracture with anterior angulation of the fracture site -right femur: supracondylar fracture of the distal femur with anterior angulation at the fracture site. On 5/28/2024 at 2:50 P.M., V17 (Physician Assistant) said that the facility should have known that I am always available by 7:00 A.M., either they call or text me a message I always available. However, I have not received notification from the facility not until 5/10/2024 from (V9). This was my first time to hear that they called answering service and no one had called back. If the answering service did not call back, they know better to call or message me at 7:00 A.M. on 5/9/2024 since I am always available. On 5/28/2024 at 4:50 P.M., V18 (R1's Attending Physician) said that this was the first time I heard that the facility had called the answering service, and no one had called back. I will find out what happened. This was a definite change in medical condition and facility should have called us on 5/9/2024. Maybe they made a mistake with phone numbers. This obviously had caused a delay of treatment such as x-ray and pain management. The facility's policy entitled Resident Change in Condition Notification dated 2/18/2021 shows: Policy Statement: Our facility will ensure and provide appropriate services and treatment to help residents .to extend possible. 1. The nurse will notify the resident's physician, on call, or NP when there has been a significant occurrence, accident, or incident involving a resident's physical, medical and mental condition .7. If a significant change in the resident's physical, medical or mental condition occurs, a comprehensive assessment of the resident's condition will be required.

Based on observation, interview, and record review, the facility failed to assess and provide pain medication for a resident who is in pain. In addition, the facility failed to reassess if the pain medication that was provided was effective. This failure resulted to R97 and R98 to experience severe pain and resulted in R97's inability to complete activities during her physical therapy session. This applies to 2 of 3 (R97 and R98) reviewed for pain management in a sample of 29. The findings include: 1. Face sheet showed that R97 has multiple medical diagnoses which include radiculopathy in the lumbar region, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Minimum Data Set (MDS) dated [DATE] shows that R97 is alert and oriented. R97's active Physician Order Summary shows that she was prescribed Gabapentin Capsule 600 mg (milligrams) twice daily and at bedtime for neuropathy, Hydromorphone HCL (Dilaudid) 4 mg tablet every 6 hours as needed for pain, and Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium Topical). Apply to tailbone topically three times a day for pain. On 2/5/24 at 1:25 PM, R97 stated that she takes her Dilaudid as a prn (as needed) medication every day at least once or twice a day and at the most 3 times day for pain. On 1/23/24 after she was given a dose of Dilaudid in the afternoon, she was informed that she ran out of Dilaudid, and the staff would re-order. The next day on 1/24/24, prior to physical therapy session, R97 requested for her Dilaudid. V24 (Nurse) informed her that her Dilaudid remained unavailable. V24 gave her the regular Gabapentin dose for her neuropathy, Voltaren topical gel for the tailbone and Tylenol which did nothing to her pain. Despite having pain on her left foot and tailbone, R97 still attended physical therapy because she didn't want to miss a session. V23 (Physical Therapist/PT) assisted her to ride the elliptical bike. She was only on the bike for three minutes when she felt the pain getting worse, she was bawling in pain. The pain was on her left foot, left leg, and tail bone. It was a 10 out 10 of shooting and sharp pain. R97 was unable to perform the elliptical bike further because of the severe pain. R97 did not have the Dilaudid for 33 hours. R97 asked for it every shift but was told it was not available. R97 instructed the staff that she wanted her Dilaudid to be given to her as soon as it was delivered. On 2/6/24 at 3:25 PM, V14 (Registered Pharmacist) stated that the facility staff placed a refill order for R97's Dilaudid on 1/24/24 at 2:25 PM. It was delivered to the facility on [DATE] at 9:15 PM. In the bingo card medication container, there is a recommended indication of when the staff should call for medication refill. It shows that when they see that there were only 5 tablets remaining, they should re-order and/or depending upon how often the resident takes the medication that the staff should call for refill. On 2/07/24 at 9:58 AM, V49 (Registered Pharmacist) stated that the pharmacy delivered medications twice daily in the morning and evening. The staff should order for refill when it is close to running out. But with regards to R97's need for Hydromorphone (Dilaudid) the staff could have gotten it from the electronic medication-controlled box while waiting for the pharmacy delivery. On 2/7/24 at 10:09 AM, V23 (Physical Therapist/PT) stated that on 1/24/24, R97 may have been tearful. V23 recalled that R97 was having severe pain severe pain on her foot. Typically, R97's tailbone hurts. V23 usually calls R97 in the morning to tell her what time V23 will pick her up, by then R97 had already taken her pain medication. Normally R97 doesn't really have pain aside from her chronic tailbone pain, but at that time R97 was complaining of pain in her left foot. R97 reported that she was waiting for the pain medication because it wasn't given to her yet, but she did not want to miss a session of the PT. R97 was very cooperative with therapy sessions and there was progress in her. R97 always finished her therapy, but that day, R97 could not complete the recumbent bike because she was hurting a lot and she couldn't walk. V23 knew that the pain medication (Dilaudid) was not available because R97 told her. On 2/7/24 at 10:32 AM, V25 (Nurse Practitioner/NP) stated that R97 has chronic pain on top of multiple medical co-morbidities. R97's Dilaudid should be given for severe pain as ordered. V25 offered to order the Dilaudid as a regular dose with increased frequency, however, R97 refused, stating that she wanted to take it only as she needed. R97 has chronic pain, Dilaudid only works for 3-4 hours, it works during PT. V25 added that she expects that the medication will be available to R97 whenever she requested it for pain. On 2/7/24 at 11:03 AM, V26 (Physician) stated that R97 has chronic pain. R97 is on a regimen of oral Dilaudid and Gabapentin to help manage her pain. If she requested the Dilaudid, it should be given as ordered. On 2/7/24 at 10:24 AM, V24 (Nurse), stated that she believed that R97's pain medication (Dilaudid) was not available at that time. On 2/7/24 at 11:29 AM, V24 also said that part of the pain assessment was to do a pain scale from 0-10, with 10 being the most painful. Obtain a physician order for the pain parameters for effective pain management. If the resident has a prn order, the medication would be given as ordered. The nurses also do post assessment of pain in about half an hour. If the resident is still having pain, then the nurse calls the doctor. The Dilaudid was not available on 1/24/24 and V24 placed the order that day. V24 recalled that R97 was upset because the Dilaudid was not available but when V24 informed R97 that she already ordered, R97 became satisfied. V24 did not check the electronic controlled box to see if the Dilaudid was available, she added that she should have gone to the electronic controlled medication box to get the Dilaudid. On 2/7/24 at 10:00 AM, surveyor and V49 (Registered Pharmacist) checked the electronic medication-controlled box which was located on the first-floor medication room. It showed available 6 tablets of Dilaudid 2 mg. V49 presented a copy of the Electronic Controlled Medication Box's Item Transaction Log dated 1/1/24 through 2/7/24 showed that there was a total of 8 tablets of Hydromorphone 2 milligrams in the electronic medication controlled box in the facility. R97's Controlled Drug Receipt/Record/Disposition form which was dispensed on 1/5/24 shows that R97 took this medication 2-3 times a day. The last dose was given on 1/23/24 at 12:30 PM. R97's Controlled Drug Receipt/Record/Disposition form which was dispensed on 1/24/24 shows that R97 was given Dilaudid 4 mg on 1/25/24 at 2:30 AM. The above Controlled Drug Receipt/Record/Disposition forms showed that R97 did not received the Dilaudid for 38 hours. Physical Therapy Notes dated 1/24/24 showed: R97 performed bilateral lower extremity (BLE) exercise to Nu-Step for 5 minutes level 1 to facilitate increase strength to BLE to increase independence with mobility. R97 actively participates with skilled intervention. R97 complaint of nerve pain in the left foot. There was no redness or irritation to the skin. R97 declined ambulation (gait training) due to foot pain. R97 states that the nurse was aware and is waiting for the medication to arrive to facility. Nurse was present at the end of the session, stating that she would discuss it with R97. In addition, the PT notes for 1/19/24 and 1/25/24 shows that R97 was able to perform gait training (On these days, R97 received Dilaudid according from the MAR). R97's active care plan with target date of 3/11/24 shows: Focus: R97 has generalized body aches and pain related to status post Perforated Colon with Ileostomy placement and Crohn's disease. Goal: R97 will not have an interruption in normal activities due to pain through the review date. Interventions: - Administer analgesia medication as per orders. Give 1/2 hour before treatments or care. Hydromorphone HCl Oral Tablet 2 MG (Hydromorphone HCl), Gabapentin, Acetaminophen - Anticipate the R97's need for pain relief and respond immediately to any complaint of pain. - Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. - Identify, record, and treat R97's existing conditions which may increase pain and or discomfort related to stroke. - Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. - Monitor/record/report to Nurse any sign and symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). - Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. -Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or c/o pain or discomfort. There was no documented comprehensive pain assessment done by V24 (Nurse) in the progress notes on 1/24/24 and no documentation of Tylenol in the MAR (Medication Administration Record) which indicate that it was being given. There was no re-assessment of the efficacy of Tylenol. 