Every finding on record at Pearl of Rolling Meadows,The

Based on interviews and record review, the facility failed to follow their policy to ensure a resident was transferred safely when staff performed an unapproved transfer following an equipment failure for one (R1) of four residents reviewed for ADL (Activities of Daily Living) assistance in a sample of four residents.Findings include:R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Rheumatoid Arthritis; Metabolic Encephalopathy; Paraplegia; Schizophrenia; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris; End Stage Renal Disease; Hypothyroidism; and Essential (Primary) Hypertension.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, shows R1's chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair) as dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.Neglect care plan initiated 12/8/2025 reads in part, I am (R1) observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect and trauma. Interventions: screening/re-evaluation, psychosocial interventions to address present psychological/emotional needs, mitigation of potential trauma related factors, psychiatric care (as indicated), attention from the NP (as indicated).ADL care plan initiated 10/5/2024 reads in part, (R1) has an ADL self-care performance deficit r/t (related to) generalized weakness, activity intolerance, poor safety awareness, contractures, musculoskeletal impairment s/t paraplegia, dm2 (diabetes mellitus), sepsis, hypertension, arthritis, ESRD (End Stage Renal Disease). Interventions: TRANSFER: The resident requires (mechanical lift) with 2 staff assistance for transfers.Fall care plan initiated 10/5/2024 reads in part, (R1) is at risk for falls r/t generalized weakness, activity intolerance, poor safety awareness, contractures, musculoskeletal impairment s/t paraplegia, dm2, sepsis, hypertension, arthritis, ESRD. Interventions: PROTECTION/SAFETY HAZARDS/PERIL: Staff will assess their physical environment, device, equipment, including furniture, appliances, beds, wheelchairs, etc. to ensure that it don't pose as a safety risk or hazard. Any device, equipment that needs repair should be removed and reported to designated personnel. Rooms and hallways should be clutter-free. Floors and surfaces should be clean and dry. Bed at a safe level based on resident's needs/risks. Any issue/s will be reported.On 8/3/2026 at 11:03 AM Per record, R1 discharged to the hospital on 7/30/2026 with no return. R1 not available for observations or interview during the course of the survey.On 8/3/2026 at 11:14 AM R2 said, On the morning of 7/22/2026, my roommate (R1) had scheduled dialysis. Our CNA (Certified Nurse Assistant) that night was V3 (Certified Nurse Assistant). V3 (CNA) got V4 (Certified Nurse Assistant) to help her with R1's mechanical lift transfer. My privacy curtain was closed but I heard V4 (CNA) say that R1's mechanical lift sling doesn't fit R1. Both CNAs kept saying It doesn't fit. R1 started crying at some point because she was in pain, and said Stop it, you're hurting me to both V3 (CNA) and V4 (CNA), but I heard them turning R1 back and forth. At some point, one of the CNAs said, If you don't want to go to the dialysis, you don't have to but they eventually transferred R1 to the dialysis chair. I didn't hear the mechanical lift; it sounded like they dragged R1 over with a sheet.On 8/3/2026 at 12:10 PM R3 said, On the morning of 7/21/2026, V3 (CNA) asked V4 (CNA) to help her with R1's transfer. R1 requires mechanical lift for her transfers. V4 (CNA) went to get R1's sling, but when V4 (CNA) attempted to put it underneath R1, V4 (CNA) said it's not going to work. V4 (CNA) said they're going to use a sheet to drag R1 over to the dialysis chair and they did just that. V3 (CNA) and V4 (CNA) placed mechanical lift in the hallway, where I was waiting and proceeded to drag R1 with a sheet from bed into a dialysis chair. I felt terrified for R1, she couldn't say anything. I witnessed all of it because I was waiting in the hallway to go the dialysis myself. I was sitting right outside of R1's room, R1's room door was wide open. After all, V4 (CNA) said, I hate working this hallway, they're so dramatic.On 8/3/2026 at 12:29 PM V3 (Certified Nurse Assistant) said on 7/21/2026 (night shift), I was assigned to R1. I had to get R1 up to the dialysis on the morning of 7/22/2026. R1 required mechanical lift for her transfers. V4 (CNA) came to help me with the mechanical lift. We placed R1 into the sling, and attempted to lift R1 off the bed, the mechanical lift got stuck. The mechanical lift was giving us problems. The mechanical lift was stopping and getting stuck as we attempted to lift R1. R1 hung right above the bed. We detached the sling and just transferred R1 with a flat sheet into the dialysis chair. There were other residents who witnessed the incident. R2, R1's roommate, heard what happened, and R3 saw what occurred and was screaming at us, so we had to hurry.On 8/3/2026 at 12:39 PM V4 (Certified Nurse Assistant) said, On the morning of 7/22/2026, I assisted R1's CNA (V3) during a mechanical lift transfer. We tried to get R1 up with the mechanical lift, but the mechanical lift wasn't working, and we had to place R1 manually into the dialysis chair. We lifted R1 with a draw sheet and placed her in the chair. Other residents were freaking out, so we had to do it fast. We were afraid that R1 was going to be late for the dialysis, and we didn't want to get in trouble for that. CNAs are trained on how to use a mechanical lift but if the mechanical lift is stuck, I don't know how to trouble shoot the lift, but we had to do something. We learn how to use a mechanical lift before we start the job, upon hire, and during orientation when we start on the floor. It would be stupid to lower R1 back into bed at that point, knowing she has to go to dialysis. We didn't do anything unsafe.On 8/3/2026 at 1:01 PM V2 (Director of Nursing) said, I was not involved in the internal investigation of the incident, but I was told about it. V1 (Administrator) said that R2 made a report that she heard V3 (CNA) and V4 (CNA) transfer R1 using a bed sheet on the morning of 7/22/2026. V1 (Administrator) said she interviewed both CNAs and they explained what happened. V3 (CNA) and V4 (CNA) were transferring R1 when mechanical lift stopped working. They had to finish manually transferring R1 into the dialysis chair by using a draw sheet and a sling. R1 did not suffer any injuries during the incident. CNAs are trained in how to use mechanical lift, upon hire, annually, quarterly and as needed. CNAs cannot leave a resident during mechanical lift failure; number one priority is resident's safety. At the very moment, I believe it was the only choice V3 (CNA) and V4 (CNA) could have made, to transfer R1 manually into the dialysis chair.On 8/3/2026 at 1:14 PM V1 (Administration), said, R2 came to me on 7/22/2026 and said she overheard a lot in the early morning. R2 said that R1 probably has bruises and broken bones after what happened. R3 also came to me and said she witnessed the incident and said that two CNAs (V3 and V4) were struggling early in the morning. I told the day shift nurse to do R1's assessment right away and notify R1's power of attorney and the doctor. I suspended both CNAs pending investigation because it was an abuse investigation. I completed the internal investigation and came to a conclusion that there was no abuse that occurred. Both CNAs stated that the mechanical lift was stuck, they were unable to maneuver it, and they had to do what they had to do to ensure R1's safety. The mechanical lift was checked, and it was not malfunctioning whatsoever. If the mechanical lift malfunctions in the middle of a transfer, CNAs should think safety first, so safely move a resident off the mechanical lift.On 8/3/2026 at 1:36 PM V6 (Maintenance Director) said, I do a mechanical lift audit once a month. An outside company comes every quarter and does their independent audit as well. As far as I know, all mechanical lifts in the facility were in working condition on 7/21/2026. There would be no reason for any of the mechanical lifts to get stuck. Immediately after the incident, all three facility mechanical lifts were checked and worked properly. The only time a mechanical lift may get stuck is when it would be placed in an enclosed area and a sensor would get covered, that's when a mechanical lift will stop operating all together. Mechanical lift either works or doesn't work; it can't be going on and off.The facility Mechanical Lift Malfunction During a Transfer (no date) reads in part, PURPOSE: To define staff response when a mechanical lift stops working before, during, or after a resident transfer. PROCEDURE: If the lift fails and the resident is suspended in the sling: 1. Stop; 2. Steady the sling only; 3. Use the emergency release to lower the resident slowly to the nearest safe surface - bed, chair, or floor; 4. Do not reuse the device. Notify the charge nurse.

