Every finding on record at Pine Crest Health Care

Based on observation, interview, video review, and record review, the facility failed to ensure one resident (R4) remained free from physical abuse by staff. This failure resulted in R4 being pushed in the chest causing R4 to fall back into the chair and being slapped repeatedly to prevent R4 from standing up. This failure affected one of four residents (R4) reviewed for abuse and had the potential to affect 152 residents residing in the facility.The Immediate Jeopardy began on 06/18/26 when V18, Certified Nursing Assistant (CNA) physically pushed R4 in the chest causing R4 to fall into a chair then slapped R4's hands in an attempt to stop R4 from standing up. V1 (Administrator) was notified on 7/29/2026 of the Immediate Jeopardy.The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 07/31/2026, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:R4 is a [AGE] year-old female with diagnosis that includes but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, anemia, adult failure to thrive and muscle weakness(generalized).On 06/18/26 at 4:45pm, the facility camera video presented show that R4 was physically pushed in the chest into a chair and slapped on the hands by V18 Certified Nursing Assistant (CNA) while V18 was attempting to redirect R4's behavior of repetitive standing. Following the incident, R4 became defensive and swung her hands but did not make contact with V18 or peers but appeared to be in distress following the interaction.The incident was witnessed by V5 (Adult Protective Services) and V20 (CNA) assigned to sit with R4. V5 reported the alleged abuse to V1 (Administrator).R4's MDS (Minimum Data Set) dated May 19, 2026, scored R4's BIMS as 3 indicating that R4 is severely cognitively impaired.On 07/22/26 at 11:00am, R4 was observed in the dining room area but unable to interview due to cognitive status.On 07/22/2026 at 9:43am V5 (Adult Protective Services) stated in part that the day of the incident (06/18/2026) he was at the facility visiting a client (another resident). While on the 2nd floor by the nurse's station V5 saw what seemed to be an abuse situation. V5 stated he saw staff putting their hands on R4 and face. V5 could not recollect the name of the resident and staff but stated he immediately made the administrator aware of what he saw and let him know he (V5) was reporting this abuse situation to the Ombudsman Program.On 07/22/26 at 4:40pm, review of the facility camera video with V1 Administrator, V2 Director of Nursing (DON) and a fellow surveyor. The video camera 6 showed residents in the dining room on the 2nd floor. R4 was seen to be supervised by V20 CNA. Between 16:54 and 16:56 (4:54pm and 4:56pm) V18 approached R4 while she was standing up and pushed her down with his left hand back into her chair and as a result R4 became defensive and started swinging her hands at V18. V18 was observed hitting R4 with his open hand (slapping motion). V18 was observed in the video swinging back at R4 and later appeared to be blocking R4.On 07/22/2026 at 4:45pm, when V1 and V2 were asked whether that is an appropriate way to de-escalate a resident exhibiting aggressive behavior and should staff provoke residents physically. V1 stated, Physical re-direction is appropriate because staff (V18) was just blocking the resident from hitting him. V2 stated that she could not see it clearly and the video was rewind and shown again. After review V2 then stated, May be the staff (referring to V18) could have handled the situation differently.On 07/22/26 at 11:00am, R4 is observed in the dining room area and was not able to be interviewed due to R4's cognitive status. R4 has severe cognitive impairment and was unable to recognize, avoid, or reliably report abusive treatment.On 07/22/26 at 3:11pm, R5 was interviewed regarding abuse and what happened on 06/18/26. R5 stated she was there and she saw what happened, but she does not want to get involved. R5 stated, I (R5) do not want to get anyone in trouble or get them fired. But one thing I (R5) know is that they (referring to staff) are not supposed to hit us (residents). If they (residents) hit you, we are all sick here with different sicknesses. They (staff) are supposed to know how to deal with her (R4). When asked whether R5 had been abused by staff in the facility, R5 stated in part, No, because I (R5) will fight back.On 07/27/2026 at review of facility camera 8 between 4:47pm and 4:56pm video on 06/18/26 showed V5 in the dining room talking with V18 and between 4:57pm and 5:04pm talking to V1 at the nurse's station. V1 stated that was when V5 was making him aware of the alleged abuse.R4's care plan documents that R4 will be treated with respect and reside in the facility free of mistreatment (i.e. abuse and neglect), this was not followed.According to the facility investigation report V18 denied any alleged abuse and documented that he was using a blocking technique. Despite the facility camera showing otherwise. The video showed V18 touching R4 first by pushing her down unto the chair.On 07/29/2026 at 2:14pm, V20 CNA was assigned to sit with R4. V20 stated that she was not really familiar with R4 because that was her second or third time sitting with her on 1:1. V20 stated that she stayed over to work from day shift on the second shift. The previous CNA, whose V20 could not remember the name, told her that R4 had been agitated all morning shift. The surveyor asked V20 what she meant by been agitated. V20 stated R4 kept standing up, was irritated and just getting up from her chair. R4 is on fall risk monitor. V20 stated that typically, when she is agitated we (referring to staff) will take R4 for a