35267 2. Nurse practitioner note, dated 1/31/24, shows R98's diagnoses included a history of wrist tenosynovitis status post right wrist arthrotomy and washout completed with antibiotics. POS (Physician Order Sheet), printed 2/7/24, shows R98 was admitted to the facility on [DATE]. The POS shows R98's diagnoses included synovitis and tenosynovitis right hand, spondylosis without myelopathy or radiculopathy thoracic region, peripheral vascular disease, and angina pectoris. The POS shows R98 had a physician order (dated 1/22/24) for Norco 10-325 mg (milligrams) 1 tablet by mouth every 6 hours as needed for pain. The POS also shows R98 had a physician order (dated 1/22/24) for Norco 10-325 mg 2 tablets by mouth every 6 hours as needed for pain. Neither physician order for Norco included parameters to indicate when the medications should be given. Pain Assessment, signed 1/22/24, shows R98 had a pain frequency he described as almost constantly, that frequently interfered with day-to-day activities, that occasionally had effect on his sleep, and almost constantly interfered with his therapy activities. R98 described his worst pain in the prior five days as a 0 out of 10 with zero being no pain and ten being the worst pain he could imagine. R98 stated his most recent pain was a 9 out of 10. MDS (Minimum Data Set), dated 12/10/23, shows R98's cognitive status was intact. On 2/5/24 at 11:18 AM, R98 was rubbing his right wrist and stated, It has been rough. R98 stated his right hand/wrist was in much pain. R98 stated he was receiving his prescribed pain medications, but they were not relieving the pain in his right hand. R98 described his current right wrist pain as 8 on a scale of 10 with 10 being excruciating pain. R98 stated he received his medication earlier that morning, but the nurse had not returned to ask if the medication was effective. R98 stated after receiving his prescribed pain medication, the pain in his right wrist was only reduced to a 7 or 8 on a scale of 10. R98 stated his pain was never relieved to a 0 out of 10. R98 stated he would consider his right wrist pain as relieved if his pain level was reduced to a 3 or 4 out of 10. R98 stated while he was in the hospital, he was receiving the same dose of his Norco every 4 hours which was better relieving his pain. R98 stated he was currently receiving his Norco every 6 hours and his pain was much better relieved. R98 stated he had not yet seen a physician or nurse practitioner/physician assistant since he had been admitted to the facility. R98 stated he had asked his nurse to change his Norco dose to every four hours, but was told, When the doctor comes, we will ask. R98 stated his physician or physician representative was supposed to see him once a week, but R98 had not yet seen one of them since he was admitted . R98 stated he had been very uncomfortable due to his right wrist pain. On 2/5/24 at 11:52 AM in R98's room with R98, V44 (Registered Nurse) stated R98 will really ask for 2 [pain pills] - he says it helps. He says zero. R98 stated she gave R98 his pain medication that morning prior to 9:00 AM but had not yet asked him if it was effective because she had been busy. R98 responded to V44 and told her his pain was never reduced to a 0 out of 10 and asked V44 to ask his physician if he could change his scheduled pain medication to every four hours instead of every 6 hours as it was scheduled in the hospital. V44 responded she would call R98's physician to request the pain medication change. MAR (Medication Administration Record), dated 2/1/24 to 2/29/24, shows R98's pain medication included Norco oral tablet 10-325 mg (milligrams) 2 tablets every six hours as needed which was ordered 1/22/24. The MAR shows no numerical measurement of pain effectiveness after the administration of R98's pain medication and each administration was responded to as E for effective. The MAR shows R98 received the Norco 2 tablets on: 2/1/24 at 11:58 AM for a pain level of 9 and marked E with no numerical measurement of pain. 2/2/24 at 9:38 AM for a pain level of 9 and marked E with no numerical measurement of pain. 2/2/24 at 6:14 AM for a pain level of 10 and marked E with no numerical measurement of pain. 2/3/24 at 10:28 AM for a pain level of 8 and marked E with no numerical measurement of pain. 2/3/24 at 7:40 PM for a pain level of 7 and marked E with no numerical measurement of pain. 2/4/24 at 8:26 AM for a pain level of 8 and marked E with no numerical measurement of pain. 2/5/24 at 9:43 AM for a pain level of 8 and marked E with no numerical measurement of pain. MAR, dated 2/1/2024-2/29/24, shows a physician order (dated 1/22/24) for Pain assessment every shift every shift for pain. The MAR shows R98 was recorded to have a pain level of zero every shift from 2/1/2024 to 2/5/2024 except for second shift 2/2/24 (2 out of 10) and 2/5/24 (7 out of 10). On 2/06/24 at 3:20 PM, V2 (Director of Nursing) stated it was her expectation that nurses reassessed a resident 15-30 minutes after the administration of pain medication is provided to see if the pain medication was effective. V2 reviewed R98's MAR and pain administration showing R98 described his pain at levels 7-10 and stated R98 was not receiving effective pain management. On 2/07/24 at 12:29 PM, V43 (Physician) stated he did not recall facility nursing reporting any of R98's pain level numbers to him. V43 stated he had a history of difficulty managing R98's pain and previously worked with non-narcotics such as gabapentin to avoid blood pressure complications for R98. V43 stated R98 lived in chronic pain and during R98's recent hospitalization , R98's pain management was front and center. V43 stated if the facility had called him to report R98's pain was not effectively relieved, he would have ordered alternative pain management treatments to relieve R98 of pain if his current regime was not effective. V43 stated, I don't want people to be in pain. Pain care plan provided by V1 (Administrator) on 2/8/24 and revised on 1/26/24, shows R98 had generalized body aches and pain related to depression and diabetic neuropathy. The care plan fails to show R98 has pain associated with is right hand. Interventions include Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. The interventions fail to show nursing was to reassess R98 for the effectiveness of his pain medication after administration. Facility Pain Management policy/procedure, reviewed 12/17/23, shows, The facility will provide adequate pain assessment and management so that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being 1. Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status (e.g., after a fall, with change in behavior or mental status). 2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: .e. Bracing, guarding or rubbing 3. Assessment and evaluation by the appropriate members of the interdisciplinary team may include: a. Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident c. Identifying key characteristics of the pain (Examples: Duration, Frequency, Location, Onset, Pattern, and Radiation) d. Obtaining descriptors of the pain (Examples: Aching, Burning, Throbbing, Tingling, Stabbing), e. Determining factors that make the pain better or worse, f. Identifying recent exacerbations of chronic pain, g. Impact of pain on quality of life j. The resident's goals for pain management and his/her satisfaction with the current level of pain control. k. The effectiveness of specific drugs and other treatments used in the past to treat pain. 4. IF the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified. 5. The interdisciplinary team and the resident collaborate to arrive at pertinent, realistic, and measurable goals for treatment 9. The interdisciplinary team is responsible for developing a pain management regimen 11. Reassess patients with pain regularly based on the facility's established intervals. 12. If when re-evaluated, findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated.