Based on interview and record review, the facility failed to protect residents' right to remain free from employee verbal abuse for 4 (R1, R4, R5, and R6) of 4 residents reviewed for abuse in a total sample of 6 residents.Findings include:R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Fibromyalgia; Chronic Obstructive Pulmonary Disease; Essential (Primary) Hypertension; Polyneuropathy; Lymphedema; Epilepsy; Obsessive-Compulsive Disorder; Anxiety Disorder; Bipolar Disorder; and Schizoaffective Disorder.According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition.Abuse care plan initiated 4/25/2025 reads in part, I am (R1) observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect and trauma. Interventions: Provide staff education on ways to properly communicate with (R1) and deescalate situation; Inform abuse coordinator of abuse allegations immediately and initiate abuse investigation. On 7/21/2026 at 11:18 AM R1 said, On 6/13/2026, at around 3:30 PM, in the first-floor dining room, V3 (Former Activity Director) told me to Fuck off. That day, I was doing puzzles with R6 during activities. While we were doing that, R4 came up to us. R4 was trying to make puzzles with us, even though we didn't want him too. R6 asked R4 to let us finish and suggested he should do another puzzle. V3 (Former Activity Director) said then that R4 can join us even though we didn't want him to. We explained that the puzzle took us several hours to complete, we're almost done with it, and we don't want R4 to mess it up, and that R4 can go and get his own puzzle. the conversation escalated and that's when V3 (Former Activity Director) told R6 to Fuck off. R6 left the dining room saying How dare you talk to me like that to V3 (Former Activity Director). I told V3 (Former Activity Director) that R6 and I were working on this puzzle really hard for several hours and he proceeded to say Fuck off to me as well. I was really hurt. I was crying after he said that. I like V3 (Former Activity Director), so I decided not to report this incident, I didn't want him to get fired. I know somebody reported it though. V2 (Director of Nursing) and V4 (Former Activity Director Assistant) came to talk to me about what happened shortly after the incident. Both V3 (Former Activity Director) and V4 (Former Activity Director Assistant) are no longer here.R4 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited Anoxic Brain Damage; Epileptic Seizures Related to External Causes; Malignant Neoplasm of Bladder; Bipolar Disorder; Major Depressive Disorder; Generalized Anxiety Disorder; Dysarthria and Anarthria; and Restlessness and Agitation.According to R4's MDS (Minimum Data Set) assessment dated [DATE] under section C, R4 has BIMS (Brief Interview of Mental Status) score of 14 indicating intact cognition.Abuse care plan initiated 2/20/2025 reads in part, Although I (R4) have been involved in an incident, there is no reason to suspect any unusual consideration, risk or concern for mistreatment. I am (R4) observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect or further trauma. R/t: physical and medical challenges. Interventions: screening/re-evaluation, psychosocial interventions to address present psychological/emotional needs, mitigation of potential trauma related factors, psychiatric care (as indicated), attention from the NP (as indicated).On 7/21/2026 at 12:09 PM Surveyor asked if R4 was present during an incident at the beginning of June 2026 when V3 (Former Activity Director) used inappropriate language during activities, R4 nodded his head and said, It was nonsense. I was trying to sit with them, I don't want to say names, when V3 (Former Activity Director) said that. I don't want to say what he said, it was very inappropriate and made me feel very uncomfortable. R4's interview limited due to R4's active diagnosis of Dysarthria and Anarthria and difficulties speaking associated with that.R5 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Epilepsy; Peripheral Vascular Disease; Essential (Primary) Hypertension; Hydronephrosis with Renal and Ureteral Calculous Obstruction; Chronic Pulmonary Embolism; Restlessness and Agitation; Anxiety Disorder; and Depression.According to R5's MDS (Minimum Data Set) assessment dated [DATE] under section C, R5 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition.Abuse care plan initiated 11/12/2024 reads in part, Resident (R5) denies any history of abuse, neglect, or mistreatment, and there are no indications that I (R5) have been a recipient or a perpetrator of mistreatment. However, given my poor and compromised health status, physical decline and need for 24-hour care, the IDT recognizes that I (R5) am considered a vulnerable adult. Interventions: Assure me (R5) that staff members are available to help me (R5) and that department heads maintain an open door policy; Provide reassurances to me (R5) & remind me (R5) that I (R5) am safe and secure.On 7/21/2026 at 12:45 PM R5 said, I was there and saw the whole thing. It was either Monday or Wednesday around 3:00 PM in the first-floor dining room. We were doing activities. R4 was there, innocently looking at R1's and R6's puzzle. R6 started yelling at R4 saying he was trying to touch the puzzle, but R4 wasn't trying to touch anything. I looked at V3 (Former Activity Director) and I could tell he was getting frustrated. Finally, V3 (Former Activity Director) told R6 to Fuck off. We all knew it was a wrong thing to say. V3 (Former Activity Director) was a good guy but he was at his limit with R6. R6 was yelling at R4 for no reason. I think V4 (Former Activity Director Assistant) was trying to deescalate the situation but R6 was beyond the point where she could had been calm down. It was just a verbal thing on V3's (Former Activity Director) part.R6 is [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Respiratory Failure; Chronic Obstructive Pulmonary Disease; Type 2 Diabetes Mellitus; End Stage Renal Disease; Essential (Primary) Hypertension: Restlessness and Agitation; Major Depressive Disorder; and Nicotine Dependence.According to R6's MDS (Minimum Data Set) assessment dated [DATE] under section C, R6 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition.Abuse care plan initiated 11/1/2023 reads in part, I (R6) present no unusual risk for abuse/neglect. There are no unusual or extraordinary risk factors present. However, given my (R6) compromised health status, physical decline and need for 24-hour care, the IDT recognizes that I (R6) am considered a vulnerable adult. Interventions: Assure resident (R6) that they are in a safe and secure environment with caring professionals; If resident (R6) is increasingly upset or agitated during care, ensure resident (R6) is safe. Politely excuse yourself and then report situation to supervisor and re-approach resident (R6) with assistance or alternative staff; Utilize behavior approaches that attempt to keep resident safe and calm by reassurance, redirection, task segmentation, cueing, reminders, re-approaching, reality orientation during care.On 7/21/2026 at 11:42 AM R6 said, Back in June 2026, after 2:30 PM, we were participating in the activities in the first-floor dining room. R1 and I were making puzzle; we were just about to be done when V3 (Former Activity Director) brought R4 to our table. R4 wanted to do puzzle with us, it's really V3 (Former Activity Director) who wanted R4 to do puzzle with us. I said, Absolutely not!. V3 (Former Activity Director) got really upset and said that R4 should be able to do puzzle with us and said Fuck off to me. I stormed out of the dining room and yelled back Fuck you! at V3 (Former Activity Director). I heard that V3 (Former Activity Director) said Fuck off to R1 as well. We didn't report the incident to anyone but someone else did. After the incident V2 (Director of Nursing) called us into the office to talk to us.On 7/21/2026 at 2:33 PM V5 (Social Service Director) said, V4 (Former Activity Director Assistant) said to me on 6/4/2026 if I heard what happened. I told V4 (Former Activity Director Assistant) that I don't know what she's talking about. V4 (Former Activity Director Assistant) said something happened between R1, R6, and V3 (Former Activity Director). I think it had to do something with another resident trying to do puzzles, but I'm not sure about the details. V3 (Former Activity Director) said Fuck you or Fuck off to R1. I asked if V4 (Former Activity Director Assistant) reported it to anyone, I don't remember her answer to that. I immediately reported the incident to V1 (Administrator) who is abuse prevention coordinator and to V2 (Director of Nursing).On 7/21/2026 at 3:05 PM V3 (Former Activity Director) said, On June 3rd, Wednesday between 2:15 PM -2:30 PM, I was assisting residents in arts and craft projects. R4 decided to come down to the dining room, to do puzzle. R1 and R6 got mad that R4 was trying to do puzzle. I explained to R1 and R6 that R4 has tendency to destroy puzzles due to his disability but still has a right to do it. I told R1 and R6 that I would get rid of the puzzle that R1 and R6 were working on if they won't share. Unfortunately, the incident escalated. We got into a heated argument with R6, R6 left the dining room, and it was pretty much quiet after that. In the heat of the moment I said, Fuck off. It wasn't directed to R6 or anybody else. I don't think what I said was appropriate, I could have handled it better. The next day, I was on vacation, and then I was suspended. I returned to work a week later. I voluntarily left couple of weeks later, and work at another facility now. I didn't report the incident to anyone, I didn't think it needed to be reported, I figured someone would say something anyway.On 7/21/2026 at 3:18 PM V4 (Former Activity Assistant) said, On 6/3/2026 around 3:00 PM, we were doing crafts with residents in the dining room on the first floor. At some point, R4 came down and wanted to join. R4 wanted to do puzzles. Some puzzles belong to R1 and R6, but we always told them they should put those away in their rooms if they don't want anybody else to use their puzzle. We explained to R1 and R6 that puzzles that are in the dining room belong to everyone and anyone can use them. The conversation escalated, V3 (Former Activity Director) said This is crap, you should all fuck off. After that R6 threw her craft at me, said Fuck you, and left the dining room. I feel that the situation could have been handled better, I know it wasn't handled right. V3 (Former Activity Director) should have never said what he said. R1 and R6 blew it out of proportion though. I don't think it was abuse, not at all, especially considering how R1 and R6 treat other residents. R1 and R6 rule the facility, and nobody does anything about it. I didn't report the incident at the time because I didn't think it was abuse. I didn't think of the incident as if it was anything to report. The next day, I was called into the office and asked about the incident. I was told that R1 and R6 were crying about what happened, I couldn't believe it. I was told I'm getting written up for not reporting the incident. I'm no longer in the facility; I gave two weeks' notice and left. I was at the facility for a little over a year and we got papers to sign that we had abuse training but there was not much of the training at all. The only good training we got was six months ago regarding how to treat and talk to residents, not so much regarding abuse. On 7/22/2026 at 10:11 AM V1 (Administrator) said, I was on vacation during an incident involving V3 (Former Activity Director). When I returned to work, on 6/8/2026, I was told by V2 (Director of Nursing) what happened. V3 (Former Activity Director) allegedly used foul language during residents' activities on 6/3/2026. I was told that there is allegation of abuse from V3 (Former Activity Director) towards R1. I did my own interviews with R1, V3 (Former Activity Director), V4 (Former Activity Director Assistant) and other residents who were present at the time of the incident. I was told that R4 was trying to do puzzle that R1 was working on for several weeks. As a result of the conflict, V3 (Former Activity Director) explained that he said, Shit to himself more so than to any other person present in the room. I asked R1 if she felt V3 (Former Activity Director) was a threat or danger, R1 denied. V3 (Former Activity Director) was suspended pending investigation, once I submitted the final report to local regulatory agency on 6/8/2026, V3 (Former Activity Director) returned to work on the following day (6/9/2026). V3 (Former Activity Director) later resigned due to unrelated reasons. The conclusion of the investigation was that verbal abuse was not substantiated. I believe I did post-incident employee abuse in-service. Staff abuse education is provided as often as we can, but scheduled abuse training is done annually and quarterly. If staff become aware of any allegation or occurrence of abuse, they should come to me immediately, if I'm not available, V2 (DON) should be immediately informed. If an incident happens outside of regular working hours, the nurse on duty should call me or V2 (DON) right away, we are available 24 hours a day.On 7/22/2026 at 10:47 AM V2 (Director of Nursing) said, The incident happened on 6/3/2026 between 2:15 PM - 4:00 PM. In the morning hours of 6/4/2026, I was told by V5 (Social Service Director) that V5 (Social Service Director) was told by V4 (Former Activity Director Assistant) that on the afternoon of 6/3/2026, there was an incident between V3 (Former Activity Director), R1, R4, and R6. I was told that residents were doing activities when R4 came in and was trying to do puzzle. R6 got upset because she didn't want R4 to do the puzzle. I was told that V3 (Former Activity Director) got frustrated and said F word, it wasn't directed to any of the residents though. Once I found out, I sent V3 (Former Activity Director) home, I interviewed R1, R6, and V4 (Former Activity Director Assistant). I then submitted the initial report and also provided in-service to V4 (Former Activity Director Assistant). We assessed R1 for well-being. All other residents who were involved said they had no concerns. I asked why V4 (Former Activity Director Assistant) did not report it immediately, V4 (Former Activity Director Assistant) said residents did not want to report it, residents said it was nothing. V3 (Former Activity Director) also didn't think it was something that needed to be reported, neither of them recognized it as verbal abuse.On 7/22/2026 at 1:53 PM V11 (Medical Director) said, After the incident, I was notified that couple residents were affected by an employee. As an effect, the employee was suspended. After the incident, facility staff discussed residents' care plans and education with me to establish necessary assessment. It is always discussed for residents' safety. I'm informed of every occurrence or allegation of abuse in the facility. We also discuss abuse issues in QAPI, but more so on as needed basis. The facility abuse prevention program emphasizes that employees get education regarding abuse, at least annually. The facility abuse policy indicates that employees should report any suspicion or occurrence of abuse right away. Employees should report any abuse incident immediately to their superior, department manager, and then to the administrator. It is important to report abuse immediately in order to investigate the incident and sustain safety of a resident. Trauma Informed Care sign in sheet dated 3/23/2026 shows V4 (Former Activity Director Assistant) presence indicating participation in most recent abuse prevention education as of 3/23/2026. Abuse sign in sheet dated 3/12/2026 - 3/13/2026 shows V3 (Former Activity Director) presence indicating participation in most recent abuse prevention education as of 3/12/2026 - 3/13/2026.The facility Abuse Prevention Program policy revised 2-2017 reads in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines).

Based on interview and record review, the facility failed to ensure staff immediately reported allegations of verbal abuse after witnessing the alleged incident, resulting in a delayed investigation. This failure affected two residents (R1 and R6) residing in the facility by preventing the facility from promptly initiating its abuse investigation and implementing timely interventions to protect residents from potential ongoing abuse, compromising residents' right to a safe environment free from abuse.Findings include:On 7/21/2026 at 9:18 AM Facility daily census shows 119 residents residing in the facility at this time. On 7/21/2026 at 3:05 PM V3 (Former Activity Director) said, On June 3rd, Wednesday between 2:15 PM -2:30 PM, I was assisting residents in arts and craft projects. R4 decided to come down to the dining room, to do puzzle. R1 and R6 got mad that R4 was trying to do puzzle. I explained to R1 and R6 that R4 has tendency to destroy puzzles due to his disability but still has a right to do it. I told R1 and R6 that I would get rid of the puzzle that R1 and R6 were working on if they won't share. Unfortunately, the incident escalated. We got into a heated argument with R6, R6 left the dining room, and it was pretty much quiet after that. In the heat of the moment I said, Fuck off. It wasn't directed to R6 or anybody else. I don't think what I said was appropriate, I could have handled it better. The next day, I was on vacation, and then I was suspended. I returned to work a week later. I voluntarily left couple of weeks later, and work at another facility now. I didn't report the incident to anyone, I didn't think it needed to be reported, I figured someone would say something anyway.On 7/21/2026 at 3:18 PM V4 (Former Activity Assistant) said, On 6/3/2026 around 3:00 PM, we were doing crafts with residents in the dining room on the first floor. At some point, R4 came down and wanted to join. R4 wanted to do puzzles. Some puzzles belong to R1 and R6, but we always told them they should put those away in their rooms if they don't want anybody else to use their puzzle. We explained to R1 and R6 that puzzles that are in the dining room belong to everyone and anyone can use them. The conversation escalated, V3 (Former Activity Director) said This is crap, you should all fuck off. After that R6 threw her craft at me, said Fuck you, and left the dining room. I feel that the situation could have been handled better, I know it wasn't handled right. V3 (Former Activity Director) should have never said what he said. R1 and R6 blew it out of proportion though. I don't think it was abuse, not at all, especially considering how R1 and R6 treat other residents. R1 and R6 rule the facility, and nobody does anything about it. I didn't report the incident at the time because I didn't think it was abuse. I didn't think of the incident as if it was anything to report. The next day, I was called into the office and asked about the incident. I was told that R1 and R6 were crying about what happened, I couldn't believe it. I was told I'm getting written up for not reporting the incident. I'm no longer in the facility; I gave two weeks' notice and left. I was at the facility for a little over a year and we got papers to sign that we had abuse training but there was not much of the training at all. The only good training we got was six months ago regarding how to treat and talk to residents, not so much regarding abuse.On 7/22/2026 at 10:11 AM V1 (Administrator) said, If staff become aware of any allegation or occurrence of abuse, they should come to me immediately, if I'm not available, V2 (DON) should be immediately informed. If an incident happens outside of regular working hours, the nurse on duty should call me or V2 (DON) right away, we are available 24 hours a day.On 7/22/2026 at 10:47 AM V2 (Director of Nursing) said, Once I found out (about the incident), I sent V3 (Former Activity Director) home, I interviewed R1, R6, and V4 (Former Activity Director Assistant). I then submitted the initial report and also provided in-service to V4 (Former Activity Director Assistant). I asked why V4 (Former Activity Director Assistant) did not report it immediately, V4 (Former Activity Director Assistant) said residents did not want to report it, residents said it was nothing. V3 (Former Activity Director) also didn't think it was something that needed to be reported, neither of them recognized it as verbal abuse.On 7/22/2026 at 1:53 PM V11 (Medical Director) said, After the incident, I was notified that couple residents were affected by an employee. As an effect, the employee was suspended. After the incident, facility staff discussed residents' care plans and education with me to establish necessary assessment. It is always discussed for residents' safety. I'm informed of every occurrence or allegation of abuse in the facility. We also discuss abuse issues in QAPI, but more so on as needed basis. The facility abuse prevention program emphasizes that employees get education regarding abuse, at least annually. The facility abuse policy indicates that employees should report any suspicion or occurrence of abuse right away. Employees should report of any abuse incident immediately to their superior, department manager, and then to the administrator. It is important to report abuse immediately in order to investigate the incident and sustain safety of a resident. Trauma Informed Care sign in sheet dated 3/23/2026 shows V4 (Former Activity Director Assistant) presence indicating participation in most recent abuse prevention education as of 3/23/2026. Abuse sign in sheet dated 3/12/2026 - 3/13/2026 shows V3 (Former Activity Director) presence indicating participation in most recent abuse prevention education as of 3/12/2026 - 3/13/2026.The facility Abuse Prevention Program policy revised 2-2017 reads in part, Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence.