walk. R4 kept standing up and so I called V18 who was familiar with her (R4). R4 became aggressive towards V18, another resident (R5) was sitting in the back corner of the dining room shouted and told R4 to sit her a** down. R4 still aggressive hitting on V18 and he (V18 was blocking her (R4) with his elbow. V20 stated that she asked the Nurse (V25) LPN (Licensed Practical Nurse) to take R4 to her room as V20 was helping another resident in the dining room to set up the dinner (dinner tray). V20 stated in part that I (V20) guess there was a visitor from the State (referring to V5 from Adult Protective Services) who saw what happened and went to report to the nurse (referring to V25 and V1 (Administrator) that we (V18 and V20) were hitting her and shouting at her (R4). V20 stated that was not what happened. R4 kept getting up and V18 tried to ask her to sit down. The surveyor asked V20 whether it was appropriate to physically push a resident with diagnosis that includes dementia and has repeated behavior of standing up who was not aggressive to self and others to sit down on the chair. V20 stated that it is not appropriate to abuse any of the residents. When asked about what form of abuse that would be V20 stated physical abuse but R4 kept standing up that was when he (V18) touched R4 to get her to sit down. V20 stated V18 was just blocking her from hitting him. V20 acknowledged watching the video on the day of incident (06/18/2026). The surveyor then asked did you see anything that indicated any form of abuse. V20 stated, No. because V18 was just trying to make R4 sit down.On 08/04/2026 at 10:58am, V33 (Social Worker Consultant) stated in part that there are lots of things to be considered that can contribute to residents' action when being aggressive. Residents can be upset, hungry, and can be in pain. Connect with them (residents) in the front, eye to eye with the resident. Engage them in conversation, arm length away from the patient. Can re-direct patients with open arms not a clenched fist. The surveyor then asks whether it is okay to push the residents into the chair. V33 stated, No, because you can hurt the residents. V33 further stated that depending on situations all approaches are safe. Techniques that can be used depending on the situation, no pushing the person into the chair. V33 stated ease the (Resident) into the chair with permission with use of gait belt from the lower portion of the body, lower back (waist area).On 08/04/2026 at 2:39pm, V34 SSD (Social Services Director) stated that when the incident happened, V34 was not in the building. V1 informed me about the incident, and he said he was starting an investigation. V34 was not shown the video of the event that led to this investigation. I am following what my administrator (V1) told me (V34) that a visitor misinterpreted what happened to (R4) and staff to be abusive. V34 stated, she knows R4 is a fall risk that needs direct help to sit down in the chair. The surveyor asked does that include pushing the resident. V34 stated no, it is more of a guided motion into the chair not pushing and not backing. Always with calm reaction. V34 stated that at times the staff can react without thinking at the time about safety with no immediate danger guide. During the same interview V34 stated she is familiar with R4. V34 stated with R4's diagnosis it is not appropriate to physically push R4 to sit down as a form of re-directing. V34 further stated With dementia they don't know what they are doing and what you are preventing them from doing. It is an impulse for them. Surveyor asked V34 when it is appropriate to physically push a resident to sit back in the chair to re-direct from repeatedly standing up, V34 stated, Never, any forceful, any unwanted touch that the resident is not okay with, can be physical abuse.On 08/04/26 at 3:44pm, V33 (Social Worker Consultant) was asked when it is appropriate to physically push a resident to sit back in a chair to re-direct them from repeatedly standing up. V33 stated like I (V33) said before that is not the first step to de-escalating any situation. All interventions should be safe, verbal approach calmly, knowing the cause of aggression is the resident in pain, stressed, bored of just sitting, and whether the staff is the cause of aggression. V33 stated right now, I am teaching them about safe methods and when it is deemed to activate the use. V33 stated repeated standing and asking the resident to sit down is not a form of aggression. On 08/06/2026 at 11:45am, V1 was asked to clarify the police report statement of V1 stating to the police officer that R4 is usually problematic and causes issues daily. V1 stated That was the police officer summary, I (V1) did not say that to him (Police Officer). I said she has advanced dementia with history of falling and on fall risk. I gave him a copy of (R4)'s face sheet showed him the diagnosis on face sheet and told him that aggression is one of the reasons the family (Son) placed R4 in the facility because (R4) had hit the son previously. V1 stated he did not recall any other additional comments. V1 further stated, I may have said problematic, but it is not part of the words I use.On 08/06/2026 at 3:48pm, V1 stated, He did not attribute V18's action as being abusive when he looked at the video, but he must admit his eyes (visions) are bad. I saw something that can be misinterpreted as abuse. What I saw in video was re-direction from V18 using side approach, a side approach is preferred but because of the space in the room there was no room for side approach. As for me I am seeing V18 doing the best re-direction possible with the space he had to work in. I (V1) saw V18 using his