Based on observation, interview and record review the facility failed to monitor, identify, and provide specific care interventions for pressure ulcer prevention and treatment for two (R1 and R2) of three residents reviewed for pressure ulcers from a sample of 11. This failure resulted in R1's developing a new pressure ulcer categorized at an advance stage 3 pressure ulcer. The findings include: 1. R1 is a [AGE] year-old resident with multiple diagnosis including hemiplegia and hemiparesis due to cerebral infarction, affecting left dominant side, perforation of intestine, encounter for surgical aftercare following surgery on the digestive system; cutaneous abscess of abdominal wall, generalized muscle weakness, lack of coordination, Crohn's disease, Candida sepsis, depression, bipolar disorder, and positive for Covid-19. R1 was admitted to the facility on [DATE]. The admission nursing assessment dated [DATE] showed that R1 was admitted with no pressure ulcers. The most recent comprehensive MDS (Minimum Data Set) dated 6/25/2023 showed that R1 was alert and oriented, was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. The functional status showed that R1 required extensive assistance from 1-2 staff with regards to bed mobility, transfers, dressing, toilet use, hygiene, and bathing. The MDS also showed that R1 had no negative behavior such as rejection of care. The assessment also showed that R1 was a high risk for pressure ulcer developing. The medical provider notes dated 9/22 and 9/18/2023 showed that R1 was calm, cooperative and was compliant with care. The care plan dated 9/22/2023 showed that R1 requires total assistance from staff for bed mobility, transfer, hygiene, and incontinence care. The intervention was for R1 be assisted for ADL, be kept clean and dry and to check every 2 hours. The care plan showed no specific interventions to prevent R1 from developing pressure ulcer paying attention to heels and ankle areas since R1 had a foot drop to the left foot. On 9/23/2023 at 11:45 A.M., together with V6 (CNA/Certified Nurse Assistant) and V5 (Registered Nurse), R1 was checked in her room. Upon entering R1's room, R1 was observed lying in bed in supine position. R1 was alert and oriented. R1 was calm and compliant when asked for skin and incontinence check. V6 removed R1's blanket. R1's lower extremities were exposed. It was observed that R1's left leg was contracted and was on a fixed positioned and had leaned on an outward rotation. R1 also was noted with a left foot drop. The left foot was also had leaned towards an outward rotation making the ankle bone rubbed against the bed surface with no off-loading from pressure. There were 3 spots of brownish drainage on the bed sheet near R1's left foot. The brownish drainage was approximately the size of a golf ball. There was also a serous drainage noted coming out from the pressure ulcer of R1's left malleolus area (left ankle). The pressure ulcer was exposed and noted with approximate 0.5 cm. in depth. There was a whitish material seen inside the wound cavity. There was no dressing that cover the pressure ulcer. The exposed pressure ulcer wound with no cover was rubbing against bed surface and was not off loaded from pressure. R1 said that on 9/13/2023, she asked the therapist to have a look at her left foot since no staff had been checking her skin. R1 said she uses a boot during therapy. R1 also said she was worried since she does not feel any sensation to her lower extremities due to her medical condition. R1 added that once the therapist had checked my left foot, it was discovered that there was a big pressure ulcer on the left ankle. If they (staff) were checking my skin, then they would have seen it before it got to that size. No one checks it, and I am rarely repositioned, I just lay down here. I wait for the staff for at least 10 minutes to 3 hours to be turn and my diaper change. My diaper was not changed since early morning, nor I was repositioned. V5 (Registered Nurse) was present during this observation. V5 said that R1's pressure ulcer wound dressing should be always in placed to prevent infection. V5 also said that R1 had an order to replace the wound dressing if needed such as if it was soiled or was not intact. The POS (Physician Order Sheet) for the month of September 2023 showed a physician order dated 9/14/2023 for pressure ulcer wound dressing to the left ankle that included cleansing the wound with a normal saline solution, (Brand name) Gel, Calcium Alginate, top with a foam dressing. The wound dressing was to be done every three days and as needed. The POS also showed an order dated 9/14/2023 to off load heels for pressure relief. This order for offloading was after the fact that R1 had already acquired the pressure ulcer to the left ankle. The pressure ulcer of R1's left ankle assessment showed as follows: -9/13/2023 showed that R1 was identified with a stage 3 pressure ulcer to the left ankle. The measurement was 1.0 cm. x 1.50 cm x 0.10 cm (Length x width x depth). -9/21/2023: wound measurement was 2.00 cm. x 1.50 cm., 0.20 cm. -9/24/2023: wound measurement was 2.0 cm. x 1.50 cm. x 0.20 cm. On 9/24/2023 at 12:51 P.M., V4 (Wound Treatment Nurse) said that R1 had acquired a stage 3 pressure ulcer to the left ankle on 9/13/2023. V4 added that the facility's policy and practice was to check each resident's skin during provision of care such as providing incontinence care, turning, and repositioning, shower, or bathing. V4 added that if staff had been checking R1's skin, then the stage 3 would have been identified sooner and at a lower stage such as stage I, an intact skin with a persistent non-blanchable redness. A stage 3 was advance pressure ulcer, and it was a stage already a stage 3 when it was identified. It will not jump to stage 3 without starting from stage I, this should had been identified sooner if skin check was done during provision of care. This is our facility's practice and policy to check skin during provision of care such as hygiene, bathing, and incontinence care. V4 also added that R1 was a high risk for developing pressure ulcer. V4 added that intervention was to turn and reposition every 2 hours, keep clean and dry. V4 said that there were no specific interventions related to prevention of pressure ulcer on the ankles especially the left ankle where the left leg was contracted and paralyzed. V4 added that she did investigated/assessed the left ankle on 9/13/2023 when the nurse that was assigned to R1 reported to her that the therapist had identified a pressure ulcer to the left ankle. V4 said it was a stage 3 pressure ulcer of the left malleolus (ankle) that it was undermined when it had started. On 9/24/2023 at 2:45 P.M., together with V2 (Director of Nursing), R1's EMR (Electronic Medical Record) was reviewed. V2 had stated that R1's Braden Scale dated 6/14/2023 was not accurate. V2 said that R1 was a high risk for developing pressure ulcer and if the Braden Scale was correctly done, then specific plan would have been triggered in R1's care plan. The care plan was also reviewed. V2 said there were no plan of care specific for pressure ulcer prevention and paying details to R1's lower extremities with left leg being paralyzed and a foot drop. On 9/25/2023 at 3:01 P.M., V3 (Wound Care Physician) stated that he saw R1 for the initial evaluation on 9/20/2023. Together with V3, the wound documentation entered by him dated 9/20/2023 was reviewed with him during the interview. V3 said that he made a wrong entry of incorrect information that R1 had a pressure ulcer upon admission. V3 also verified that his documentation regarding unavoidable wounds were the surgical abdominal wounds due to perforation. V3 added that R1 was a high risk of developing pressure ulcer especially to the left lower extremity due to contracture, foot drop, and paralysis. V3 added that that (R1's) stage 3 pressure ulcer to the left heel was preventable. V3 added that if there were specific interventions that were put in place such as off-loading from pressure in bed or when up with a walking boot, this could have been prevented. V3 also added that nutritional interventions should have been included as preventative measure. V3 said that I do not know why it was already a stage 3 when it was identified. If skin was monitored, there should have been signs of stage I, a lower stage and not a stage 3. There must be an existing sign such as redness, discoloration, painful to touch prior to becoming a stage 3 pressure ulcer. It was an overwhelming scenario when I went to see (R1) on 9/20/2023. The nurses and nursing assistants were overloaded with work, so I am not sure how residents' care such as offloading measure, repositioning timely were being done in a manner to prevent pressure ulcer. They were like working 50% work force as observed. I guess nobody wants to work because the facility was under special circumstances because of Covid outbreak. V3 said that he had debrided R1's pressure ulcer on 9/20/2023 and had removed 0.90 % of nonviable material of slough/fibrin quality/dead tissue. Surveyor asked V3 what the possible whitish material was seen as observed on 9/23/2023 if in fact it was debrided 90% of the non-viable tissues. V3 said that was why I want the x-ray result if it was osteomyelitis related to bone infection so (R1) can be given correct treatment such as antibiotics as soon as possible. I will call them now (facility) to follow up with the x-ray result, this was ordered since 9/20/2023, I do not want any problem that might happened such as sepsis. V3 said if only specific interventions including off-loading, skin monitoring, nutritional approach were in place, then this stage 3 pressure ulcer could have been prevented. I will revise my documentation to correct the wrong information. The nutritional notes dated 9/19/2023 showed that it was only after the fact that R1 had developed stage 3 pressure ulcer when dietary intervention was addressed. 