Based on observation, interview, and record review the facility failed to follow their policy on the management of garbage and rubbish containing food waste when not in active use. This deficiency has the potential to affect all 116 residents receiving food from the kitchen. On 6/9/2026 at 9:20 AM during kitchen initial round one garbage bin about 1/3 full of refuse was without a lid/cover. Garbage bin was not in active use. V11 (Dietary Aide) said that the garbage bin should be covered. V12 (Dietary Manager) at 11:31 AM said that the garbage bin should be covered. V12 (Dietary Consultant) at 11:33 AM said that garbage bin should be covered when not in active use. The Pearl of Rolling Meadows Policy & Procedure ManualPolicy Section: Sanitation and Food SafetyTitle: Garbage and Rubbish DisposalPolicy: Garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters.Procedure:All garbage and rubbish containing food waste shall be kept in containers.All containers shall be provided with tight-fitting lids or covers, and such containers must be kept covered when stored or not in active use.F814 cited.

Based on observation, interview, and record review, the facility failed to implement infection control practices as evidenced by 1. During meal observation. 2.During medication administration. 3 Storing personal belongings in the housekeeping cart. 4. Not posting signage of enhanced barrier precautions (EBP). This deficiency has the potential to affect all 119 current residents of the facility reviewed for Infection control.Findings include: 1. On 6/9/26 at 12:37 PM, observed V8 (Activity Aide) passing out meal trays to multiple residents on the second-floor dining area, and no hand hygiene performed before or after each tray or resident contact. On 6/9/26 at 12:45PM, V8 said that she should have performed hand hygiene before and after, but said she forgot to do so. 2. On 6/10/26 at 8:45AM, during medication observation V18 (Licensed Practical Nurse) did not perform hand hygiene before start of medication preparation or after medication administration. On 6/10/26 at 9:00AM, V18 said she did not perform hand hygiene before or after medication preparation and should have done so for infection control purposes. On 6/10/26 at 11:45AM, observed V18 donning on gloves no hand hygiene performed. On 6/10/26 at 11:55AM, V18 said before and after glove usage hand hygiene is to be performed, but said she forgot to do it before applying gloves on. On 6/10/26 at 12:10PM, V2 (Director of Nursing) made aware of above observations and said that staff should follow infection control practices and should ensure appropriate hand hygiene is performed before and after meal administration and contact with residents, before and after glove usage and before and after medication administration. Facility Policy on Hand Hygiene revised 1/14/2026 Policy Statement It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Procedure: 1.Soap and water is required for hand hygiene when: a. Hands are visibly soiled; g. Before and after assisting a resident with meals; j. After removing gloves or aprons: and k. After completing duty. 2. Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g. when soap and water is not indicated per #1 above). Hand hygiene is to be performed: a. Prior to caring for a resident; d. After caring for resident including after removing gloves; and e. After contact with the resident environment. 3. On 6/9/2026 at 9:35 AM V10 (Housekeeping) has personal belongings (purse and sweater) next to clean rugs placed inside the housekeeping cart. V10 then proceeded to remove her belongings after surveyor inquired. On 6/9/2026 at 10:07 AM V3 (Infection Control Nurse) said personal belongings should not be stored inside the housekeeping carts. On 6/10/2026 at 8:45 AM V2 (Director of Nursing) said no personal belongings should be placed inside the housekeeping carts for infection control purposes. Belongings should be stored in their lockers. On 6/11/2026 at 9:53 AM V1(Administrator) said no personal belongings should be placed inside housekeeping carts. This is important because of infection control and there's chemicals inside the cart. Housekeeping personnel should put belongings in the lockers provided. Policy and Procedure Policy: Housekeeping Carts, date of review 1/1/2026 Purpose: To establish standards for housekeeping cart organization, stocking, security, cleanliness, and use to ensure a safe, sanitary, and efficient environment for residents, staff, and visitors in the nursing home. Responsibilities: Housekeeping Staff Housekeeping Supervisor Ensure compliance with infection prevention standards 4. On 6/9/2026 at 1:11 PM R3 with central line catheter/permacath located on the upper chest area used for hemodialysis. Outside the room there was no visible signage for Enhanced Barrier Precaution (EBP). On 6/9/2026 at 1:12 PM V3 (Infection Control Nurse) said there should be an EBP signage outside the room. On 6/10/2026 at 8:45 AM V2 (Director of Nursing) said if a resident has a permacath an EBP signage should be posted so staff would know how and when to use personal protective equipment (PPE). Review of EBP Precautions list, updated 6/1/2026, read, R3 factor in-dwelling medical device. Order Summary report, order date 5/31/2026 read Enhanced Barrier Precaution due to: Permacath dialysis access. Policy and Procedure Guideline: Enhanced Barrier Precautions, review date 1/14/2026 General: EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Guideline: 6. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE

Based on observation, interview and record review the facility failed to provide services and treatment to maintain and prevent further decrease in range of motion for one of six residents (R125) reviewed for range of motion in a sample of 24. Findings include: On 6/9/26 at 12:00PM, observed R125 sitting in dining area with no Left ankle foot orthosis (AFO) brace in place.On 6/9/26 at 12:10PM, V7 (Registered Nurse) said that R125 has an order for Left foot AFO to be in place when out of bed, said that whoever got R125 out of bed should have applied it. V7 verified R125 did not have left foot AFO in place.On 6/10/26 at 12:05PM, V2 (Director of Nursing) said that if residents have an order for braces or splints in place they should have them on. V2 said that usually it is applied when resident is out of bed and after restorative or certified nurse aides range of motion if applicable. R125 Physician order active 6/5/26 indicates- Left ankle, foot orthosis (AFO) on left foot. DON (Apply) when out of bed. DOFF (Remove) when in bed. R125 review of Care plan indicates Left AFO splint related to left foot drop date initiated 6/5/26. Intervention: Left foot AFO brace. Apply when out of bed. Remove when in bed. Facility Policy on Managing Residents with Impaired Physical Mobility. Revised 3/3/26.Policy Statement: The facility will provide care and management of physical mobility impairment based on cause and nature for deformity. Provide programs to prevent contractures and or further decline.Guideline:2. Treatment of Contracturesb. The following may be utilized in general: a. Physical therapy and occupational therapy evaluation and treatment as indicated. b. Restorative program based on assessment. c. Medical Devices: Supportive devices such as splints and casts may be applied to stretch the tissues of the affected body part based on therapy/MD recommendations. 4. Encourage the patient to use assistive devices and grooming aids as needed.

Based on observation, interview, and record review, the facility failed to follow its policy for self- administration procedure affecting 1 of 4 residents (R5) reviewed for medication safety in a sample of 24.Findings Include:On 6/9/2026 at 10:20 AM four pieces of white pills broke in half and in medication cup were on top of the R5's bedside table. R5 said it is her potassium medication that she would take after eating breakfast. R5 said staff would always leave it for her.On 6/9/2026 at 10:25 AM V9 (Nurse Supervisor) said medication should not be left at bedside. V9 proceeded to take the medication with her.On 6/10/2026 at 8:45 AM V2 (Director of Nursing) said no medication should be left at bedside. If resident can self-administer an assessment and care plan should be completed. Review of records with V2 indicate there was no documentation of physician order, assessment and care plan for self-administration of medication completed for R5.Order Summary, 6/4/2026, read: Potassium Chloride ER Tablet Extended Release 20 MEQGive 2 tablet by mouth one time a day for hypokalemia. Policy and Procedure read:Policy: Self Administration of Medication Program, reviewed 4/20/2026Statement: It is the policy of the facility to allow the resident and legal representative of the resident the right to self-administer medication when it has been deemed by interdisciplinary team that it is clinically appropriate.Procedure:1. The facility will allow the resident to self-administer drugs if the interdisciplinary team, has determined that this practice is safe. Nurse will complete a Self-Administration of Medication Assessment.10. Appropriate documentation of the above determinations will be documented in resident's care plan. Guideline: Medication Administration, Review date 4/18/2025Subject: Medication AdministrationIntent: 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, LPNGuideline:17. Remain with the resident to ensure that the resident swallows the medication

Based on interview and record review, the facility failed to ensure signed consents for the use of psychotropic medications (a drug which affects behavior, mood, thoughts, or perception) were obtained from the resident's representative related to the risks and benefits of using psychotropic medications for one of one resident (R2) reviewed for psychotropic medication use. Findings include:On 4/9/2026 at 11:30am this writer reviewed, R2 Physician Orders dated 1/8/2026 Quetiapine Fumarate 25mg, give 0.5 tablet by mouth three times a day for behavioral disturbances and on 1/25/2026 Quetiapine Fumarate 25mg give 12.5mg by mouth STAT for agitation one time only.On 4/9/2026 at 12:30pm V4(Nurse) said I spoke with the Nurse Practitioner concerning R2 behaviors, an increase in R2 psychiatric medication was ordered, I did not obtain a consent, If the nurses take an order for antipsychotic medication, then the nurses should obtain the consent moving forward I will do so.On 4/9/2026 at 1:50pm V2(Director of Nursing-DON) said I expect when a nurse obtains an order for a psychiatric medication that nurse should obtain a consent right away.An order summary report indicated that R2 had an order on 1/8/2026 for Quetiapine Fumarate oral tablet 25mg, give 0.5mg tablet by mouth three times a day for behavioral disturbance hold if drowsiness notes. An order on 1/25/2026 for Quetiapine Fumarate 25mg give 12.5mg by mouth STAT for agitation one time only. Facility Policy: Psychotropic Drug Use 3/20/2020Revised on 6/11/2025General:The purpose is to promote the safe and effective use of psychotropic medications that are used in lowest possible dose and time frame and have indications for use that enhance the resident's quality of life.Responsible Party:RN, LPN, Health Care Provider, PharmacistGuideline:Initiating the Use of Psychiatric Medications:7. If an order is obtained for a psychotropic medication, the resident, family, or POA must be in formed of the risks and benefits of the medication. The facility must obtain informed consent. If the family or significant other is not able to sign the consent, phone consent will be taken by the nurse verifying the consent. This document will be placed in the medical record in the designated area.

Based on interview and record reviews, the facility failed to ensure medication were administered as ordered by a Physician for one of three residents (R1) reviewed for medication administration. Findings Include:On 4/7/2026 at 11:40am R1said that she does not receive her medication at 6am and that medication help to balance her thyroid.On 4/7/2026 at 2:00pm this writer reviewed R1 electronic medication administration record indicating that on 3/5/2026, 3/28/2026 and 4/3/2026 at 6am levothyroxine sodium 125mcg. did not have a signature. On 4/9/2026 at 1:00pm V9(Nurse) said I did not work on those days, I think I would have signed them out or maybe I forgot to sign them out.On 4/9/2026 at 1:45pm V2 (Director of Nursing-DON) said I expect the nurses to sign out all medications if it is not signed it was not given.An order summary written on 6/25/2025 Levothyroxine sodium oral tablet 125mcg give 1 tablet by mouth one time a day related to unspecified hypothyroidism. A care plan focus of at risk for manifestations of hypothyroidism AEB, an intervention to administer hypothyroidism medication as per MD order.Facility Policy: Physician Orders Date 7/1/2020, Review date of 3/20/2026.Intent: Facility has a process to ensure that all Physician Orders are documented appropriately.Policy:Licensed Professional Nurses/Registered Nurses will follow orders form a physician and documented in a timely manner.All complete orders are entered in the EHR. Medication Administration 3/20/2020, Review 4/18/2025Policy and Procedure, Subject: Medication AdministrationIntent: 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, LPNGuideline:Medications are administered by licensed personnel only.18. If medication is not given as ordered, document the reason on the MAR.

Based on observation, interview, and record review, the facility failed to implement its smoke policy by allowing residents to smoke near the main entry door and not having metal containers with self-closing cover devices in smoking areas. This applies to all four smokers (R1, R2, R3, and R4) reviewed for safe smoking in a sample of 4.The findings include:On 12/19/25 at 9:12 AM, V2 (Director of Nursing/DON) stated that we have four smokers (R1, R2, R3, and R4) in the building, and our designated smoke area is on the left side of the building (50 to 60 feet away from the main entry door) with benches.R1 is a [AGE] year-old male with intact cognition as per the Minimum Data Set (MDS). On 12/19/25 at 9:15 AM, observed R1 coming from the left side of the building after smoking. R1 stated, I pretty much smoke here on the left side of the building. Sometimes I go to the right side of the building to smoke.On 12/19/25 at 9:15 AM, observed the designated smoke area with V2 and observed cigarette butts on the ground with no metal containers with self-closing cover devices in the smoking premises.On 12/19/25 at 11:10 AM, observed the facility's main entry door with V3 (Social Service Director). The main entry door was observed with benches on both sides, 10-15 feet away from the entry door. Observed numerous cigarette butts around both benches close to the main entry door.On 12/19/25 at 11:05 AM, observed the right side of the building (50 to 60 feet away from the entry door with V3 and observed two benches and cigarette butts on the ground, with no self-closing devices in the premises.On 12/19/25 at 11:00 AM, V3 stated, The smoking residents are supposed to smoke on the left side of the building. We are telling them, but they don't listen. If the residents are smoking near the entry door, the receptionist is supposed to redirect them to the designated area. There should be self-closing devices in the designated smoking premises.On 12/19/25 at 11:20 AM, V1 (Covering Administrator) stated, I just came to cover for the administrator here. This facility used to be a non-smoking facility. Now they admit smokers, too. We will clean up the cigarette butts near the entry door and educate residents not to smoke there.A review of the facility presented a policy on smoking residents (reviewed on 4/18/24) document:2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building.4. Metal containers, with self-closing cover devices, are available in smoking areas.