dominant hand to reposition R4 into the chair and blocking R4 who was swinging at him. V18 did not use his dominant hand to confront R4. I (V1) interviewed two other CNA's looking at the situation and they deny that V18 did anything inappropriate. V1 further stated when the surveyor asked whether repeated standing up by R4 constituted aggressive behavior, V1 stated, No.As of 08/06/2026 at 4:35pm, during this investigation V18 (CNA) and V26 RN (Registered Nurse) were unable to be reached via telephone or at the facility. The facility schedule presented by V2 showed V18 calling off and V26 not on schedule.When applying reasonable person concept, the action of V18 has the potential to put R4 and other vulnerable residents at risk for serious harm that can result in psychological and physical abuse.Facility Abuse policy presented dated 2/2/26 documents that residents in the facility are to be treated with dignity and respect. Abuse is defined as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm. The willful in the definition of abuse means the individual must have acted deliberately.Physical abuse is the infliction of injury on a resident that occurs other by accidental means. Listed physical abuse includes but not limited to hitting, and slapping, it includes but not limited to Facility Abuse Prevention and Reporting presented date 2/2/26 documents indicated in part under Interna Reporting Requirements and Identification of Allegations that employees are required to report any allegation or suspicion of potential abuse they observe, hear about, or suspect to the administrator.The facility policy titled Behavior Management for Agitated Behavior presented dated 4/14 documents under targeted behavior that agitated behavior which represents a danger to self and others, due to Alzheimer's disease with anxiety, dementia, mental illness or other illnesses. Preventive measures listed include but are not limited to observing residents for behavior escalating of anxiety, aggression such as loud voice tone and ringing, swearing, yellowing(yelling), and/or other irritability. Approaches to use when encountering a potentially violent resident listed includes but not limited to recognizing that agitation and anger are part of dementia and not done deliberately.Facility policy on Resident Rights presented dated 11/18 documents that employees should offer all residents privacy and treat all residents with respect, kindness and dignity. To provide an environment of care that supports a positive self-image.The Operational protocol for Geriatric Behavior De-Escalation presented documents under managing Residents who have already stood up unassisted that when a geriatric resident has already stood up unassisted and in standing independently, staff must follow a strict realistic, physically safe nursing procedure that avoids confusing spatial commands, such as telling a dementia resident to step backward, which they cannot visually process and will cause them to trip. Listed steps include but are not limited to approaching the resident from the front calmly. Establish supportive proximity. Position yourself within arm's reach at a 45-degree angle with open hands visible at waist level, acting as a steady physical anchor. Use guided physical seating. Because dementia residents suffer from visuospatial deficit and cannot process abstract spatial instructions, staff must physically guide the descent, staff place one supportive on the resident's waist or lower back and offer an [NAME] hand on the residents 's waist or lower back and offer an arm or hand for steady support.The Immediate Jeopardy that began on 06/18/2026 was removed on 07/31/2026 when the facility took the following actions to remove the immediacy. On 08/04/2026 the survey team verified by observation, interview, and record review, that the facility implemented the following to remove the immediacy.Facility: Pine Crest Healthcare Plan of Removal: F600 Abuse The following shall serve as the facility's written credible allegation of compliance which will be achieved. This is in no way an admission of guilt, but rather submitted as per the regulatory requirement. On June 18, 2026, a Visitor from Adult Protective Services reported allegation of abuse to Charge Nurse and then repeated the allegation directly to the Administrator, Abuse Coordinator. On June 18, 2026, once the abuse allegation was reported, V18 (CNA) was removed immediately from residents' presence and sent home pending investigation. On June 18, 2026, the resident was examined by Charge Nurse and found no apparent injuries. On June 18, 2026, the Administrator notified the Family (R4 Son) who visited R4 shortly after the alleged incident and Physician of the allegation. On June 19, 2026, R4 was seen and examined by NP. This will be ongoing. On June 22, 2026, the facility began re-educating the current Staff (Nurses, CNAs, Dietary, Housekeeping, Laundry, Department Heads, Activities, Social Services) on Abuse Prevention and Dementia Behavior Deescalation. V18 was included in training. This re-education continued through June 25, 2026. Focus of re-education included in general: Managing residents with behaviors/agitation De-escalating behaviors for individuals with dementia Abuse Identifying triggers Screening Types Reporting Investigating Consequences/Discipline Beginning June 22, 2026 and ongoing, all future Staff will be mandated to receive Abuse training from Administrator or Assistant Administrator and Deescalation training from Social Services Director prior to caring for residents. Training will include the information listed above. As of June 22, 2026, R4 continues on 1:1 status/monitoring due to behaviors. On