2. R2, is a 67 -year-old resident with multiple diagnosis including cerebral palsy, paraplegia, osteomyelitis of vertebra, sacral and sacrococcygeal region, encephalopathy, anemia, lack of coordination, stage 4 pressure ulcer to the sacral region, and positive for Covid-19. R2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. The Wound assessment dated [DATE] showed that R2 was admitted to the facility with the following pressure ulcers: -7/3/2023 right buttock stage 3 pressure ulcer; measurement was 5.0 cm. x 5.0 cm. x 0.30 cm (Length x Width x Depth) -6/30/2023 sacrum stage 4 pressure ulcer; measurement was 6.50 cm. x 9.0 cm. x 0.80 cm. -7/24/2023 right scapula stage 2 pressure ulcer admission nursing assessment dated [DATE] showed that R2 was admitted with pressure ulcers. The most recent comprehensive MDS (Minimum Data Set) dated 7/24/2023 showed that R2 was alert and oriented, was cognitively intact with BIMS (Brief Interview Mental Status) score of 14/15. The functional status showed that R1 required extensive to total assistance from 1-2 staff with regards to bed mobility, transfers, dressing, toilet use, hygiene, and bathing. The MDS also showed that R2 had no negative behavior such as rejection of care. R2 was also incontinent of bladder and bowel elimination. The POS (Physician Order Sheet) for the month of September shows an order dated 8/16/2023 for the sacral pressure ulcer wounds to cleanse with normal saline or wound cleanser, pat to dry and apply skin prep to periwound, and apply (Brand name gel), cover with ABD (abdominal pads) and secure with tape Daily and PRN (as needed) * may use foam/dry dressing. The care plan dated 9/21/2023 showed that R2 be turned and repositioned every 2 hours, to keep clean and dry and apply moisture barrier for pressure ulcer and skin integrity management. On 9/23/2023 at 10:30 A.M. V8 (CNA/Certified Nurse Assistant) said that he does not know when R2 was last change with incontinence brief or turned and repositioned as he had not taken care of him since he started his shift at 6:30 A.M. Together with V8, R2's skin and incontinence care was checked. R2 was lying in bed and said that he was not change with my diaper since last night. V8 said that he tries to provide assistance to his assigned residents, but it was just overloaded with heavy care and not able to provide every 2 hours check and repositioning as required. V8 had unfastened R2's incontinence brief. The brief was heavily soaked with urine. The brief with padded soak absorbent foam material had coagulated already due to heavy soaked from urine. R2's entire sacral area was raw red, with bleeding noted dripping off from entire sacrum/buttocks areas. R2's pressure ulcer to the right buttock and sacrum pressure ulcer was exposed, no wound dressing and wound was in direct contact and contaminated with urine. R2 was not turned for unknown period but definitely more than 2 hours and approximately was 4 hours. The policy for Skin Prevention dated 5/2017 showed All residents will receive appropriate care to decrease the risk of skin breakdown. 2. All residents will be evaluated daily during care for any changes in their skin condition. 2. Dependent residents will be assessed during care for any changes in their in skin including redness (non-blanching erythema), and this will be reported to the nurse. The nurse will be responsible of alerting the Health Care Provider and the wound care coordinator.5. Residents unable to reposition themselves will be repositioned at least every two hours. Unless contraindicated, elevate heels off the bed surface and avoid skin -to-skin contact. 9. Clean skin at time of soiling and at routine intervals. 10. If incontinent, use a moisture barrier. The policy for pressure ulcer wound dressing dated 6/9/2022 shows Facility will ensure that the right environment will be provided all wounds to enhance and promote wound healing. 1. Wound or treatment nurse follows physician/NP (Nurse practitioner) order for the appropriate wound dressing. The policy for Wound Prevention and Healing dated 7/24/2023 showed Braden Scale will be completed to determine the patient's level of risk and implement interventions to prevent development of pressure injuries. Facility will inspect skin during showers, daily and weekly skin checks as scheduled and as needed. Nurse will provide wound care per physician orders.

Based on observation, interview and record review, the facility failed to provide treatment and services regarding a resident's excoriated sacral areas and follow their plan of care to protect and maintain skin integrity, promote wound healing, and prevent wound infection. This failure resulted in the development of a newly opened wound on R3's right upper thigh, and R2's excoriated sacral areas with active bleeding and was contaminated with urine-soaked incontinence brief. This applies to two of three residents (R2 and R3) reviewed for skin alteration. The findings include: 1. The EMR (Electronic Medical Record) shows that R3, a [AGE] year-old, with diagnoses that included metabolic encephalopathy, morbid obesity, diabetes mellitus type 2, neuropathy, congestive heart failure, vascular dementia, without behavioral disturbance, psychotic and mood disturbance, anxiety, Alzheimer's disease, hypertension, repeated falls, depression, COPD (chronic obstructive pulmonary disease), lack of coordination, reduce mobility, and Covid-19 positive. On 9/23/2023 at 11:30 A.M., R3, was in her room, was heard screaming for help. R3 can be heard from few doors away. R3 had been screaming for approximately 5 minutes. Surveyor proceeded to check R3. When seen, R3 was sitting in her wheelchair without a head rest. R3's neck and head were leaned back without support. R3's lower extremities and almost entire buttocks area were almost on the floor. R3's legs were spread open that seems to be stopping R3 from falling. R3's was not able to maneuver her hips/thighs and noted that her wheelchair size did not have enough space for R3 to maneuver. R3 was wearing tight legging pants. R3 was screaming help, help, I want to go to bed! My hips and butt hurts, I cannot take it anymore, I have been sitting for long time and causing me pain. V18 (Director of Social Service/Manager on Duty on the initial day of survey/Saturday, 9/23/2023) was present during this observation. Surveyor asked V18 to get assistance. V7 (CNA/Certified Nurse Assistant) came and said she was the assigned CNA for R3. V7 said I cannot transfer nor reposition her in her wheelchair by myself. (R3) needed a minimum of 2 person assist for transfer and needed a mechanical transfer lift device for transfer to bed. I am waiting for another CNA to come and help me. Surveyor asked V18 to find another CNA to come and assist V7 to prevent R3 from falling. V10 (CNA) came to help. V10 said there is no way we can reposition her (R3) from her wheelchair, the sling of the transfer device was placed incorrectly behind (R3's) back, we just have to use the lift device, support her legs and buttocks and slowly transfer her. V7 and V10 transferred R3 in bed. V7 and V10 unfastened R3's brief incontinence pad. R3 was observed with an open wound with an approximate size of a dime. The open wound was noted with dried maroon blood. The wound was also located along the linear mark on R3's right upper thigh close to the groin. The elastic band from the incontinence brief pad was indented to R3's skin and created a linear mark and an open wound to R3's right upper thigh. V7 and V10 said the wound and the linear mark was caused from the elastic band from the incontinence brief based on the placement of the tight elastic band that was indented to R3's skin. R3 was heavily soaked with urine and smear of stool when V7 had unfastened the incontinence brief. V7 said that she does not know how long R3 was sitting in her wheelchair. V7 said that R3 was already sitting in her wheelchair when she came in to work at 6:30 A.M., V7 said that she did not have time to provide ADL care assistance such as repositioning and incontinence care to R3 since she has a heavy load of residents and that R3 needed 2 persons assist for ADLs. V7 also said that R3's bed sheets were all soaked with urine and had formed a ring formation that was a stain from urine. V7 said they just left her (R3) like that including the soiled bedding and smell of urine lingering around her room. I have to change the