Based on observation, interview, and record review the facility failed to revise and update the comprehensive care plan for one resident identified with injury of unknown origin. This deficiency has the potential to affect 1 of 3 residents (R1) reviewed for Injury of Unknown Origin in a sample of 3. Findings Include:R1 admitted to facility on 11/6/2018. Diagnosis information includes senile degeneration of brain, Alzheimer's disease, primary generalized osteoarthritis, vascular dementia. On 11/25/2025 at 10:43AM, R1 in the second-floor dining room, seated on the wheelchair with pillow on her back and no protective (geri) sleeves worn was observed.Review of Illinois Department of Public Health (IDPH) final report, date 8/25/2025, State Report indicate R1's intervention include staff to place pillows on her sides when up on wheelchair, to provide additional support or cushion when leaning on hard surface. Will provide Gerisleeves to both arms. Review of comprehensive care plan report did not indicate the occurrence and revision/updated interventions of R1's injury of unknown origin date of 8/20/2025.On 11/25/2025 at 10:21 AM V2 (Director of Nursing) and V3 (Restorative Nurse) both stated there was no plan of care revision/update for R1 addressing pillows to be placed on the sides while sitting on the wheelchair and R1 to wear bilateral protective (geri) sleeves. V2 stated care plan should have been updated after concluding her investigation of R1's injury of unknown origin, date 8/25/2025 to reflect the new plan of care. V2 stated resident care plan is updated when there are changes, quarterly, and after investigation of injury of unknown origin.On 11/25/2025 at 10:55 AM V4 (Registered Nurse) stated she's aware of R1's injury of unknown origin (bruising on the left cheek) but doesn't know the new interventions on her care plan. V4 said she reviews care plan at the start of her shift. Policy and ProcedureTitle: Comprehensive Care Plans, Reviewed 9/18/2025Policy Statement: To meet the resident's physical, psychosocial and functional needs, facility will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and target goals.Procedure:10. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review the facility failed to notify the local emergency room hospital of a resident's transfer for 1 of 1 resident (R1) reviewed for admission, transfer and discharge. Findings include:On 8/12/2025 at 11:30am V4(Nurse) said that R1 had an unwitnessed fall and was found on the bedroom floor with a pillow under his head, V4 said that R1 is alert and oriented times one and unable to say what happened R1 was assisted to the bed and the nurse practitioner gave orders to send to the local emergency room for an evaluation. V4 said that she gave report to the oncoming nurse of the incident, prepared documents, while R1 was waiting for the ambulance to arrive, V4 said she did not notify the local emergency room hospital of R1 transfer because she did not know when the ambulance would arrive, V6(Nurse) expressed understanding. On 8/12/2025 at 1:00pm V6(Nurse) said that he received report from the ongoing nurse of R1 fall and that R1 is alert but confused and would not be able to say what happened to him. V6 said when the ambulance arrived, he gave documents to the ambulance, and he did not notify the local emergency room of R1 arrival for an evaluation of a fall that is for the ambulance driver to do we don't do that here. On 8/12/2025 at 1:10pm V2 (Director of Nursing-DON) said I expect all nurses to notify the receiving facility of a transfer even if they can advocate for themselves or not, R1 is confused and cannot speak for himself the local emergency room hospital should have been notified.On 8/12/2025 at 1:15pm V1(Administrator) said I expect all nurses to give a full report to the receiving facility of any resident transferring. An admission Record dated 8/12/2025 indicates R1 has a diagnosis of Delirium due to know physiological condition, cognitive functions and abnormalities of the gait and mobility, a care plan dated 8/12/2025 for impaired cognitive function/dementia or impaired thought processes. Facility Policy:Transfer or Discharge, Emergency revised 2/28/2025Policy Statement:Emergency transfers or discharges may be necessary to protect the health and /or well -being of the resident. Procedure:4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures. b. notifies the receiving facility that the transfer is being made.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for residents at high risk for falls and failed to implementing interventions for a resident with wandering behaviors. These failure applied to three of five residents (R52, R56, and R61) reviewed for falls and resulted in R52 sustaining a right hip fracture and a head injury requiring medical treatment. Findings include: Per the facility's incident log from 09/01/2024 - 03/24/2025 the facility has had 73 unwitnessed falls with 18 of them involving memory care residents, R52 had a fall each month from December 2024 - March 2025 with two of them being unwitnessed, and R61 had four falls within three weeks of admission with three of them being unwitnessed. 1. R52 is a [AGE] year-old female with a diagnosis history of Dementia with Behavioral Disturbance, Anxiety Disorder, Age Related Cataracts, and Stroke who was admitted to the facility 02/06/2019. The facility's incident log from 09/01/2024 - 03/24/2025 documents R52 had a witnessed fall on 12/18/2024 at 9:13 AM, and unwitnessed falls on 01/12/2025 at 4:30 AM, and on 02/09/2025 at 6:55 AM Per the facility's reportable event log received 03/24/2025 R52 had a fall on 12/18/2024 that resulted in a right hip fracture and a fall on 01/12/2025 that resulted in a laceration of her head. R52's quarterly Minimum Data Set, dated dated dated [DATE] documents she requires supervision or touching assistance for walking 10-150 ft. R56's fall risk assessments dated 12/18/2024 and 12/24/2024 documents she is at high risk for falls. R52's current care plan created 02/18/2019 documents she exhibits behavioral symptoms as evidenced by wandering and at times can be difficult to redirect and unaware of her safety needs with an intervention implemented 02/18/2029 of approaching/speaking in a calm manner and an intervention implemented 05/17/2019 of walking with R52 when she is wandering to ensure safety. R52's current care plan created 04/20/2019 documents she is at risk for falls related to diagnosis of dementia, confusion, poor communication/comprehension, poor safety awareness, wandering, and behaviors of feeling around door joints and attempting to open the door and leave the unit with intervention implemented 04/20/2019 including follow facility fall protocol, interventions implemented 03/21/2024 including staff to assist her in the dining room when meals are ready, allow her more sleep instead of having her wait in the dining room for meals; and intervention implemented 02/09/2025 of ensuring there is adequate supervision in the dining room. R52's current care plan created 12/19/2024 documents she has had an actual fall on 12/18/2024 which resulted in a fracture with interventions including staff checking her location and activity to ensure if she is properly and safely positioned in bed or chair/wheelchair. R52's current care plan initiated 01/12/2025 documents she had a fall on 01/12/2025 which resulted in a laceration on her left temple. Fall Risk Management report dated 12/18/2024 documents R52 was observed walking down the hall after breakfast towards the door and when she was getting close by the door the nurse called her trying to redirect her and she turned around quickly, lost her balance and fell landing on the right side of her hip. The facility's reportable event investigation report dated 12/19/2024 documents on 12/18/2024 R52 was observed walking towards the door and when she was getting close to it, the nurse called her and tried to redirect her, she turned around quickly, lost her balance, had a change in plain and was sent to the emergency room for further evaluation and treatment and was admitted with a right hip fracture. Fall Risk Management report dated 01/12/2025 documents at 4:30 PM R52 was found on the floor with a laceration on her head and was bleeding, while V20 (Nurse) was passing medications with her cart she turned around for a second and the next thing she heard behind her was the sound of a fall; contributing factors to R52's fall included confusion, impulsiveness, need for two person assistance with transfers, history of falls, observations of attempts at getting up without assistance recently, recently having surgery on her right hip, and diagnosis of fracture of right lower leg. R52's hospital discharge report dated 01/12/2025 documents she was diagnosed with a closed head injury, and scalp laceration and received laceration repair. The facility's reportable event investigation report dated 01/18/2025 documents R52 had an unwitnessed fall at approximately 4:40 PM on 01/12/2025 and sustained an approximately 3-centimeter laceration to her head, was sent to the emergency room for further evaluation and treatment and returned the same day to the facility with three staples to be removed in 7 days. Fall Risk Management report dated 02/09/2025 documents R52 had an unwitnessed fall and was observed sitting on the floor in front of her wheelchair by the dining room with the root cause being losing her balance and falling when attempting to stand up from her wheelchair. On 03/26/25 at 03:28 PM V18 (Restorative Nurse) stated he is the fall coordinator. V18 stated R52 has always been able to walk, and she fell on [DATE] due to suddenly turning around. V18 stated R52 had a fall at 4:30 PM on 01/12/2025. V18 stated R52 was sitting in the dining room and trying to stand. V18 stated a nurse was present and tried to catch her but didn't make it in time. V18 stated he believes the nurse was administering medications at the time. V18 stated there are usually a lot of residents in the memory care dining room. V18 stated usually there are two aides in the dining room at mealtimes and at that time there was not two aides possibly due to passing trays. V18 stated at least two aides are needed in the dining room for proper supervision. V18 stated on 02/09/2025 R52 was near the dining room in her wheelchair and attempted to stand up and loss her balance and fell . V18 stated this was an unwitnessed fall so there weren't any staff present. V18 stated there should be some staff present to monitor residents. On 03/27/2025 at 8:47 AM V2 (Director of Nursing) stated if there are several residents in the dining room, they would be sending more than one staff to supervise but it is not always their protocol to always assign and/or station two nurses or CNAs (Certified Nursing Assistant) at all times when residents are present in the dining room. V2 stated she understands that residents need supervision. V2 stated she was the one who conducted and completed the investigation after R52's fall incident and the nurse was by the dining room door beside her med cart where she can see the resident, but unfortunately, she wasn't able to get to the resident as fast as she could to prevent her fall. On 03/27/2025 at 10:19 AM V2 (Director of Nursing) stated on 01/12/2025 when R52 had a fall there were 36 total residents in the memory care unit. V2 reported there are 12 residents in the memory care unit that are at high risk for falls. In response to the surveyor asking if a nurse is the only staff in the dining room with multiple residents on the memory care unit, and she is passing medications while someone is falling, doesn't that make it difficult to assist the resident who begins to fall or even monitor all the residents present in the dining room; V2 replied that on 01/12/2025 the CNA (Certified Nursing Assistant) was asked to assist another resident with toileting and a nurse was in the dining room to oversee the residents while the other was helping with bringing residents to the dining room for dinner. On 03/27/25 at 03:03 PM V18 (Restorative Nurse) confirmed R52 and the nurse that witnessed her fall on 12/18/24 were inside the unit during the incident. V18 stated R52 and the other memory care residents usually roam around the memory care unit and wont usually attempt to leave and when they reach the exit door they turn back around. V18 stated if staff saw R52 approaching the memory care unit exit door they can monitor her to ensure she's ok and they usually just let the residents walk around. V18 stated in R52's particular situation on 12/18/2024 he can't think of anything the nurse could have done differently to prevent her fall because staff weren't expecting her to fall the way she did. V18 stated he doesn't think the nurse calling out to R52 could have startled her. V18 agreed the nurse was likely not close by R52 when she was approaching the door and therefore her voice calling out to R52 would not have been soft and low and agreed that the nurse would have had to call out to R52 loudly enough to be heard and get R52's attention. When asked by surveyor if the nurse could have just guided R52 away from the door rather than calling out to redirect her V18 could not provide any information. 2. R56 is a [AGE] year-old female with a diagnoses history of Alzheimer's, Dementia, Generalized Anxiety Disorder, Restlessness and Agitation who was admitted to the facility 04/12/2023. The facility's incident log from 09/01/2024 - 03/24/2025 documents R56 had an unwitnessed fall 03/21/2025 at 5:15 PM R56's current care plan created 04/25/2023 documents she is at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, and poor safety awareness with interventions implemented 04/25/2023 including follow facility fall protocol. R56's quarterly fall assessment dated [DATE] documents she is at high risk for falls. Fall Risk Management report dated 03/21/2025 documents R56 had an unwitnessed fall and was observed sitting on the floor on her right-side by the dining room and the root cause of the fall being she most likely fell asleep in her wheelchair while waiting for dinner. On 03/26/25 at 03:28 PM V18 (Restorative Nurse) stated according to the investigation of R56's fall on 03/21/2025 the nurse reported R56 fell asleep while sitting in her wheelchair and fell forward in the dining room. V18 stated this was an unwitnessed fall. V18 stated staff were likely passing trays and unable to catch R56. On 03/27/2025 at 10:19 AM V2 (Director of Nursing) reported the facility does have enough staff to assist the residents in the dining room. V2 reported the facility usually has nursing and activity staff present in the dining room during meals. In response to surveyor asking should there be multiple staff in the memory care dining room during mealtimes or when multiple residents are present; V2 reported they usually have 2 Nurses, 3 CNAs and 1 Activity Aide to assist with the residents. In response to surveyor asking why should there be multiple staff present in the memory care dining room during meal times or when there are multiple residents; V2 responded they have nursing to assist with feeding the residents and activities assist with passing the trays and just rounding to make sure residents have what they need. 3. R61 is a [AGE] year-old male with a diagnoses history of Dementia with Behavioral Disturbance, Encephalopathy, and Depression who was admitted to the facility 02/10/2025. On 03/24/25 at 10:57 AM Observed R61 in his room in his bed wearing a gown and protective sleeves over both his arms. Observed R61's right arm with multiple scabs and his right-hand knuckles with multiple scabs with dry blood sticking to the sleeve, a bruise, and a small bandage. The Facility's incident log from 09/01/2024 - 03/24/2025 documents R61 had a witnessed fall on 03/04/2025 at 8:30 AM, and unwitnessed falls on 02/13/2025 at 5:11 AM, 02/22/2025 at 2:30 PM, and 03/08/2025 at 11:05 AM. R61's admission Fall Risk assessment dated [DATE] documents he is at high risk for fall. R61's current care plan created 02/11/2025 documents he is at risk for falls related to generalized weakness, increased confusion, impaired cognition, altered mental status, and multiple medical conditions including activity intolerance and has exhibited behaviors of putting himself on the floor with intervention implemented 02/11/2025 of ensuring his call light is within reach and encouraging him to use it for assistance as needed, assessing and anticipating his personal needs and needs of activities of daily living such as toileting, incontinence care, eating etc. during rounds, ensuring he is centered in bed and bed bolsters are properly secured as appropriate and trunk and extremities are properly aligned and supported; intervention implemented 03/04/2025 of placing him in the dining room in the morning if he is observed up and awake if he will allow. R61's current care plan created 02/19/2025 documents he exhibits poor safety awareness and attempted to get out of chair/bed without staff monitoring and has difficulty comprehending redirection. Fall Risk Management report dated 02/13/2025 documents R61 had an unwitnessed fall in his room and was observed laying on the floor on his right side with his head at the foot of the bed and mattress halfway off the bed and tilted; R61 reported he slid off the bed; Contributing factors include being admitted to facility due to fall and increased confusion, observed with agitation and confusion, and having diagnoses including pneumonia and altered mental status; Root causes of the fall include R61 moving on his bed and the mattress tilted and he slid off to the floor. Fall Risk Management report dated 02/22/2025 documents R61 had an unwitnessed fall and was found on the floor in the hallway lying on his right side and his wheelchair behind him with the root cause being R61 making his way to the room from the dining room, wanting to go to the toilet, attempting to self-transfer without assistance, and losing his balance and falling. Fall Risk Management report dated 03/04/2025 documents R61 had an unwitnessed fall in his room and was observed sitting on the floor and reported he put himself on the floor; he was observed to have small scratches on both his knees with the root cause including attempting to get out of bed. Fall Risk Management report dated 03/08/2025 documents R61 had an unwitnessed fall and was observed lying on the floor on his right side by the hallway close to the nurses station and was observed with a bump on the right side of his forehead, skin discoloration, skin tears on multiple fingers on his left hand, skin tears on his right hand and right elbow and was sent to the emergency room for evaluation; R61 reporting he wheeled himself on his wheelchair and slipped from the wheelchair; the root cause of the fall includes R61 sliding down from his wheelchair. On 03/26/25 at 03:28 PM V18 (Restorative Nurse) stated R61 is very impulsive and has had previous attempts to get out of bed on his own before falling 02/13/2025 and interventions for this would include low bed, floor mats, encourage toileting, offering to get him up in the wheelchair when already awake, offering activities, and trying to redirect him. V18 stated R61 needs frequent supervision, and should be somewhere he can be monitored. V18 stated if R61 has been sitting in a place for a while he'll try to wheel himself somewhere. V18 stated R61's falls o 02/22 and 03/08 were due to him attempting to ambulate himself in the wheelchair and he will attempt to stand up. V18 stated interventions for this behavior is to have R61 close by staff for monitoring. On 03/27/2025 at 1:34 PM in response to surveyor asking would lack of supervision or insufficient supervision cause of fall to be unavoidable; V2 (Director of Nursing) replied that the need for supervision or level of supervision is a factor, depending on the resident and a high-risk resident that is not adequately supervised is more likely to have a fall than a more mobile resident. The facility's Fall Prevention and Management Policy received/reviewed 03/25/2025 states: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. High-Risk Precautions will be implemented to residents and patients whose scores on Resident/Family Notification fall Risk screen shows high risk with interventions including but not limited to meaningful and or scheduled rounds.