August 3, 2026, Consultation Group is scheduled to do Staff training on Behavior Deescalation. The facility evaluated its abuse prevention system to determine what factors may have contributed to the incident. Facility management, including the abuse coordinator have reviewed the facility's abuse policy and procedures and determined that they are appropriate. The facility has reviewed client medical records and revised physician orders as appropriate to minimize resident's risk for behaviors, while at the same time preserving individual client rights and dignity. The facility evaluated its abuse prevention system by conducting staff interviews, following facility abuse protocol, given previous abuse training and prevention to staff, identifying the possibility of overstimulation for R4, identifying possibility of the initial CNA being overwhelmed with R4's behavior. As a result of these things, Initial CNA requested the assistance from a co-worker, R4's dining/activity room monitoring was changed to lessen the possibility of overstimulation, CNA was counseled prior to being sent home to remove self from such close contact, when possible, when residents become agitated, staff were instructed to remove other residents, if necessary, from agitated residents if can't remove the agitated resident from the situation. Consulting Group has begun behavior deescalation training with staff as on July 30, 2026, and will continue until all staff, with exception of those on vacation or leave, are re-educated as of August 3, 2026. Any Staff on vacation or leave will be re-educated upon their return to work. Resident exhibits behaviors of repeated impulsive standing and combative behaviors when redirected. According to R4's son, this behavior was exhibited at home warranting her nursing home admission. On the day in question, June 18, 2026, R4 was repeatedly standing from chair, attempting to leave area and becoming combative with staff when redirected. Staff repeatedly escorted her on walks in attempt to calm her without success. CNA involved was asked for assist due to the behaviors and noncompliance to verbal redirection. R4 has history of falls as a result of her unsteady gait and impulsiveness; thus warranting 1:1 monitoring. R4 is currently on 1:1 staff monitoring and has been for over a year. To help prevent recurrence, R4's 1:1 dining room monitoring location was changed to the main dining room on 2nd floor where there is more higher functioning residents with less sensory stimulation from noise content and level. On June 19, 2026, R4 was seen and examined by NP who ordered Xanax 1mg as needed (PRN) and Sertraline 75mg at bedtime. The CNA involved was immediately removed from resident contact and sent home pending investigation. Staff was re-educated on Abuse and Deescalation techniques for Dementia residents. Care plan reviewed and deemed appropriate.Facility did not have the IDPH findings at the time of re-education to address. Physical interventions, resident rights and dementia related behaviors were addressed in the June 22, 2026, re-education. Post tests method was used in all abuse and behavior education sessions to evaluate staff's knowledge after training. The written post tests were also discussed verbally with each educational group for clarification and understanding purposes. Minimal yearly and PRN, all Staff is re-educated on Abuse and Dementia. Both educations are accompanied with a post year minimally yearly. CNA involved was re-educated on both Abuse and Dementia related behaviors with post tests taken (see attached for August 2025 and June 2026). Facility will continue to educate on Abuse and Dementia upon new hires in all departments, minimally yearly and PRN per occurrences. Testing in both areas will be done minimally yearly in order to evaluate the effectiveness of the training. Administrator, Abuse Coordinator, will continue to follow the Abuse Policy while performing daily rounds, monitor incident reports, gather any resident and/or family concerns, quarterly and PRN care plan conferences to address any concerns, monthly Resident Council Meeting and monthly QA Meetings noting all allegations of abuse. Administration and Social Services Director will be responsible for staff education which will include, but may not be limited to, in the areas of Abuse (identifying triggers, screening, reporting, types, consequences/discipline, investigating) and Dementia Related Behaviors (deescalation techniques, warning signs, staff and resident body language, physical interventions, resident rights). Administrator will be responsible for overall compliance to plan of correction in conjunction with the Social Services Director by actively participating in the general orientation process by ensuring the above in-services are completed prior to resident care. The general orientation checklist and Abuse posttest will be maintained in Employees' files for future reference. The Quality Assurance Quality Improvement Team meets monthly. This event will also be brought to the next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly. Completion Date: July 31, 2026 R4 placed on 1:1 supervision and monitoring,Facility staff training initiated and on-going on behavior De-escalation + appropriate physical redirection.Facility staff training initiated and on-going on abuse and Dementia related behaviors.Educating plans to educate staff upon hire in all departments.Testing staff in both areas.Gathering any resident/family concerns in these areas and addressing the concerns.Monthly notification of QA meetings of all allegations of abuseV1 (Administrator) making daily rounds in evaluating the effectiveness of the training.