bedding but did not wash her (R3). V7 also said that the open wound on the right upper thigh was newly developed. R3 said that due to her prolonged sitting without being repositioned, tight wheelchair, it had caused too much pain around her hips and buttocks area. It was also observed that R3's wheelchair had no seat cushion as a comfort device and R3 was seated directly on a vinyl material of the wheelchair. The most recent MDS (Minimum Data Set) dated 9/12/2023 shows that R3 was cognitively moderately impaired with BIMS (Brief Interview Mental Status) score of 9/15, required extensive to total assistance from 2-3 staff assist for bed mobility, transfers, dressing, and toilet use. R3 required mechanical transfer lift device for transfers. The care plan dated 9/12/2023 showed that R3 has an ADL self-care performance deficit related to weakness, decrease strength, low activity tolerance, due to diagnoses of metabolic encephalopathy, morbid obesity, limited mobility, impaired transfer ability. Interventions included for staff to provide extensive to total assist with transfer, bed mobility, locomotion, toileting, personal hygiene's, and bathing. To prevent skin alteration, the intervention was to keep skin clean and dry, check R3 every two hours and assist with toileting as needed, and provide loose fitting, easy to remove clothing. The care plan intervention also included for staff to ensure that R3 is centered in bed, positioning device is functional and up as appropriate, and trunk and extremities are properly aligned and supported. The care plan also showed for staff to check and ensure R3 is properly and safely positioned in bed or wheelchair. 2. R2, is a 67 -year-old resident with multiple diagnosis including cerebral palsy, paraplegia, osteomyelitis of vertebra, sacral and sacrococcygeal region, encephalopathy, anemia, lack of coordination, stage 4 pressure ulcer to the sacral region, and positive for Covid -19. R2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. admission nursing assessment dated [DATE] showed that R2 was admitted with pressure ulcers. The most recent comprehensive MDS dated [DATE] showed that R2 was alert and oriented, was cognitively intact with BIMS score of 14/15. The functional status showed that R2 required extensive to total assistance from 1-2 staff with regards to bed mobility, transfers, dressing, toilet use, hygiene, and bathing. R2 was also incontinent of bladder and bowel elimination. The care plan dated 9/21/2023 showed that R2 be turned and repositioned every 2 hours, kept clean and dry and apply moisture barrier for skin integrity management. On 9/23/2023 at 10:30 A.M. V8 (CNA) said that he does not know when R2 was last change with incontinence brief or last turned and repositioned as he had not taken care of him since he started his shift at 6:30 A.M. Together with V8, R2's skin and incontinence care was checked. R2 was lying in bed and said that I was not change with my diaper since last night. V8 said that he tries to aid his assigned residents, but he was just overloaded with heavy care and not able to provide every 2 hours check and repositioning as required. V8 had unfastened R2's incontinence brief. The brief was heavily soaked with urine. The brief with padded absorbent foam material had already coagulated due to the heavily soaked urine. R2's entire skin of the sacral area was raw red, excoriated with blood dripping from the open excoriation of the sacrum/buttock areas. R2's pressure ulcer to the right buttock and sacrum pressure ulcer was exposed, and open wounds were in direct contact and contaminated with urine. There was no trace that a moisture barrier paste was applied to sacral excoriation and that the plan of care was followed to manage skin alteration. On 9/24/2023 at 12:51 P.M., V4 (Wound Treatment Nurse) said that R2 had pressure ulcers to the right buttock and sacrum V4 also said that R2's sacral region was excoriated and that a moisture paste skin barrier was the plan of care to preserved R2's skin alteration and prevent it from worsening. V4 said that there should be a trace of the moisture paste skin barrier even if (R2) was soaked with urine, which was the purpose of the skin barrier paste . it is very hard to remove the barrier paste, it has to be wipe multiple times to remove, you can visibly see if indeed the paste was applied. The policy for Skin Prevention dated 5/2017 showed All residents will receive appropriate care to decrease the risk of skin breakdown. 5. Residents unable to reposition themselves will be repositioned at least every two hours. Unless contraindicated, elevate heels off the bed surface and avoid skin -to-skin contact. 9. Clean skin at time of soiling and at routine intervals. 10. If incontinent, use a moisture barrier. The facility's policy for ADLs dated 10/20/2021 showed Facility ensures that residents receive ADL assistance and maintains resident's comfort, safety, and dignity. 6. Assist the resident to be clean, neat and well-groomed. The facility's policy for urinary incontinence dated 6/16/2023 showed Facility ensure and provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infection to the extent possible. Use check and change strategy that is done by checking resident's continence status at regular intervals . The facility's policy for repositioning dated 7/20/2023 showed Facility will provided guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair bound residents to prevent skin breakdown, promote circulation and provide pressure relief for resident .4. Residents who are in bed will be on at least every two-hour repositioning

Based on interview and record review the facility failed to assess and provide necessary care and services for a resident when she was found on the floor after a fall. This failure resulted in R1 not being sent to the hospital for treatment of [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. The findings include: R1's Electronic Medical Record (EMR) accessed on 10/9/20 shows that R1 has [DIAGNOSES REDACTED]. R1's Fall/Incident Report dated 9/25/20 states, Resident was observed on the floor by her CNA (Certified Nurse Aide) beside her bed. Immediate Action Take: ROM (Range of Motion) rendered. Per thorough investigation by the IDT team, it was determined that resident who is an independent ambulator attempted to get out of bed and fell . Did not complain of pain after fall, nurse assessed. On 10/9/20 at 10:50AM V3 (LPN- Licenses Practical Nurse) stated, I was in the 900 wing day room- my CNAs brought {R1} in and said that she had had a fall. I asked if she had any pain, stood her up and did ROM to all her extremities. That was around 8:00PM on Friday, 9/25/20 - I didn't report it. I left at 10:15PM and I came back in about 6:30AM. The night nurse said she complained of pain about 4:30AM so I called the doctor to talk to him about it. He came in and looked at her. The CNA's said they observed her on the side of her bed on the floor. The CNA's didn't come and get me first. The CNAs should come and get the nurse before they move the resident. {R1}didn't know what happened and said she didn't have any pain and just wanted to go to bed. I didn't report the fall. It was busy and she seemed to be ok. The next day she was hurting and I was scared because I had not reported it. I reported it on Monday- it was eating me up. On 10/9/20 at 11:00AM V4(CNA- Certified Nursing Assistant) stated, I was working that night and I heard someone screaming- yelling out in Spanish - Help me! I found {R1} on the floor. I went to get my partner and we put her in the chair. She was in her bed prior to that. I found her on the floor next to her bed. V5 (CNA) took her to the dining room. {R1} had no complaints of pain when we stood her up. It is our mistake that we did not go get the nurse first. I was busy on my hall so I did not see {V3} assess {R1}. On 10/9/20 at 11:10AM V5 stated, I put her to bed and I went to see someone else. I was with the other resident and {V4} told me {R1} was on the floor. She was sitting on the floor next to her bed and legs straight out in front of her. We picked her up and put her in the chair. I told {V3}- that {R1} was on the floor and we picked her up. I put her in the dining room and I left to go tend to another resident. I did not see {V3} assess{R1}. {R1} had no complaints of pain when we picked her up. We stood her up and put her in the chair. {R1} was not able to tell us what happened. We are supposed to tell the nurse before we move the resident. We didn't think it was anything. She was not in pain- so we thought she just slid off her bed- there was no sign of injury. On 10/9/20 at 1:30PM V6 (RN- Registered Nurse) stated, I worked night shift that night so I came in about 10:30PM. {R1} was fine. Nothing was reported to me about a fall. She slept comfortably through most of the night and then about the end of my shift she was complaining of pain. I went in and assessed her. Nothing was communicated to me about a fall so I really didn't know to look for anything. First she said her leg hurt, then it was a headache then just generalized pain. I spoke to {V7- CNA} that night and he didn't report anything unusual, no