Based on observation, interview, and record review, the facility failed to ensure that staff provide shower and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected four (R16, R24, R28, and R86) of five residents reviewed for ADL care. Findings include: R24 is [AGE] years old and has resided at the facility since 2016, past medical history includes hemiplegia and hemiparesis following nontraumatic intracranial hemorrhage affecting right dominant side, chronic obstructive pulmonary disease, chronic kidney disease stage 1, pain in left leg, etc. On 03/24/25 10:20AM, R24 was observed in her room, awake and alert and stated that she has been at the facility for a while, R24 said that she has issue with showers because it seems like they do not have enough people to do the showers. R24 said that she does not receive her showers two times a week as scheduled. Resident stated that she does not have any wounds that she is aware of, but her bottom feels raw, and she cannot see back there. Resident cannot recall the last time she was showered, added that she mostly gets bed bath. Shower schedule for the second floor documented that R24 is supposes to get shower on Monday and Friday on day shift. Review of shower sheets from January to March showed that R24 received about 4 showers. Restorative care plan initiated 4/30/2016 states that R24 that has ADL Self-care deficit related to physical limitations. Interventions include Assist to bathe/shower as needed. Shower Tues-Fridays. Assist with daily hygiene, mobility task, toileting, grooming, dressing, oral care and eating as needed, Resident is totally dependent on 1 staff for showering/bathing, etc. R86 is [AGE] years old and have resided at the facility since 2021, past medical history includes unspecified cord compression spinal stenosis cervical region, lymphedema, bilateral primary osteoarthritis of knee, hypothyroidism, etc. 03/24/25 10:45AM, R86 was observed in her room with her husband, awake, alert and oriented and stated that she has been here for three years, everything is going wrong, she is supposed be transferred with a sit to stand machine, the facility still has her marked as a being transferred by a mechanical lift. R86 added that she does not get her scheduled showers, only bed baths, and has only received three showers since admission to the facility. R86 is scheduled for showers on Tuesday and Friday, shower sheets for January through March 2025 showed that R86 received about three showers and mostly bed baths. Care plan initiated 12/21/2021 states, R86 has an ADL self-care performance deficit r/t dx of Spinal Stenosis, Cord Compression, Lymphedema, Morbid Obesity. Interventions: BATHING/SHOWERING: The resident requires substantial assistance by 1 staff with bathing/showering. Provide sponge bath when a full bath or shower cannot be tolerated. The resident requires partial assistance by 1 staff to turn and reposition in bed. The resident requires partial assistance by 1 staff for upper body dressing and substantial assistance for lower body dressing. R28 is [AGE] years and has resided at the facility since 2024, past medical history includes type 2 diabetes, chronic respiratory failure, dependence on renal dialysis, absence of right leg below the knee, acquired absence of left leg below the knee, end stage renal disease, etc. 03/24/25 10:45AM, R28 was observed in her room, awake and alert and stated that she is doing okay. Resident said that she does not get out of bed, do not get showers only bed baths. R28 was asked if she would like to get showers and she said that will be fine for a change. R28 is scheduled for showers on Tuesday and Saturday on second shift. Review of shower sheet from January to March showed that R28 received one shower, a couple of bed baths. Care plan initiated 2/16/2024 states: The resident has an ADL self-care performance deficit r/t bilat BKA, needs assistance with personal care. Interventions: The resident requires substantial assistance with showering/bathing. The resident requires supervision by 2 staff to turn and reposition in bed. The resident requires partial moderate assist with 1 staff with personal hygiene and oral care. The resident is totally dependent on (2) staff for toilet use. R16 is [AGE] years and has resided at the facility since 2019, past medical history includes but not limited to malignant neoplasm of colon, morbid (severe) obesity, frontotemporal neurocognitive disorder, anxiety disorder, history of falling, etc. On 03/24/25 11:06AM, R16 was observed in his room sleeping but awakes to greetings. R16 was noted wearing a hospital gown and looked very dirty, resident's room was cluttered with clothes and garbage. R16 have lots of facial hair and overgrown hair, brownish substances noted on long fingernails. 03/25/25 10:58AM, R16 was observed in his room sleeping but responds to greeting, stated that he is doing okay and noted with long dirty fingernails on both hands, overgrown hair, and lots of facial hair, still wearing a hospital gown. R16 is scheduled for showers on Monday and Thursday second shift. Shower sheets for January to March documented about four showers for the resident. Restorative care plan dated 8/27/2019 states R16 has an ADL self-care performance deficit r/activity Intolerance, Fatigue, Limited Mobility. Intervention include Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. The resident requires supervision by x1 staff with showering as necessary. The resident requires supervision by x1 staff to turn and reposition in bed as necessary. On 03/26/25 03:00 PM, V1 (Administrator) said that some residents refuse their shower, when a resident refuses shower, they offer a bed bath and if resident still refuses, the staff is supposed to go back different time to see if resident will accept. Shower refusals are supposed to be documented in medical record by staff. Surveyor requested any progress notes documented for shower refusal for any of the residents, but none was provided. Activity of daily living support with showers policy reviewed 5/22/2024 states in part: residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Residents who are unable to carry out ADL independently will receive the services necessary to maintain good nutrition, grooming and personal oral hygiene. Under procedure 2 (g). Showers will be offered and encouraged twice a week. If resident refuses alternative bed bath/sponge bath with perineal care will be given as option. If resident continues to refuse, MD/POA will be notified if a pattern has been established weekly and as indicated.

Based on interview and record review, the facility failed to provide residents with palatable and attractive food. This failure affected 13 of 13 residents (R20, R24, R28, R38, R32, R84, R70, R41, R117, R126, R69, R78, and R35) reviewed for dining. Findings include: On 3/24/2025 at 10:17AM, R20 said that the food is very bad, she does not eat anything from the facility and has to order food from outside all the time. At 10:20AM, R24 said the food is not good and they do not really have a lot of alternatives to choose from. At 10:45AM, R28 said she does not like the food and has her family bring her food from outside. At 10:50AM, R38 said the food is not good. At 10:54AM, R32 stated he hasn't had a warm breakfast in months. At 11:15AM, R84 and R70 said the food is always cold. At 11:35AM, R41 said the food is horrible. I have to have my family grocery shop for me, and I eat what I have in my refrigerator. It is to be noted that R41 had her own refrigerator in her room with multiple various food items for meals and dry storage goods stored. At 11:40AM, R117 said the good is very poor quality and when you ask for extra items, they do not give it to you. At 11:48AM, R126 said the food is not good. Said the waffles are always hard. At 11:56AM, R69 said I do not like the food, and it is too bland. On 3/26/2025 at 1:15PM, R78 said the food is terrible. I believe they have a really low budget and serve us cheap food products. R35 said at this time that the food is always cold. It is to be noted that there were seven grievances dated 1/1/2025-3/22/2025 showing a concern related to the food being served including but not limited to food being served cold and disliking the food. Resident Council Meeting Minutes dated 1/23/2025 states in part but not limited to the following: The cake is not frosted enough, some of the dishes did not have enough sauce or spices. The food is sometimes cold. On 3/26/2025 at 10:50AM, V12 (Dietary Director) was interviewed regarding resident food concerns. V12 said I do not always attend the resident council meetings. Said when residents express food concerns the staff should be letting me know so that I can follow-up with them.

Based on observation, interview, and record review, the facility failed to ensure that staff provide incontinence care in a timely manner for a resident assessed as dependent on staff for Activities of Daily Living (ADL). This failure affected one (R24) of one resident reviewed for incontinence care. Findings include: R24 is [AGE] years old and have resided at the facility since 2016, past medical history includes hemiplegia and hemiparesis following nontraumatic intracranial hemorrhage affecting right dominant side, chronic obstructive pulmonary disease, chronic kidney disease stage 1, pain in left leg, etc. On 03/24/25 at 10:20AM, R24 was observed in her room, awake and alert and stated that she has been at the facility for a while, she has issue with showers because it seems like they do not have enough people to do the showers. R24 said that she has not been changed today and have been waiting to be changed. R24 said that she is very wet right now, she was not changed during the night shift, the last time she was changed was yesterday before she went to bed. R24 stated that she does not have any wounds that she is aware of, but her bottom feels raw, and she cannot see back there, it is usually painful when she sits for a long time. On 03/24/25 at 11:30AM, observed incontinence care for R24. Upon entering the room, noted a very strong urine odor, and observed two adult brief that were both soaked with urine and brownish in color. Resident's bed pad and sheet were noted to be wet with brownish colored ring like stain in the middle. V5 (C.N.A) confirmed that resident's bed she and the bed pad are wet with urine. with urine. R24 was noted with redness and excoriation all over her bottom, with some whitish substances. V 5 stated that they apply barrier cream to resident's bottom after every incontinence brief change. Regarding the two adult briefs, V5 said that R24 have that because he gets wet very often, but she is not the one that put the two adult briefs on her. Care plan dated 1/2/2025 states that resident has urinary incontinence related to functional incontinence, impaired mobility, and physical limitations. Goal states that resident will have no complications related to incontinence. Interventions: Provide assistance with toileting, provide incontinence care as needed, report changes in amount and frequency, use absorbent pads/ briefs as needed. On 03/26/25 at 03:00 PM, V2 (DON) said that residents can wear two incontinence briefs at a time if it is their preference and it will be care planned. V2 added that R24 gets upset if she does not get two incontinence briefs. Surveyor asked V1(Administrator), V2 (DON) and V17 (CNO) if having two incontinence briefs justify leaving resident soaking wet, and whether it is acceptable for a resident to wait a whole day before their incontinence brief is changed and they all said that it is not acceptable, residents should be changed as needed. Urinary incontinence care policy revised 2/13/2025 states in part; Our facility will ensure and provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Incontinence care will be provided by nurse or C.N.A every shift based on incontinence needs of resident. Staff will ensure that incontinence needs are met.