Based on interview, observation, and record review the facility failed to follow their Activities of Daily Living Policy to provide podiatry care to R7, this failure affected one (R7) of three residents reviewed for ADL Care (grooming).On 4/30/2026 at 2:13 P.M., R7 gave permission for V13 (CNA) to assess R7s toenails with the state surveyor. V13 described R7 left and right big toenails as long and thick, and looked like R7s toenails had not been cut for like a year. V13 stated she previously told R7s floor nurse to refer R7 to the podiatrist.On 4/30/2026 at 2:26 P.M., V11 (Licensed Practical Nurse/ LPN) and V14 (R7s family member) also observed R7s left and right toenails and stated R7s toenails were thick and long. Nurse surveyor observed V11 putting R7s right sock on and R7 flinched his foot. V14 stated R7s right toe is sensitive. V11 and V13 stated R7s should have been referred to the podiatrist.On 4/30/2026 at 2:33 P.M., V15 (Medical records) stated R7 has not been seen by the podiatrist in March 2026 or April 2026 because she was not notified. V2 (Director of Nursing/DON) stated it is expected for the nurses and CNAs to perform grooming, nail care to residents and if needed, refer the resident to the podiatrist. V2 stated if she were to be notified that a resident needs to be seen by a podiatrist she will inform V15. V2 stated It is expected for the CNAs and nurses to assess resident's toenails during ADL care. V2 and V15 stated they were not notified that R7 needed to be added to the podiatry list.During record reviewed of R7s shower sheets provided by the V2 (DON), R7s shower dates 4/3, 4/7, 4/10, 4/14, 4/17, 4/21, 4/24 4/28, a circle around N indicating R7s nails were not trimmed. R7s Minimum Data Set (MDS) dated [DATE] section GG documents R7 is dependent (helper does all of the effort) on staff for putting on/taking off footwear. R7s ADL ( Activity of Daily Living) care plan revised 4/16/2025, documents R7 has a Self Care Deficit and requires assistance with ADL's to maintain the highest possible level of functioning AEB (As evidenced by) the following limitations and potential contributing factors: Weakness, declined endurance, Confusion, Gait/balance problems, Incontinence, Vision/hearing problems, tremors related to: Parkinson. Activities of Daily Living (ADLs) PolicyPurpose: To preserve ADL function, promote independence, and increase self-esteem and dignity. Interventions Grooming: Maintaining personal hygiene, self-manicure (safety awareness with nail care)

Based on record review, interview and observations the facility failed to provide a safe, functional, sanitary and comfortable environment for the residents of the facility. This failure involved the common area shower rooms on both the first and second floors and affects all residents in the facility. The shower facilities available to the residents are in need of repairs and deep cleaning to give the residents a space to feel comfortable using on a daily basis. R1 will be known as R5 and is not available to be interviewed while writer was at the facility. R5 is a 67 year of female whose diagnosis includes: DISORDER OF THYROID, UNSPECIFIED(E07.9),ESSENTIAL (PRIMARY) HYPERTENSION(I10), PARANOID SCHIZOPHRENIA(F20.0), UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION(F29), THYROTOXICOSIS, UNSPECIFIED WITHOUT THYROTOXIC CRISIS OR STORM(E05.90), DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MILD, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY(F02.A0), MENTAL DISORDER, NOT OTHERWISE SPECIFIED(F99), VITAMIN D DEFICIENCY, UNSPECIFIED(E55.9), OTHER CONSTIPATION(K59.09), SPASMODIC TORTICOLLIS(G24.3)R5 was unavailable at the time of survey to be interviewed. The complainant for this survey was V11 (her Maximus Case Manager) to whom R5 made the complaint. V11 in turn did not make the facility aware of the complaint, per his Agency's policy he just called the hotline to make the complaint. V11 stated that this was to protect the identity of the resident. V11 was reached by telephone on 01/23/26 at 10:31AM. V11 was able to state that he met with his client at the facility during a visit last year, in the Fall in the conference room on the first floor. V11 then stated that the shower room in question was located right next to the conference room. This description of the location matched the conference room that this writer was working from on the first floor of the facility. V11 described the condition of the bathroom as horrible with broken tiles on the floor, no curtains for privacy and mold throughout the bathroom. 