falls or anything. Her vital signs were ok. I didn't feel there was any reason to call the doctor. I gave her [MEDICATION NAME]- [MEDICATION NAME] and then she was ok, she went back to sleep. I spoke to the oncoming nurse {V3} and told her what was going on. Then {R1} started screaming in pain. {V3} did not report any falls to me at that time either. On 10/9/20 at 1:45PM V7 stated, {R1} was quiet most of the night. She didn't complain about pain until I went in there about 4:00AM. She was hard to change. She sometimes gives me a hard time but she was more vocal than usual. {V6} was around so I told him and he went in to see her. I went on to care for the other residents. An undated written statement by V3 reads, Friday 9/25/20 8:00PM, my two CNAs came to me to let me know they observed {R1} on the floor beside her bed and they placed {R1} in her wheelchair and brought her to the 900 dayroom. I ask {R1} if she had any pain and she replied no. I did ROM on {R1} too, no pain. {R1} was put back to bed at 9:00PM. I came in 9/26/20 at 6:30AM and the third shift nurse said {R1} complained of pain around 4:30AM and was given [MEDICATION NAME]. I was asked by Supervisor and Director of Nursing did she fall and I replied No. I was scared because I didn't do fall report that night. A written statement by V5 dated 9/27/20 reads, This is to inform you that I worked in 900 last Friday (9/25/20) 2nd shift when this incident happened. I was putting my residents to bed and I was going to the dining room to take another resident to the bathroom and prepare her for bed, when I heard someone saying ayuda me. I went back at the hallway and checked who was it. I entered (R1's) room and saw her sitting on the floor. I went back to tell {V5} that {R1} was on the floor. We went back to (R1's) room instead of calling the nurse to see her (sorry about this, it's an honest mistake). We got her up and sat her in her wheelchair and {V5} took her to the dining room. After about 30min-1 hour I helped {V5} put {R1} to bed. I told {V5} to tell the nurse what we did and what happened and she did tell the nurse. During the rest of the shift I kept checking her. I did my rounds at 9:45PM and she said it hurts and I said where is your pain and was pointing her private part so I checked if she's wet but she wasn't. This is all I can say about the incident. Progress Notes dated 9/26/20 state, Was summoned to resident room by CNA, saying resident is complaining of pain, and won't stand for her. ROM was rendered but resident screamed in pain, I ask if she fell she replied, she don't remember. Called Physician who ordered STAT X-Ray of Right Leg, Right foot, and Right hip. Order carried out. Physician's Progress Note dated 9/26/20 at 3:16PM states, Patient is being followed in her room in presence of RN in charge. RN states when she came this morning noticed patient was complaining of R Lower Extremity limited pain , initially unclear the specific site of pain. Patient unable to get out of pain. No reports regarding a fall Extremities: Bilateral Lower Extremities w/o evidence of hematoma. Right Lower Extremity with external rotation, sensitive to touch and ROM especially hip, equal peripheral pulses bilateral. Neg Homans sign bilateral. 1. Right Lower Extremity pain. Findings suspicious regarding Hip involvement, ? FX, XRay ordered already but not here, recommend patient to be transferred to emergency room for further evaluation. Progress Notes dated 9/26/20 at 3:02PM state, {R1's physician} called to send resident out to ER Went to resident's room and tried to check on her R leg /thigh. Resident screams when I try to touch leg. It is externally rotated and shortened. No swelling noted. Tylenol 650mg given for comfort. Resident's daughter aware . 5:10PM {21 hours after fall} Resident was picked up by ambulance personnel. R1's Hospital History and Physical dated 9/26/20 states, [AGE] year old female .presented to the ER after she was found in bed with pain in her right leg . X-Ray of hip and pelvis showed displaced and mildly angulated right femoral neck fracture. This same document states, Assessment and Plan: Right femoral neck fracture. Likely secondary to fall as patient has bruises on head and neck. The facility policy entitled Falls dated 7/2014 states, Facility Guideline following a fall incident: 1. Evaluate the resident for any injury and alert the Health Care Provider and Emergency Contact. 2. Complete a fall event. This event includes the circumstances surrounding the fall, devices in use, full body observation for injury, pain, range of motion and neuro checks.

Based on interview and record review the facility failed to ensure a resident was free from neglect by not documenting a resident's fall and assessment in the medical record and not reporting the fall to the next shift or the physician in a timely manner. This failure resulted in R1 not receiving treatment for [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for falls/neglect in a sample of 3. The findings include: R1's Electronic Medical Record (EMR) accessed on 10/9/20 shows that R1 has [DIAGNOSES REDACTED]. R1's Fall/Incident Report- Risk Management dated 9/25/20 states, Resident was observed on the floor by her CNA (Certified Nurse Aide) beside her bed. Immediate Action Take: ROM (Range of Motion) rendered. Per thorough investigation by the IDT team, it was determined that resident who is an independent ambulator attempted to get out of bed and fell . Did not complain of pain after fall, nurse assessed. On 10/9/20 V8(RN- Restorative Nurse Coordinator) stated, I came to work on that Monday (9/28) and we went to the morning meeting. We were aware that {R1} had gone out to the hospital with a [MEDICAL CONDITION] but there was nothing in risk management to tell us what happened. Usually we have the meeting and then a few of us stay after and discuss the falls and work on the interventions. After the meeting {V10- Assistant Director of Nursing} and another nurse manager said that they needed to discuss {R1} in private with {V1}Administrator based on some of the statements they received. Then we {V8 and V9- Restorative Nurse} were excluded from any further discussion about the incident. A few days passed and I went in to look at the documentation to see if I could piece some things together. Something seemed a little off. Since we were not privy to the statements I decided not to involve myself in it anymore. I was asked on that Monday (9/28) to let {V3- LPN} know that she needed to enter her documentation into the computer. The Risk Management form was completed 10/6/20. Usually restorative enters the plan into the risk management form but we were not involved in this one. On 10/9/20 at 10:50AM V3 (LPN- Licenses Practical Nurse) stated, I was in the 900 wing day room- my CNAs brought {R1} in and said that she had had a fall. I asked if she had any pain, stood her up and did ROM to all her extremities. That was around 8:00PM on Friday, 9/25/20 - I didn't report it. I left at 10:15PM and I came back in about 6:30AM. The night nurse said (R1) complained of pain about 4:30AM so I called the doctor to talk to him about it. He came in and looked at her. The CNA's said they observed her on the side of her bed on the floor. The CNA's didn't come and get me first. The CNAs should come and get the nurse before they move the resident. {R1}didn't know what happened and said she didn't have any pain and just wanted to go to bed. I didn't report the fall. It was busy and she seemed to be ok. The next day she was hurting and I was scared because I had not reported it. I reported it on Monday- it was eating me up. An undated written statement by V3 reads, Friday 9/25/20 8:00PM, my two CNAs came to me to let me know they observed {R1} on the floor beside her bed and they placed {R1} in her wheelchair and brought her to the 900 dayroom. I ask {R1} if she had any pain and she replied no. I did ROM on {R1} too, no pain. {R1} was put back to bed at 9:00PM. I came in 9/26/20 at 6:30AM and the third shift nurse said {R1} complained of pain around 4:30AM and was given [MEDICATION NAME]. I was asked by Supervisor and Director of Nursing did she fall and I replied No. I was scared because I didn't do fall report that night. On 10/9/20 at 1:30PM V6 (RN- Registered Nurse) stated, I worked night shift that night so I came in about 10:30PM. {R1} was fine. Nothing was reported to me about a fall. She slept comfortably through most of the night and then about the end of my shift she was complaining of pain. I went in and assessed her. Nothing was communicated to me about a fall so I really didn't know to look for anything. First she said her leg hurt, then it was a headache then just generalized pain. I spoke to my CNA (V7) that night and he didn't report anything unusual, no falls or anything. Her vital signs were ok. I didn't feel there was any reason to call the doctor. I gave her [MEDICATION NAME]- [MEDICATION NAME] and then she was ok, she went back to sleep. I spoke to the oncoming nurse {V3} and told her what was going on. Then {R1} started screaming in pain. {V3} did not report any falls to me at that time either. A Late Entry Progress Note written by V3 dated 9/26/20 at 8:28AM (Per the EMR the note was completed on 10/6/20) states, Resident was observed on the floor beside her bed by CNAs on 9/25/20 at 8:00PM. Resident was brought in 900 day room, where I rendered ROM on all extremities with no pain. Resident was put to bed by CNA 30 minutes later. The next morning resident complained of pain and was sent to ER. Progress Notes dated 9/26/20 , written by V3, state, Was summoned to resident room by CNA, saying resident is complaining of pain, and won't stand for her. ROM was rendered but resident screamed in pain, I ask if she fell she replied, she don't remember. Called Physician who ordered STAT X-Ray of Right Leg, Right foot, and Right hip. Order carried out. Physician's Progress Note dated 9/26/20 at 3:16PM states, Patient is being followed in her room in presence of RN in charge. RN states when she came this morning noticed patient was complaining of R Lower Extremity limited pain , initially unclear the specific site of pain. Patient unable to get out of pain. No reports regarding a fall Extremities: Bilateral Lower Extremities w/o evidence of hematoma. Right Lower Extremity with external rotation, sensitive to touch and ROM especially hip, equal peripheral pulses bilateral. Neg Homans sign bilateral. 