Based on observation, interview, and record review, facility staff failed to follow facility medication administration policy of ensuring that staff document the administer narcotic medications in the narcotic count sheet, and failed to ensure that the narcotic medications are properly reconciled by staff. These failures affected three (R39, R43 and R70) of five residents reviewed for psychotropic medications and have the potential to affect residents in the North wing, TCU, and memory care units of the facility. Findings include: R39 is [AGE] years old and has resided at the facility since 2026, past medical history includes, but not limited to malignant neoplasm of unspecified kidney, except renal pelvis, chronic pancreatitis, unspecified dementia, type 2 diabetes, anemia, etc. Physician order dated 6/7/2024 showed the following: Morphine Sulfate (Concentrate) Solution 20 MG/ML *Controlled Drug* Give 0.25 ml sublingually every 2 hours as needed for pain; sob. 03/25/25 11:15AM, reviewed the standard even medication storage cart on the second floor with V7 (LPN) and noted the following: R39 had one bottle of morphine sulfate, 20mg/ml solution. the narcotic administration sheet documented 5ml as the amount left, review of the medication bottle showed 3.5ml on hand. V7 said that she is not sure what happened but will follow up with the director of nursing. R43 is [AGE] years old and has resided at the facility since 2028, past medical history listed include, but not limited to restlessness and agitation, generalized anxiety disorder, personal history of malignant neoplasm of breast, vitamin D deficiency, anemia, etc. Physician order dated 11/13/2023 showed the following: Ativan Solution 2 MG/ML (Lorazepam) *Controlled Drug*Give 0.5 milliliter sublingually three times a day related to restlessness and agitation (R45.1) may use Ativan prn (as needed) in between scheduled if needed hold if RR <12, then call NP/MD. On 03/25/25 11:45AM, reviewed the odd cart in the memory unit with V8 (LPN) and noted the following: R43 had a bottle of Lorazepam 2mg/ml solution in the refrigerator. The narcotic count sheet documented on that the resident had 17.5ml left, review of the bottle showed more than 30ml remaining. V8 said that there is still a lot left because the medication comes full when it is received. The amount documented as received on 3/16/2025 in the narcotic count sheet is 30ml. R70 is [AGE] years and has resided at the facility since 2024, past medical history includes, but not limited to primary osteoarthritis right and left shoulder, type 2 diabetes, ocular pain left eye, legal blindness, etc. Physician order dated 3/21/2025 show the following: Morphine Sulfate 20mg/ml *Controlled Drug*Give 0.25 ml by mouth two times a day for pain/SOB Hold for drowsiness and/or for respirations less than 14 and Give 0.25 ml by mouth every 4 hours as needed for pain/ SOB Hold for drowsiness and/or for respirations less than 14. On 03/25/25 11:15 AM, reviewed the TCU unit medication cart with V9 (RN) and noted the following, R70 had one bottle of morphine sulfate 20mg/5ml solution in the refrigerator. Narcotic count sheet documented 28.5 mg as the quantity remaining, the actual medication on hand was 25mg. This observation was presented to V9, and she said that she does not know why the quantity on hand is less that the amount documented in the narcotic count sheet. On 03/26/25 9:39 AM, V2 (DON) said that she investigated and found out that some nurses were giving the medication to V9, but were not documenting in the narcotic sheet but document in the medication administration record (MAR). Nurses are supposed to sign both the narcotic sheet and the MAR whenever medication is administered. For R43, V2 said that the resident still has a lot of medication remaining because the medication comes full, moving forward, the facility will start documenting the actual amount received to help with accurate reconciliation. Facility protocol on controlled substances dated 8/13/2023 under documentation guideline started in part: complete documentation in the narcotic book prior to administering controlled substances to the resident. Check the count with each administration to ensure accuracy. Initial the Medication administration record (MAR) after administering medication. Counting: All controlled substances including the ER narcotic kit and medications in the refrigerator must be counted at each shift change. Both the oncoming and outgoing nurse should look at the card and narcotic book to ensure accuracy.

Based on interview and record review the facility failed to provide Quality of Care/Treatment related to clinical management of Urinary Tract Infection (UTI) affecting 1 of 4 (R3) residents reviewed for Quality of Care/Treatment. Findings Include: On 3/11/2025 at 11:05 AM V3 (Assistant Director of Nursing/IP) stated on 1/13/2025, he received an order from V18 (Nurse Practitioner) to start R3 with antibiotic Bactrim twice a day for 3 days. V3 stated he entered the order into the electronic medication administration (EMAR) to reflect first dose in 1800 to be administered by nurse on duty. Bactrim antibiotic was ordered STAT from Pharmacy and delivered on 1/14/2025 at 12:31AM to facility. V3 stated first dose of antibiotic can be obtained in the facility convenience box (also known as pixes, capsca). V16 (Licensed Practical Nurse/LPN) nurse to give the first dose acknowledged she did not give the Bactrim as ordered on 1/13 at 1800 to R3. V13 (Licensed Practical Nurse), AM shift nurse on 1/14/25, verbally stated she gave the antibiotic Bactrim on 1/14/2025 at 0900 but acknowledged not signing the EMAR. V13 said EMAR is signed as soon as medication is given, I should have signed the EMAR. On 3/13/2025 at 11AM, V2 (Director of Nursing) said medication should be given as ordered and nurse to sign off on the EMAR for record administration. Review of R3's Electronic Medication Administration (EMAR) dated 1/1/2025 - 1/31/2025 indicated no nursing signature of administration on 1/13/2025 in 1800 and 1/14/2025 at 0900. Review of Progress Note Effective date 1/11/2025 at 11:54 Type: Medical Practitioner Note (Physician/NP) read: Late Entry: received a call from nurse that patient is complaining of pain with urination. Okay to collect UA with culture reflex. Nurse to call with results. Review of V14 (Licensed Practical Nurse/LPN) 1/11/2025 Progress Note read: Received new order to collect UA, may straight cath if necessary. Review of Order Summary Report, Order date 1/11/2025 read: Culture, Urine. No other order reviewed for UA (Urinalysis) on 1/11/2025. On 3/13/2025 at 11:28 AM, V18 said she was not aware that the order put in by the nurse on 1/11/25 was only for culture and UA was not done. On 3/11/2025 at 12:32 PM, V6 (Restorative Nurse) denied the allegation of R3 sustaining a fall due to urinary tract infection (UTI). V6 stated R3's Fall incident on 12/18/24 investigated with root cause analysis of R3 going to bathroom unassisted. On 12/22/24 R3 sustained another fall with root cause of transferring without assist. V6 stated care plan was updated on both fall incident and R3 has not had any fall since the last one in December. Reviewed R3's medical record: Fall Assessments (on Admission, Quarterly, Other) and Care Plan, no concern. Rounds to facility conducted. No resident complaint about Quality of Care/Treatment. Reviewed Facility Policies and Procedure: Fall Prevention and Management, revised 4/8/2024, Medication Administration, revision date 8/1/24, Antibiotic Stewardship, dated reviewed 8/20/22, Resident Change in Condition Notification, date revised 12/18/23, no concern.