01/23/26 -11:00AM Conference room: V4 (Maintenance Director) and V5 (Housekeeping Manager) and I began to tour the common area shower rooms; we started with the 400 hall shower room which was locked (allegedly due to residents smoking in there on the overnight shift). V4 had been called to assist with unlocking the bathroom door, as the nurse and V5 did not have a key to unlock the door. Once inside the shower room, it was apparent that this shower room had not been cleaned for a while as evidenced by the dark brown stains in the toilet bowl. The toilet was functional and did flush, when activated, it spewed dark brown water. The tiles on the floors and walls have tiles that are chipped, there are a couple of shower areas in the shower room that are not separated by a curtain, and assistive devices are stored in the room. There is also varying degrees of a dark substance on the grout of parts of the walls and floors throughout the shower room. 01/23/26 11:15AM 200 hallway shower room was next to be reviewed by V4, V5 and this writer. This door was unlocked and was unoccupied at the time. There were bath blankets on the floor and there was urine in the toilet that was not flushed. There were chipped 1x1 tiles on the floor and other chipped and/or broken tile on the walls. There is also varying degrees of dark substances on the floors and walls. The room was also used as storage for assistive devices and there was no privacy curtain to cover the toilet when it was in use. The toilet can be viewed from the hall when the door is open and there is no lock on the door to prevent that. The lack of locks could be considered a safety measure, but according to the DON (V3) most of the residents on the first floor are more independent and shower without assistance. So, it is entirely possible that the door can be opened, form the outside, while a resident is showering or toileting. Also, R5 is a resident of the first floor and according to her care plan, she requires assistance with ADLs.During this interview, when V5 was asked how often the shower room was cleaned, V5 stated that she, along with the housekeepers, make rounds and determine when they need to be cleaned that then clean them. However, V13 (housekeeper) stated that the bathroom is cleaned once a shift and if someone request it. 01/23/26 11:30AM Shower room on the 500 hallway was not available for shower use as it was entirely used for storage. 01/24/26 1:00PM-1:30PM all shower rooms on the second floor have crumbling tile, lack of privacy curtains, and varying levels of dark substances on the floors and walls. The shower rooms now have a log on the back of the door to detail when that particular shower room has been cleaned. Each shower room at the time of this viewing had been cleaned at least two times. There still were no curtains, and the dark substance was still on the floors and walls. 01/23/26 laundry room on the first floor: R2 (president of resident counsel) was interviewed as she did her laundry and stated that she was not aware of any problems in the facility, then instantly stated that the only thing she can recall hearing problems about from residents was the shower rooms and how filthy they were.01/23/26 conference room: During the interview with V5 regarding the cleaning protocol for the bathroom (V6) the IP came into the conference room and was asked about if there is a policy for how often showers should be cleaned or if there is a policy for the remediation of the dark substance. V6 stated that she is mainly there for the antibiotics and not so much for housekeeping. V5 stated that she was starting to work on adding curtains to each bathroom today. This has not been completed prior to me exiting the survey. 01/24/26 11:00AM Conference room: V4 told me that the supplies (grout) for the shower rooms had been purchased and that the cracked tiles on the floor had been filled in. The receipt for the supplies had been left on the table and added to the attachments. The shower rooms had been cleaned prior to my arrival today and the logs to not the times of the cleaning were on the back of the shower room doors. During the course of the investigation, it was noted that there were at least 3 complaints made in resident councils, and stated in the minutes, regarding the shower room. These shower rooms are the only place to take a shower as the bathroom attached to bedrooms only provides a toilet and sink for residents in that room, as well as some of the residents in adjourning rooms as the bedroom bathrooms are a Jack-and-[NAME] style bath for two rooms.There was no facility policy on housekeeping protocol for shower cleaning that V4 or V5 could produce for this writer. There was also no log of hte frequency of cleaning for the shower rooms, nor scheduled cleaning of the shower rooms available to review. Based on observations, interviews and record reviews that facility did not provide a clean, safe, comfortable and/or sanitary area for the residents to shower and a deficiency was cited.