1. Right Lower Extremity pain. Findings suspicious regarding Hip involvement, ? FX, XRay ordered already but not here, recommend patient to be transferred to emergency room for further evaluation. Progress Notes dated 9/26/20 at 3:02PM state, {R1's physician} called to send resident out to ER Went to resident's room and tried to check on her Right leg /thigh. Resident screams when I try to touch leg. It is externally rotated and shortened. No swelling noted. Tylenol 650mg given for comfort. Resident's daughter aware . 5:10PM, 21 hours after fall Resident was picked up by ambulance personnel. R1's Hospital History and Physical dated 9/26/20 states, [AGE] year old female .presented to the ER after she was found in bed with pain in her right leg . X-Ray of hip and pelvis showed displaced and mildly angulated right femoral neck fracture. This same document states, Assessment and Plan: Right femoral neck fracture. Likely secondary to fall as patient has bruises on head and neck. The faciltiy policy entitled Abuse dated 1/2019 states, Neglect means the failure of the facility, it's employees or its service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish, or emotional distress. Further, neglect means a facility's failure to provide, or willful withholding of adequate medical care .

Based on interview and record review the facility failed to stay in attendance while a resident (R1) at risk for falls showered in a shower chair in the shower room. This failure led to R1 falling out of the shower chair and fracturing the right femur and hitting R1's head. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of three. The findings include: R1 was discharged from the facility November 26, 2017 and was reviewed as a closed record. R1 was admitted to the facility on [DATE] per the admission face sheet. The current physician orders [REDACTED]. The fall risk assessment dated [DATE] in R1's clinical record showed that R1 had two falls within six months of the assessment. The assessments showed that R1 had a deficit with memory and recall at times, impaired vision, occasional incontinence, required hands-on assistance to move place to place, unable to independently stand and at risk for falls. The MDS (Minimum Data Set) dated September 11, 2017 showed that R1 had trouble remembering what day it was and unable to recall words at times. The MDS showed that R1 required two person physical assist for transfer from bed to chair and toilet use. The MDS showed that R1 required one person physical assist for person hygiene. Under section G0120 bathing the MDS showed that R1 received the support of two people for bathing. The current care plan for R1 showed that R1 was at risk for injury from falls and had poor balance with unsteady gait. The interventions in place showed that R1 required extensive assist of two persons for transfers and pericare. The care plan showed that R1 was to continue use of a custom high back wheelchair to aid in positioning. The care plan showed that R1 required assistance with bathing and showering as necessary. An occurrence report dated June 6, 2017 showed that at 2:40 pm R1 was found on the floor. The report showed that R1was in the shower and had an abrasion to the right knee and an abrasion to the right cheek. The report showed that because there was injury to the head neurological checks were required. The report showed that R1 had no other injuries at that time. The root cause analysis after facility investigation showed that the staff member was in the shower room with the resident, giving the resident a shower. The staff member stated that the resident was reaching for the soap and tipped forward out of the chair. The report recommended that staff ensure resident personal care items are within reach of the resident. Nursing notes dated November 26, 2017 and timed at 8:11 am that R1 was noted on the floor in the shower and orders were received to obtain x-rays of the right knee and left arm. A nursing note written at 10:24 am R1 was noted on the floor in the shower room. The note showed that R1 had right knee redness and complained of left arm pain. The same note showed that on reassessment R1 had a new area of redness to the left side of forehead and had become lethargic. The note showed that R1 was sent to the community hospital. On November 26, 2017 at 12:12 pm the nursing note showed that the community hospital had intubated R1 and was sending the resident to another hospital for evaluation. A nursing note written at 3:04 pm showed that R1 was at the hospital that R1's neurologists practices and was admitted with a stroke. The SBAR (Situation, Background, Assessment, Recommendation) form dated November 26, 2017 showed that R1 was alert and responsive and had pain to right knee and left arm after the fall. An occurrence report written on December 6, 2017 at 12:04 pm showed that on November 26, 2017 at 7:15am R1 fell off the shower chair onto the floor. R1 was unsupervised at the time. The report showed that R1 was found face foreword on the left side with her arm under her body. The report showed that R1 complained of pain to right knee and left arm. The report showed that R1 was subsequently sent to the community emergency room due to lethargy and pain. A vital sign and Neurological assessment sheet dated November 26, 2017 showed that at 7;15 am the facility started to monitor R1's vital signs and neurological status. The assessment sheet showed that at 10:00am R1 had a change in consciousness and increased heart rate and blood pressure. An x-ray report dated November 26, 2017 that was done at the facility after the fall and prior to transfer to the hospital showed that R1 had a displaced fracture to the right knee. There was no record of head cat scan or x-ray ordered or performed. The facility policy for falls dated August 2014 showed that the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. On December 13, 2017 at 9:05 am V1 Administrator said that V3 CNA (Certified Nursing Assistant) had left R1 in the shower room on a shower chair to get wash cloths. V1 said that while V3 was out of the shower room R1 fell out of the chair. V1 said that at approximately 10:00 am R1 had become lethargic and was sent to the community hospital. V1 said that the x-ray taken at the facility prior to transfer showed that R1 had fractured R1's femur. On December 13, 2017 at 9:25 am V4 LPN (Licensed Practical Nurse) said that she could hear screams from the shower room. V4 said that R1 was found face forward with her arm under her body. V4 stated, (R1) complained of pain to her arm and her right knee. I gave her pain medication and did assess her neurologic status and vital signs every 15 minutes. I sent her to the hospital because she didn't verbally answer my questions. V4 was not aware of how R1 fell . V4 said that V3 CNA had stepped out of the shower to get towels. On December 13, 2017 at 11:53 am V3 CNA said that R1 required the assistance of one person for showers. V3 said that V3 set R1 up with supplies and left the room to get a towel. V3 said half way down the hall V3 could hear R1 scream and yell. V3 said that R1 was laying face forward on the floor. V3 stated, (R1) complained of pain to R1's right leg. V3 said that the care plan for R1 did not show her to provide supervision during the shower. On December 13, 2017 at 1:33 pm V2 DON (Director of Nursing) said that the hematoma on R1's forehead was noted just prior to being sent out to the hospital at approximately 10:15 am. V2 stated, The CNA's should bring all supplies needed for care into the shower. On December 13, 2017 at 2:10 pm via telephone V5 Medical Doctor and Medical Director of the facility said that R1 was sent out to the hospital because of a fall in the shower. V5 stated, (R1) was not safe to be left alone in the shower room without supervision. I would not agree to R1 being unsupervised unless R1 was secured in the chair somehow.