Based on interview and record review the facility failed to return a resident's personal belongings after discharge from the facility for 1 of 3 residents (R1) reviewed for misappropriation of property in the sample of 9 . The findings include: R1's EMR (Electronic Medical Record) shows that R1 discharged from the facility on 10/10/24 after calling 911 for himself, going to the hospital and being admitted to another facility. On 12/20/24 at 9:45 AM V5 (Social Service Director) stated, He went to another facility and I think he has transferred to another facility since then. Someone came from the other facility and picked up his mail and a store brand box (mail item.) He has called several times about his belongings- everything we had was in my office and that was just his mail. The only thing I know he had in his room was a lot of books. He had different shirts on while he was here so I know he had clothes. He was given the opportunity to come pick up his stuff. I had several phone calls with him and would say he is coming on Tuesday and then it would be Thursday. I even called (Social Service Agency) because they had some involvement with him while he was here. I got a call from the police on Monday because he called the police about his stuff. They said he needs to deal with the facility he is at now to get his belongings. It's been over 2 months now so his stuff has gotten discarded. After so long- usually 30 days, his stuff gets discarded- all we had for him was his mail and someone came and picked that up. On 12/20/24 at 9:55 AM V6 (Housekeeping Supervisor) stated, The stuff we had - after 30 days we throw it away. I never had any conversations with (R1). He had like 3 big boxes of books and we discarded them in mid November. On 12/20/24 at 11:05 AM, V1 (Administrator) stated, We found 2 boxes of his stuff (just now) and I called him- so as soon as he calls me back I will let you know. There is some crayons and papers and stuff in the box- I didn't want to go through all of his stuff. But I called him and let him know it is here. (Surveyor asked about the 3 boxes of books and his clothes) I don't know about those but we found 2 boxes and I called him and let him know. V1 stated that the facility did not have an inventory list for R1's belongings. The Facility Concern Form dated 12/16/24 (same date as the complaint) states, Resident discharged from the facility in October. Never picked up belongings. Several phone calls about picking up belongings with no follow-through. Informed items needed to be picked up due to unable to store. The resolution states, Items he had via mail kept and picked up by new facility. Resident content with (?). This form also shows the staff involved with this concern as V1, V5 and V6. The facility policy entitled Abuse Policy and Procedure dated 11/15/24 states, Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on interview and record review the facility failed to ensure a resident was free from physical abuse to 1 of 9 resident (R4) reviewed for physical abuse in the sample of 9. The finding include: R4's face sheet show R4 79 y/o that has diagnoses that includes dementia, wanderer, restlessness and agitation. R4's facility assessment dated [DATE] show R4 is severely cognitively impaired. The same assessment under section E (Behavioral Symptoms and frequency) show: [R4 has] Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others .) behavior of this type occurred 1-3 days Wandering . behavior of this type occurred 4-6 days R4's careplan with initiated date of 6/10/24 shows, R4 exhibits physically aggressive behaviors. R/t: cognitive deficit, dx of dementia, poor comprehension. Resident becomes combative unprovoked. He has bitten a staff members arm that required medical attention. He has grabbed a CNA who was trying to change him causing 2 broken finger nails. He will swing at staff when trying to provide care. He has attempted to take glasses off staff member and break them, he has hit staff on multiple occasions R/t: cognitive deficit, dx of dementia, poor comprehension The Facility Reported Incident sent to the state agency as final dated 11/6/24, (incident date 11/4/24) show, R4 (79 y/o) with dementia and behavioral disturbances. R3 (90 y/o) with Alzheimer and dementia .it was reported by the CNA (V4), R4 was trying to maneuver R3's wheelchair to fix as he does based on the history of his professional work. In the interaction, R4's right hand accidentally made contact with R3's face .The staff immediately separated both residents . On 12/20/24 at 9:20 AM, R4 was in dining room sitting in a chair agitated. R4 was spitting everywhere in the dining room. V13 ( Certified Nursing Assistant CNA) who was also in the dining room said R4 was like this, with behaviors-agitated, spits all over, can be aggressive and when R4 wanders, R4 was hard to redirect. V13 said R4 needed to be monitored closely. In the same dining room, R3 was quietly sitting in her wheelchair alert and pleasant. R3 said she was fine. On 12/20/24 at 9:35 AM, V3 (License Practical Nurse-LPN) said she was the Nurse working last 11/4/24 when the incident happened between R4 and R3. V3 (LPN) said she was in the Nurses station and can hear R4 and R3 yelling at each other at the opposite end of the hallway. Then she heard R3 screamed he hit me! he hit me! repeatedly. V3 said she went to check on them immediately, R3's left side of her face was reddened. They were both immediately separated. R4 was placed on 1:1. Both of their Physicians and family were notified. Facial X-ray's was ordered for R3 with no fractures noted. R4 was sent out to the hospital. R4 has behaviors of physical aggression. R4 should have been monitored closely and not get near R3. When a resident hit another resident that is abuse. At 9:50 AM, V4 (CNA) said R4 was up and about and wanders. R3 was in her wheelchair and able to wheel herself around the unit. On 11/4/24, both R4 and R3 were noted to be at the end of the hallway arguing and yelling at each other. R4 was wanting to push R3's wheelchair, R3 was saying no!, no! to R4. V4 said that was all that she can recall. V4 confirmed R4 has history of physical aggression towards others. V4 said when a resident hit another resident that is abuse. V4's signed statement dated 11/6/24 show I witnessed both residents arguing, over the chair (R3's wheelchair) R4 was wanting R3's wheelchair that she was using- she said no but he (R4) tried to push the chair swinging his arms and touched her face. I separated both residents, R4's hospital records dated 11/4/24 show, The patient (R4) is a 79 y/o who has significant dementia and does not talk, . had physical aggression and hit someone at the SNF (skilled Nursing Facility). Apparently, he always have aggressive behavior, Patients family had refused medications. He is over here for clearance so he can start on medications. On 11/4/24 at 11:30AM, both V1 (Administrator) and V2 (Director of Nursing) said due to R4's aggressive behavior towards R3, the family now had agreed to medicate R4's physical aggressions. The facility facility on Abuse dated 10/24/22 show, 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 and chemical restraints not required to treat the residents medical symptoms. Physical Abuse-is the infliction of injury on a resident that occurs other than by accidental means and that require medical attention. Physical Abuse including hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to properly monitor/supervise a high fall risk resident and ensure safety during incontinence care. This affected one of three (R2) residents reviewed for safety during care. This failure resulted in R2 rolling out of bed suffering a laceration to the head which required six sutures at the hospital. Findings Include: R2 is a [AGE] year old with the following diagnosis: malignant neoplasm of the stomach, dementia, anxiety disorder, and repeated falls. An Incident note dated 6/5/24 documents the CNA (V10 - Former CNA) called the nurse's attention to R2's room. R2 was observed lying on R2's left side on the floor with a red substance noted on the floor. R2 stated that R2 rolled out of bed. Pressure was applied to the head by wrapping with gauze to stop the bleeding. 911 was called. The Hospital Records dated 6/5/24 document R2 presented to the emergency department with a fall. R2 reportedly was reaching for an item and fell off the bed, striking the left side of the head on the ground. R2 was found in a pool of blood and complaining of pain in the left arm. A 2 cm x 2 cm laceration was noted over the left temple with a large hematoma and was pulsating blood. The laceration was closed with six sutures. A CT scan of the head was negative as well as a left forearm x-ray. R2's family member refused for R2 to return to the facility so R2 was admitted for placement. On 7/30/24 at 3:06PM, V6 (Nurse) stated V10 called V6 into R2's room due to R2 falling from the bed. V6 reported R2 had a laceration to the left side of the head and blood was coming out of the wound. V6 stated asking R2 what happened to which R2 replied that R2 rolled out of bed. V6 stated R2 was asked first what occurred before asking V10. V6 reported V10 also stated that R2 rolled out of bed while V10 was providing incontinence care. V6 stated R2 was able to move around the bed but needed staff assistance to completely turn over. V6 reported the bed was not in the lowest position at the time of the fall due to R2 being changed so R2 fell from a higher level. On 7/30/24 at 3:40PM, V7 (Restorative Nurse) stated R2 was a high fall risk due to having multiple falls, poor safety awareness, confusion, and not being physically able to move as normal. V7 reported the fall on 6/5 was due to R2 rolling out of the bed while R2 was being changed. V7 stated per V10's statement, R2 was being restless and V10 turned to grab something and when V10 turned back around R2 was rolling out of bed. V7 confirmed an intervention of bed bolsters should have been in place at the time of the fall. V7 reported R2 was a one person maximum assist with bed mobility. V7 stated once R2 was turned to the side, R2 was able to hold the side rail and assist, but R2 wasn't able to turn R2's self. V7 reported a resident should never be left unattended while they are laying on their side for safety reasons. V7 said, The proper positioning in the bed and monitoring is just safer for the resident and helps prevent any falls. On 7/31/24 at 9:56AM, V8 (DON) stated first speaking with V6 who told V8 that R2 rolled off the bed while being changed. V8 reported to the speaking with V10 about the incident. V8 stated V10 said V10 was changing R2's brief and turned R2 to the right side and V10 then began reaching for a new brief. V8 reported not being sure of V10's exactly location but was somewhere along the bedside. V8 said, She (V10) let go of the resident for a second. The resident rolled over onto her back then off of the bed. V8 stated R2 lost R2's balance after R2 rolled to R2's back and fell off the bed. V8 reported R2 is a high fall risk due to poor safety awareness, needing assistance with ADL care, lack of mobility, and previous falls. V8 stated R2 is alert and oriented times two with confusion. V8 reported R2 is a substantial/maximum assist with bed mobility but is able to move some and grab onto the grab bar when turned. V8 described the positioning device that is mentioned in the reportable is like a side rail, but it's a quarter of the size. V8 stated the positioning aide helps the resident hold on when they're being turned. V8 reported V10 did walk out during the interview due to getting flustered and resigned at that time. V8 stated R2 was sent to the hospital and ended up getting sutures to the laceration. On 7/31/24 at 11:08AM, V9 (Primary Physician) stated R2 had a laceration to R2's head from a fall. V9 reported R2 was being changed and fell from the bed. V9 stated R2 is a one assist. V9 reported the CNA was reaching over for a brief and during this time, R2 somehow fell from the bed. V9 stated R2 only had the capacity to hold R2's body to the side. V9 was unaware if R2 was on R2's side or R2's back when R2 rolled out the back. V9 reported V10 just went to grab something and R2 ended up rolling off the bed. V9 said, I'm not exactly sure how this would happen. She probably lost her balance somehow. On 8/1/24 at 9:09AM, V8 was unaware if the bolsters were on the bed at the time of the fall but stated if they were on the care plan then they should have been on the bed. V8 said, I think she just turned too quickly over to her back then rolled to her side off the bed. V8 confirmed R2 did roll off the same side the CNA was standing on. V8 stated the CNA was grabbing a brief to put on R2 but never left the bedside per V10's interview. When asked how R2 was able to roll so quickly to R2's back, left side, and then over the bolster before V10 stopped R2, V8 responded, I don't know how she was able to roll onto her back and then onto the floor so quickly without the CNA stopping her. I don't know. V8 reported R2 is a substantial/maximum assist with bed mobility but R2 can begin to roll R2's self to the side. On 8/1/24 at 9:17AM, V6 stated both R2 and V10 confirmed R2 rolled out of the bed causing the fall but V6 was unsure of the exact manner to which R2 fell out of the bed. V6 was not able to recall if the bed bolsters were in place. V6 reported R2 was lying on R2's left side but was on the right side of the bed if you are facing the bed at the foot. V6 said, When you are changing a resident everything you need should be at the bedside. If you need to go get something you forgot then the resident should be put back in the middle of the bed and the bed lowered to the floor. You shouldn't be grabbing for things even if they are closer because it takes your attention away from the resident and then accidents like this can happen. The surveyor called V10 throughout the survey to obtain an interview regarding the incident but a call was never returned. The Fall Event dated 6/5/24 documents R2 fell in R2's room. R2 was lying in the bed getting R2's brief changed immediately prior to the fall. R2 reported that R2 rolled out of bed. R2 is able to respond verbally per baseline. An injury to the top of the scalp was noted with a red substance coming from the scalp. The SBAR Communication Form dated 6/5/24 documents R2 was transferred to the hospital due to a fall. The Fall Investigation Report dated 6/5/24 documents at 6:45 PM, the CNA called the nurse to R2's room. R2 was observed lying on R2's left side next to the bed. R2 was bleeding from the face head area on the left side where R2 was lying. Pressure was applied with gauze bandages. R2 stated that R2 rolled out of bed. 911 was called. R2 was oriented to person and place per baseline. Predisposing factors of the fall are poor safety awareness, periods of agitation and restlessness, weakness, and use of psychotropic medication. The root cause of the fall documents after further investigation, staff was providing incontinence care to R2. R2 was lying on the right side in bed. As the CNA was reaching for the incontinent brief, R2 abruptly turned over onto R2's back. R2 then continued turning and was not able to grab the positioning device for control to stabilize R2's balance causing R2 to roll out of bed and onto the floor. The Final Incident Report dated 6/11/24 documents R2 is a long-term resident that resides on the dementia unit. R2 is alert and oriented times two with periods of confusion. R2 is able to move in bed with the help of the positioning device and one staff assist. R2 was observed on the floor next to R2's bed with a laceration to the left temple with bleeding. R2 was sent to the hospital and was admitted with a hematoma to the left temple and required six sutures to the laceration to the left temporal area. The CNA that was providing care at that time of the fall reported R2 was lying on the right side in the bed and the CNA was standing behind R2 on the other side of the bed. As the CNA was reaching for the incontinence brief at the bedside, R2 abruptly turned over onto R2's back. R2 continued turning to the left side and was not able to grab the positioning device to stabilize R2's balance. This caused R2 to fall onto the floor on the same side where the CNA was standing. The x-ray and CT of the cervical spine and head were done at the hospital and showed no acute abnormality. The Fall Assessment 4/26/24 documents a score of 24 indicating R2 is at high risk for falls. R2 has a history of multiple falls, has poor memory and recall ability, is totally incontinent of both bowel and bladder, has agitated behavior, requires hands on assistance to move from place to place, and has a decrease in muscle coordination. The Fall Risk assessment dated [DATE] documents a score of 27 indicating R2 is a high fall risk. A score of 16 or above indicates a resident is at high risk for falls. The Restorative Nursing Program Documentation dated 4/26/24 documents R2 has impaired mobility due to decreased range of motion related to generalized weakness, poor trunk control, and poor safety awareness. The Care Plan dated 5/24/20 documents R2 is at risk for falls due to poor safety awareness related to cognitive impairment, impaired mobility, and generalized weakness. An intervention on 5/12/23 documents bed bolsters were put in place. The Care Plan dated 8/10/22 documents R2 has had an actual fall with no injury. An intervention documented on 5/12/23 documents staff will ensure that R2 is centered in bed, positioning device is functional and up as appropriate, floor mats are in place as appropriate, and trunk and extremities are properly aligned and supported. The Care Plan dated 8/24/23 documents R2 has had an actual fall on 8/24/23, 9/2/23, 9/10/23, and 9/14/23 with no injury. An intervention documented on 9/14/23 documents staff will ensure that R2 is centered in the bed, position device is functional and up as appropriate, bed bolsters are properly secured as appropriate, and trunk and extremities are properly aligned and supported. The care plan with no date documents R2 is challenged by dementia and mental illness which impedes on R2's safety awareness and judgment. This care plan also documents R2 has an ADL self-care performance deficit related to weakness. An intervention documents R2 requires limited to extensive assist by one staff to turn and reposition in the bed as necessary. The Minimum Data Set (MDS) Section GG dated 4/26/24 documents R2 is a substantial/maximal assist indicating the staff member does more than half of the effort. The staff member lifts or holds the resident's trunk or limbs, and provides more than half the required effort. R2 is dependent when going from a sitting to a lying position indicating the staff member does all of the effort. R2 is not ambulatory. The facility provided the surveyor with a drawing of the incident to describe where the CNA was standing in relation to R2, the bed, and how close the bedside table was to the bed. According to the description of the incident and drawing, R2 should not have been able to turn from R2's right side to R2's back and over to R2's left side before being stopped or assisted by the CNA that was allegedly standing directly next to the bed. With the description of the incident and drawing, it can be determined that R2 was not properly monitored or supervised while the CNA was providing incontinent care if R2 had enough time to roll from R2's right side to R2's back then continue rolling onto R2's left side over the bed bolsters and then out of the bed. The policy titled, Fall Prevention and Management, dated 4/8/24 documents, Policy Statement: the facility is committed to its duty of care to residence and patients in reducing risk, the number and consequences of falls, including those resulting in harm and ensuring that a safe patient environment is maintained .Fall Interventions: a. Universal fall precautions/facility fall protocol will be implemented to all residents and admitted to the facility, regardless of risk scores.

Based on observation, interview, and record review, the facility failed to implement fall interventions for 2 of 3 residents (R4 and R5) reviewed for fall interventions and supervision in a sample of 14 residents. This failure resulted in R4 falling out of bed and sustaining a nasal fracture. Findings include: The Face Sheet documents R4 was admitted to the facility on [DATE], with a diagnosis of cognitive communication deficit and unsteadiness of gait and mobility. The care plan on admission documents R4 was at high risk for falls. The interventions in place were to anticipate the resident's needs, have call light in place along with commonly used items, and initiate the facility's fall protocol. R4's Care plan, revised 4/10/23,/ reads; floor mats while patient is in bed, may remove for ADL care and mealtimes or as patient requested. R5's care plan, revised 2/17/23, reads, low bed, and floor mats. Keep extra blankets within easy reach. Positioning: staff will ensure that resident is centered in bed, positioned device is functional and up as appropriate, floor mats are in place as appropriate, and trunk and extremities are properly aligned and supported. The incident report, dated 4/7/23, documents R4 is alert and oriented to person and place but has some confusion. At 9:00pm, R4 was observed sitting on the edge of the bed and trying to get up. R4 was confused and thought there were ants on the floor. R4 was redirected and assisted to the bathroom then put back to bed. At 10:00pm, R4 was found on the floor next to the bed. R4 was confused and was bleeding from the bridge of the nose. R4 was sent to the local hospital and diagnosed with a fractured nasal bone. R4 returned to the facility on [DATE], with floor mats added to the care plan. On 5/9/23 at 12:35pm, R4 and R5 were observed in bed with no floor mats at the bedside, and bed not in the lowest position. R5's floor mats were observed, one leaning on R5's wheelchair, and the other leaning on R5's drawer. Surveyor observed V12 (Registered Nurse/RN) and V13 (RN) adjust R4 and R5's bed to the lowest position. Surveyor and V1 (Administrator) observed R4 and R5's room with no floor mats at the bedside. On 5/9/23 at 12:45pm, V12 (RN) stated R5's bed should be in the lowest position and floor mats at both sides of the bed. On 5/9/23 at 1:00pm, V13 (RN) stated R4 should have floor mats at the bedside and the bed should be in the lowest position. On 5/10/23 at 1:40pm, V2 (DON) stated the bed should be in the lowest position and floor mats at the bedside for resident with high fall risk. Facility policy dated 11/10/22 reads Policy Statement: facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of fall including those resulting in ham and ensuring that a safe patient environment is maintained. Procedure: 1.Fall Risk Screening. d. High risk residents and patients for falls will receive individualized interventions as appropriate to risk factors. 2. Fall interventions c. Interventions will depend on identified and assessed risk factors, including root cause/every after fall or when a pattern has been identified. 7. Fall Interventions Monitor. a. facility will initiate monitoring of intervention for residents who fall in the facility and with history of fall, who trigger the falls CAA, and when a resident falls. Frequency and duration of monitoring of intervention will be based on current risks.