Based on observation, interview and record review the facility failed to follow their Safe Patient Lifting Policy resulting in a resident fall with a fracture. This applies to R1, one of three residents reviewed for falls in the sample of three. The findings include: According to the face sheet in the medical record R1 is a [AGE] year old non-ambulatory female with [DIAGNOSES REDACTED]. According to the quarterly MDS (Minimum Data Set) dated 08/18/15 R1 is coded as a total assist for transfers with 2 plus staff to assist. A transfer evaluation was completed on 07/16/15. The recommendation was the use of a mechanical lifting device with two staff required for transfer to and from bed to chair, chair to chair or toilet to chair. A facility Incident Report of 09/12/15 concluded that during transfer of R1 to bed the sling on the mechanical lift tore and ripped. Staff member, E1, CNA (Certified Nurses Aid) lowered R1 to the floor. R1 was sent to the emergency room where an x-ray showed a fracture to the right distal humerus. On 09/25/15 E2 (Administrator) stated R1 was being transferred on 09/12/15 with only one staff member present. E2 stated R1 requires two staff members for transfers and E1 did not provide an explanation for transferring R1 by himself. Facility policy titled Safe Lifting Policy notes that transfers will be designated into five categories. The fifth category, T= Total Lift Transfer (mechanical lift type) with two or more caregivers (Total Assist). The policy also notes Laundry staff and all staffing with patient contact will conduct inspection of slings; if slings are found to be impaired then sling is to be removed from use. On 09/25/15 E2 provided the sling that had torn while R1 was being transferred. The upper seam that was torn from the strap was inspected along with the rest of the straps. Signs of wear were also found on another of the intact seams. R1 was observed on 09/25/15 sitting in wheelchair in the dining room. R1 had a cast with a sling to the right upper extremity. When asked what happened to her R1 stated, He dropped me. Z1 (attending physician) stated on 09/30/15 she was aware of the incident that occurred on 09/12/15. Z1 said she was not familiar with all of the details of the incident or that R1 had been transferred by only one staff member when the incident occurred.

Based on observation, interview and record review the facility failed to implement interventions according to current standards of practice to reduce the risk of an accident for 2 of three residents (R1 and R3) sampled for fall risk. This resulted in R3 falling from the bed during incontinence care and R1 falling from bed unnoticed because of the lack of implementing careplanned interventions. Findings include: R3 is a resident with [DIAGNOSES REDACTED]. Record review shows that R3 was admitted to the facility on [DATE], for physical therapy after a fall at home. While at the hospital, R3 complained of L knee pain. According to interview of Z5, pain in the left knee was a problem for R3 for years. During the hospitalization however the knee was examined and Xrayed. The Xray report dated 4/7/11 states that based on three different views the impression is that there is the presence of "severe osteoarthritis without acute injury." After transfer to the facility, R3 complained of occasional generalized pain with emphasis on the left knee and back. R3 reported relief from the pain medication she received according to the universal progress notes (UPN) and the 72 hour charting. On 4/30/11, R3 was receiving incontinence care from E5 . During the process of receiving care E5 called the nurse to the room to report that during repositioning of R3, R3 had fallen off the bed. The nurse on duty documented in the UPN that: " No injury was noted. No shortening or rotating of extremities." This was at 4:45am. R3 was placed back into bed with the use of a Hoyer lift and two Certified Nurse Aides (CNA). A subsequent note written at 7:55am documents R3 had sustained a long superficial abrasion and spotted bruising on the upper right back. At 9:45am, the notes document that R3 is complaining of pain to the R hip and R leg. "Resident is moaning and screaming with repositioning." The physician was notified about the pain and new orders were received for Xray to R hip and R thigh. The next note at 11 am documents R3 is verbally unresponsive with slurred speech and foaming at the mouth. R3 was sent to the hospital for evaluation. On admission to the hospital, Xrays showed that R3 had fractures of the R hip and bilateral fractures of the L and R femurs. These fractures resulted in R3 undergoing surgery for [REDACTED]. On interview, Z1 the orthopedic surgeon stated that the fractures were the result of :" a severe traumatic injury." Z1 did not attribute the injury to any particular time or event during the interview. R3 was interviewed upon return to the facility. R3 was lethargic and speech was soft and slow. When asked what happened when the aide changed her that night she had her fall, R3 responded that: "I fell hard." Review of personnel file of E5, the CNA, showed that a disciplinary action had been taken against E5 for "failure to follow facility P&P (policy and procedure.)" Review of the clinical record of R1 showed that on 4/7/11, R11 had suffered a fall from bed that resulted in a R femur fracture. At the time of the fall, R1 had a care plan in place that was initiated 3/9/11 for R1 being (High) risk for falls due to "confusion, poor comprehension and deconditioning". Some of the interventions to prevent injury included : a working and reachable call light in place; the bed in low position; ensure bed alarm in place as needed; anticipate and meet resident needs; REVIEW INFORMATION ON PAST FALLS AND ATTEMPT TO DETERMINE CAUSE OF FALLS. Alter/ remove any potential causes if possible. The documentation in the clinical record does not reflect if any of these interventions were in place at the time. Alterations to the care plan that were made on 4/7/11 include: the addition of the use of a hugger mattress, low bed, extra mat and bed alarm. On 5/5/11, after returning from hip surgery, R1 suffered another fall from bed. Documentation shows that at 4:55am R1 was heard yelling out for help. She was found at the side of the bed sitting on the floor mat. At this time R1 was without her gown on. When R1 removed her gown the alarm went with it and it failed to alarm according to the nursing note documentation. Documentation in the nurses notes of 5/5/11 at 6:30am show that a second alarm was not in place as had been promised to the POA (power of attorney). The care plan also documents the use of a sensor alarm and /or an extra bed alarm as interventions for R1.

Based on observation, interview and record review the facility failed to ensure that a CNA (certified nurse aide) properly performed incontinence care on a resident (R3) while in bed resulting in R3 falling from the bed to the floor. Findings include: On 4/30/11, R3 was receiving incontinence care from E5 . During the process of receiving care E5 called the nurse to the room to report that during repositioning of R3, she had fallen off the bed. E5 was interviewed over the phone and stated that she had turned the resident toward her while rendering incontinence care but failed to position her in the center of the bed and thus she(R3) rolled out of the bed onto the floor. The nurse on duty documented in the UPN that: " No injury was noted. No shortening or rotating of extremities." This was at 4:45am. R3 was placed back into bed with the use of a Hoyer lift and two Certified Nurse Aides (CNA). A subsequent note written at 7:55am documents R3 had sustained a long superficial abrasion and spotted bruising on the upper right back. At 9:45am, the notes document that R3 is complaining of pain to the R hip and R leg. "Resident is moaning and screaming with repositioning." The physician was notified about the pain and new orders were received for Xray to R hip and R thigh. The next note at 11 am documents R3 is verbally unresponsive with slurred speech and foaming at the mouth. R3 was sent to the hospital for evaluation. On admission to the hospital, Xrays showed that R3 had fractures of the R hip and bilateral fractures of the L and R femurs. These fractures resulted in R3 undergoing surgery for [REDACTED]. On interview, Z1 the orthopedic surgeon stated that the fractures were the result of :" a severe traumatic injury." Z1 did not attribute the injury to any particular time or event during the interview. R3 was interviewed upon return to the facility. R3 was lethargic and speech was soft and slow. When asked what happened when the aide changed her that night she had her fall, R3 responded that: "I fell hard." Review of personnel file of E5, the CNA, showed that a disciplinary action had been taken against E5 for "failure to follow facility P&P (policy and procedure.)"