Based on observation, interview, and record review, the facility failed to follow physician order and facility policy regarding a stat order for X-ray. The facility also failed to notify the attending physician of the results of the X-ray once obtained until the next day. This failure resulted in a delay of treatment and pain for R1 for over 40 hours. This applies to 1 of 3 residents (R1) reviewed for injuries of unknown origin. The findings include: The EHR (Electronic Health Record) shows R1 was originally admitted to the facility on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes, dated 1/18/2022 at 2:45 P.M., shows R1 was guarding R1's left hip due to pain when therapy treatment was being provided. Review further of the progress notes shows at 2:50 P.M., R1 was had pain to R1's left hip, and V17 (R1's Attending Physician) was notified. The progress notes shows a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review further of the progress notes, dated 1/19/2022 at 6:29 P.M., shows Followed up with (X-ray provider) regarding STAT x-ray .Per (x-ray provider), the technician is scheduled to come out tonight to do the X-ray The POS (Physician Order Sheet) for the month of January 2022 shows a physician order, dated 1/18/2022 at 2:43 P.M., for R1 to have STAT -X-ray to left hip due to pain. The EHR under radiology results shows it was on 1/19/2022 at 9:31 P.M that R1's x-ray to the left hip was completed and was reviewed at 9:45 P.M. The result was fracture of the left hip. The progress notes, dated 1/20/2022 at 7:21 A.M., shows R1 was sent to the hospital for further evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The hospital record, dated 1/20/2021, shows R1 has left hip pain during the internal and external rotation of the left hip. R1 underwent ORIF (open reduction internal fixation) surgery of the left hip on 1/21/2022. R1 was readmitted back to the facility on [DATE]. On 2/11/2022 at 12:30 A.M., R1 was lying in bed. R1 was non -verbal. R1 was being assisted by V13 (Certified Nursing Assistant) for lunch. V13 said R1's baseline was R1 is confused and not able to verbalize needs. When asked if R1 can be checked for R1's surgical site, V13 showed R1's left hip and surgical incision; reinforced tape dressing was noted to the left hip area. On 2/11/2022 at 2:02 P.M., V5 (Physical Therapist) said on 1/18/2022 at approximately around 11:00 A.M., V5 provided therapy treatment to R1. V5 said V5 noticed R1's left hip was swollen. V5 also said R1 was guarding R1's left hip and did not want R1's left hip to be touched because of pain. V5 added V5 immediately reported V5's observation to V19 (Nurse). On 2/12/2022 at 4:30 P.M., V19 stated V5 informed V19 that R1 was guarding R1's left hip during therapy treatment on 1/18/2022, sometime around 11:00 A.M. V19 added V19 immediately checked R1 and R1 was in pain to the left hip. V19 also said this was something new, since R1 was comfortable during the morning rounds on 1/18/2022. On 2/12/2022 at 2:20 P.M., V2 (Director of Nursing) stated on 1/18/2022, right around after lunch, V5 had informed V2 that R1 was noted with a swelling to the left hip and R1 was having pain. V2 said V2 then called V17, and V17 ordered stat x-ray of the left hip. Together with V2, R1's EHR was reviewed. V2 said it was on 1/19/2022 at 9:43 P.M. that left hip x-ray was completed, and was reviewed at 9:45 P.M. There was no documentation V17 was notified until the morning of 1/20/2022 at 7:04 A.M., when V17 ordered for R1 to be sent out to the hospital for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/12/2022 at 3:00 P.M., V3 (Nurse Consultant) also said stat x-rays at the facility have to be done within 4 hours from the time it was ordered.

Based on observations, interviews, and record review, the facility failed to implement the fall prevention policy, failed to update and modify a resident's plan of care, and failed to provide supervision for high risk fall residents. This failure resulted in R3 falling and sustaining an occipital bone fracture. This applies to 1 of 3 residents (R3) reviewed for fall from a sample of 11. Findings include: Record review of an incident report, dated 4/16/20, documented R3 had a fall in the dining room on 4/16/20. Record review on fall care plan indicates that the facility didn't update the fall care plan to prevent further falls through incorporating the root cause of the fall. Record review on an incident report, dated 5/13/2020, documented R3 had a fall in the hallway, and ended up having a bump on the front of her left forehead. On 1/11/2021 at 12:03 PM, V2 stated, On 5/13/20, I don't think anybody witnessed the fall. R3 was on high risk for fall, and somebody should have supervised/monitor the resident. Record review on fall log, the incident report, and reportable indicates R3 had a fall in the hallway on 6/2/20 with 2 centimeters (cm) skin laceration at the back of her head with a small amount of bleeding. The resident was unresponsive with eyes open and breathing. Record review on hospital record on CT (Computerized Tomography) of the brain indicates the progression of the [MEDICAL CONDITION]. Record review on fall log, the incident report, and reportable indicates R3 had an unwitnessed fall on 7/31/20 and was sent out to the local hospital. Record review on hospital record on CT of the brain, dated 7/31/20, indicates nondisplaced right occipital bone fracture. Record review on R3's fall risk assessment, dated 6/9/20 (55), 7/31/20 (65), 6/2/20 (40) 7/31/20 (65), indicates that R3 was on high risk for fall (any score > 44). On 1/5/2021 at 12:40 PM, observed dementia unit activity/dining room with sixteen residents, including R3, with no staff supervision. On 1/5/2021 at 12:45 PM, observed V5 (Certified Nursing Assistant) wheeling a resident from the hallway to the dining/activity room. V5 stated, I am supposed to be here, But one of the residents walked out of the dining room, and I didn't see her walking out. I went to the hallway to bring her back. On 1/5/2021 at 12:47 PM, V3 (nurse) stated, Somebody should be there to monitor the residents in the dining room closely, as some of them have multiple falls. On 1/6/2021 at 11:41 AM, V2 (Director of Nursing) and V9 (Fall coordinator) stated, Residents on fall precaution always need to be supervised. V5 should have to call somebody to stay with residents while he went to bring the other resident back to the room. On 1/7/2021, V2 stated, Post fall investigation should reflect root cause and care plan should have been updated. Our restorative nurse was supposed to update the care plan. She should have nailed down the root cause and update the care plan. She was not doing her job, and I let her go. On 1/11/2021 at 12:03 PM, V2 stated, The staff was there but wasn't able to stop fall. On 1/7/2021 at 2:30 PM, V7 (Attending Physician) stated, R3's [MEDICAL CONDITION] from the fall that happened on 6/2/20 wasn't bad, and she didn't have to go through any brain surgery. On 1/7/21 at 2:30 PM, V7 stated, R3 has dementia and is vulnerable for fall. Her bones are brittle due to her medical conditions, and the facility should not leave those residents unattended. On 1/11/2021 at 12:03 PM, V2 stated, On 6/2/20, R3 had an unwitnessed fall, and somebody should have supervised R3 while she was in the hallway. On 1/11/2021 at 12:03 PM, V2 stated, On 7/31/20, R3 had an unwitnessed fall, and somebody should have monitored R3 closely to prevent fall. Facility presented Fall Reduction Program, dated 6/16/2020, document: All residents will receive adequate supervision, assistance, and assistive devices to prevent falls. The care plan is updated with any new interventions for every fall based on the root cause.

Based on observation, interview and record review, the facility failed to follow standards of practice and ensure that a mechanical lift was utilized according to manufacturer specifications and according to facility policy which affected one resident (R2) of four residents reviewed for mechanical lift transfers in a sample of 10. These failures resulted in R2 falling from the mechanical lift and suffering a right femur fracture which required surgical repair. Findings include: R2 is not interviewable. A Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 2 out of 15 which indicates that R2 has Severe Cognitive Impairment. R2's MDS dated [DATE] documents: Functional Limitation in Range of Motion: 1) Impairment on one side 1) B. Lower extremity. This MDS also codes R2 as requiring Two+ persons physical assist for Transfer between surfaces. It is documented in R2's progress notes that on 6/26/18 at 7:20pm, R2 experienced a fall. On 2/21/19 at 12:00pm, V16 (LPN-Licensed Practical Nurse) indicated that she was R2's nurse on 6/26/18. V16 stated, (V15-CNA-Certified Nurse Assistant) called me immediately after the fall. I was in the middle of report. (V15) said (R2) was on the floor. When I entered the room, she did not have the sling on. (V15) used a sit to stand lift. (R2) fell in the bathroom from the lift. She was in between the toilet and the sink. She complained of right hip pain. Per administration, V15 is no longer employed at the facility. V15's Statement regarding R2's fall reads: At around 8:00, (R2) needed to go to the bathroom. I called out for help. (R2) said, They normally do it with one person. At that point, I put her onto the lift myself. She asked me to use one buckle instead of two. I pushed her into the bathroom and she was trying to squat and she let go. She had her arms up in the air and she let go. She thought she was on the toilet. Her butt hit the toilet. She was between the sink and the toilet. She was laying on her back. V15 ran to the nurses station for assistance. R2's progress notes dated 6/26/18 document that R2 was transferred to a local hospital at 8:15pm and admitted with a right femur fracture. R2's Care Plan which was initiated on 8/2/17 documents: Focus: Requires assistance/potential to restore function for TRANSFERRING from one position to another as related to muscle weakness. Goal: At times, resident prefers to transfer using a sit to stand lift with two person assist. Interventions: Two person assist using sit to stand lift with blue sling. R2's Care Plan which was initiated on 2/14/17 documents: Focus: Transfer - sit to stand lift 2 person assist when using lift - blue sling. Goal: to transfer safely. On 2/25/19 at 2:00pm, V2 (DON-Director of Nursing) stated, (R2) did not want the second buckle on. She said it was too tight. (V15) listened to (R2) regarding the buckle. What came out of this? We identified that there was not enough room in the bathroom to accommodate two staff people to assist with a bariatric type patient. Room was too small. Re-inserviced staff that two people are required for a mechanical transfer. That was our policy even before this incident. I ordered more support slings of proper sizes, different sizes. V2 indicated that she no longer has the previous company's policy regarding sit to stand transfers but knows that the policy was that a mechanical transfer required two people for a safe transfer. On 2/25/19 at 1:11pm, V7 (CNA/preceptor for CNA's) stated, We follow the guidelines to secure both straps for a safe transfer. On 2/26/19 at 10:20am, V5 (CNA preceptor) demonstrated a sit to stand transfer in the bathroom where R2's fall occurred. V5 stated, Company policy is that two persons are required for a mechanical transfer. Need both buckles engaged and fastened for full support. V5 demonstrated that R2 could not have fallen on the floor with the sling support still in place. V5 lowered the machine to its lowest point and with V5 putting his maximum weight towards his buttocks, V5 was still suspended about six inches off of the ground. With V5 recreating the use of one fastened buckle, when he beared his full weight and put both arms in the air, the support sling began to slide upwards to his chest area. V5 stated, Well I guess if she put all her body weight down and she raised her arms, if the support sling is not tight, she slipped through and fell on the floor. It was discovered that the bathroom was too small to allow the sit to stand machine to be directly in front of the toilet. The machine had to be angled towards the toilet which would make it difficult to lower R2 directly onto the toilet seat safely. The manufacturer specifications indicate that the mechanical lift should be used to transport residents over short distances with examples given as from bed to wheelchair and from wheelchair to toilet. The room that R2 resided in at the time of the fall was measured from the bed to the toilet in the bathroom. On 2/26/19 at 1:30pm, V18 (Maintenance Director) measured from the bed to just outside the bathroom door as nine feet. From just outside the bathroom door to the toilet, measured five feet. The total distance R2 was transported on the sit to stand device was 14 feet. On 2/26/19 at 3:15pm, V13 (Mechanical Lift Representative) indicated that the fastening of both buckles on the support sling were necessary for safety reasons. V13 stated, If not both buckled, not enough support. On 2/21/19 at 12:26pm, V6 (Medical Director) confirmed that if staff used appropriate safety measures and followed manufacturer specifications for the sit to stand lift, R2's fall was avoidable. V6 stated, Yes, the risk of injury should be less if mechanical lift used correctly. (R2's) right [MEDICAL CONDITION] could have most definitely been prevented. R2's hospital record documented that R2 required Intramedullary Nailing of Right Femur Fracture which was performed on 6/28/18. The manufacturer specifications for the sit to stand mechanical lift document: Intended use: (Mechanical lift) is a mobile raising aid intended to be used on a horizontal surface for raising to a standing position and short transfer (e.g. raising from bed and transit wheelchair, or from wheelchair to toilet) in hospital, nursing home or other health care facility. Warning: The sling chest support strap must always be applied and fastened when using the sling. The sling support strap will help to support the resident in the sling during the raising procedure. The strap also retains the sling in correct position around the resident. Warning: The resident shall not be transferred over long distances.