Based on interview and record review, the facility failed to follow its abuse policy by not ensuring that residents were free from physical and verbal abuse. This affected two of three residents (R1 and R2) reviewed for abuse. This failure resulted in R1 experiencing, a facility staff member directed inappropriate and profane language toward R1. R1 reported feeling disrespected, childlike, and angry as a result of the interaction. This also resulted in (R2) experiencing a facility staff member struck R2 on the head. Using the reasonable person concept, this action would cause a R2 to feel fear and intimidation. Findings Include: R1's brief interview for mental status dated 8/26/25 documents a score of fifteen which indicates cognitively intact. Social service note dated 8/12/25 documents: Abuse investigation initiated on 8/6/25 concluded that staff (V4) mistreated R1 by telling him FU (fu*k you) too. On 9/16/25 at 2:32pm, V1 (administrator) said, R1 was verbally aggressive with V4 (PRSC). V4 was terminated for responding to R'1's verbally aggression by replying f**k you too. V1 said, V4's response could be considered as verbal abuse. On 9/16/25 at 3:56pm, R1 who was assessed to be alert and oriented to person, place, time and situation, said he had been informed to come in from a smoke break by V10 (cna). R1 said, he was walking down the stair from the smoking shelter toward the building entrance. R1 said, V4 brushed pass the V10 (cna), began yelling, being verbally aggressive and acting like a bully. R1 said, V4 told him it's time to come in now. R1 said, he replied to V4 by saying, telling V4 not to talk to him like a child. R1 said, V4 and him were arguing. R1 said, V4 had an attitude. R1 said, during the argument V4 cursed at him saying fu*ck him. On 9/17/25 at 2:06pm, V7 (asst. administrator) said, R4 was terminated for group three offense. Group III Offenses: 1st Offense- Termination of Employment: Use of vile, foul, or abusive language toward a supervisor, resident, resident family member or other staff member. Arguing with a resident, family member, doctor or visitor.On 9/18/25 at 1:03pm, V10 (cna) said, R1 was notified twice to come in from the smoking patio because it was dinner time. V10 said, R1 was an independent smoker and was allowed to be out of the patio without staff supervision. R1 was taking his time coming back into the building but he was not causing a problem. V10 said, V4 told R1 he had to come in. V10 said, V4 was hostile and rude towards R1. V10 said, R1 replied, he was already informed by V10 to come in. V10 said, V4 became agitated. V10 said, V4 did not attempt to redirect R1. V10 said, the manner in which V4 spoke to R1 was not professional. R1 and V4 began to argue. R1 cursed at V4. V4 called, R1 out of his name. V10 said, both V4 and R1 started cursing at each other. V10 said, V4 told R1 fu*k you too. On 9/18/25 at 3:01pm, V1 said, he labelled that interaction as mistreatment instead of abuse because one can argue that it was a back and forth conversation between cognitive (alert) individuals. V1 said, in the general population, people argue and swear. People said, fu*ck you in the community. V1 said, the word fu*ck you does not have the same stigma as it use too. V1 was asked if his facility was general population or a skilled nursing facility. V1 reply, it's a skilled nursing facility. V1 said, an employee should not be telling a resident fu*ck you which is why she was terminated. Abuse Policy Employee Acknowledgement dated 3/25/25 documents: Residents of this facility are to be treated with dignity and respect. Any individual who willfully abuses, or neglect a resident or misappropriated a resident' property or money will be terminated. V4's name was signed and printed with a witness signature. Facility Preliminary Incident Investigation Report Form dated 8/6/25 documents the facility has an allegation that may involve one or more of the following reportable situations. Verbal and Mental abuse was checked. The allegation: R1 approached V1 and informed V1 that a staff member (V4) swore at him. Witness statement dated 8/7/25 documents: V4 originally stated that she did not curse at R1. V4 stated, she wasn't truthful with V1 because she didn't think he would be understanding. V4 did admit she was wrong for engaging with R1 and allowing him to get her upset Facility Final Incident Investigation Report Form dated 8/12/25 documents: Allegation of mistreatment substantiated Corrective Action Form dated 8/13/25 documents: Mistreatment of a resident. Abuse investigation initiated 8.6.25 concluded employee (V4) engaged in resident (R1) mistreatment. Prior discussion or warning on the subject: No formal warning. Instructed on work rules on 3.25.25. Resident shall not be abused or mistreated. Corrective action required: Termination. Abuse policy dated 2011 documents: the facility affirms the right of our residents to be free from abuse. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction or injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 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 their age, ability to comprehend or disability. Mental Abuse includes, but is not limited to humiliation, threats of punishment or deprivation. R2 was diagnosed with Schizophrenia. Brief interview for mental status dated 5/8/25 and 8/6/2025 documents a score of four which indicate severe cognitive impairment. Facility preliminary incident investigation report dated 7/25/25 documents: Alleged victims mental status: R2 was alert and oriented times two. R2 is hard of hearing. Circumstances of the alleged incident: Two residents (R5 and R4) complained that a certified nursing assistance (V6/cna) was loud while giving R2 activities of daily living (ADL) care and told R2 to pick up that shit. They also noted that they heard R2 yell ow and were concerned that R2 might being mistreated or abused.Witness statement dated 7/25/25 written by V8 (nurse) documents: R2 stated that she is sick of that lady always knocking her around. R5 informed V8 (nurse) that V6 is verbally aggressive towards R2 everyday V6 works with R2. Final reportable dated 8/1/25 documents: R2 told the nurse (V6) cna was mean to her. Later in the interview, R2 claimed the cna push her to stop wiping her bottom. On 9/16/25 at 2:36pm, V1 (administrator) said, he received an allegation of abuse against V6 (cna). R4 reported that V6 was loud with R2. R5 reported, that he overheard V6 telling R2 to pick that sh*t up then he heard R2 yell ouch. V1 said, he interviewed V6 who reported she told R2 to pick up her poo-poo off the floor. V1 said, V6 used the verbiage poo-poo. V1 said, he could not substantiated the allegation of abuse so V6 was transferred to work on second floor away from R2. V1's witness statement dated 7/25/25 documents: R2 said, V6 hit her in the head with a towel and pushed her out of the bathroom. V1's witness statement dated 7/29/25 documents: R2 said, she don't want her to take care of her anymore. She (V6) is always telling me what to do and pushing me.On 9/16/25 at 3:14pm, R5 who was assessed to be alert and oriented to person, place, time and situation, said V6 was yelling aggressively at R2. R5 said, the walls are very thin. R5 said, he shares a common wall with R2. R5 said, he heard, V6 clearly through the walls. R5 said, R2 is hard of hearing, but V6 was yelling louder than she needed too. R5 said, he has heard staff talk to R2 before and they wasn't as loud as V6 was that night. R5 said, V6 told, R2 you sh*tted on yourself. You got sh*t on the floor. R5 said, V6 was verbally abusive toward R2. R5 said, the way V6 spoke to R2 was elderly abuse. R5 said, V6 is a bully and does not deserve to work with the elderly or in this facility. R5 said, R4 also heard, V6 speaking verbally aggressive to R2. On 9/16/25 at 3:24pm, R4 requested that V1 be present during his interview, R4 who was assessed to be alert and oriented to person, place, time and situation, said, he was in the hallway across from R2's room at the time of the incident. R4 said, he heard V6 speaking to R2 extremely loud. R4 said, R2 is hard of hearing. R4 said, a few times, when V6 spoke to R2, it was a little more than just speaking loud because R2 was hard of hearing. R4 said, V6's tone was extreme. R4 said, V6 spoke to R2 with a lack of respect. R4 said, he spoke openly to the staff asking staff if they could hear the commotion between V6 and R2. R4 said, V6 was given R1 harsh commands, V6 told R4 to go in the bathroom and take your clothes off harshly. R4 said, then he heard a thud on the wall. R4 said, when V1 interviewed R2, V1 asked if V6 hit R2. R2 replied, she hit me on the head. On 9/16/25 at 3:34pm, R2 was interview by V1 while surveyor stood inside of R2's room but out of sight of R2. V1 asked, R2 what happen with V6 when V1 had to come in early. R2 said, I already told you. R2 said, V6 use to hit me. R2 said, I was going to call the police on V6. R2 said, V6 hit me that day. V6 hit me in the head that day. V1 said, R2 told four versions of the interactions with V6. V1 said, V6 hitting R2 on the head was one version. On 9/17/2025 at 2:28pm, V8 (nurse) said, she spoke with R2 after her interactions with V6 and being informed by R5. V8 said, R2 said, she was sick of her knocking her around. V8 said, R2 did not specifically say V6 name. V8 said, has never heard R2 accused any staff member of being physically aggressive, knocking her around or hitting her prior to this incident. Social service noted dated 7/25/25 documents: Abuse allegation initiated this morning at 5:30 AM. Resident claims that she had a bowel movement and kept digging at it thinking it was stuck, arguing with staff who said she needed to stop and pointed out that she had made herself bleed because she was rubbing on her hemorrhoid. She claimed that the CNA was pushing her to get out of the room and stop rubbing her hemorrhoid. Abuse policy dated 2011 documents: the facility affirms the right of our residents to be free from abuse. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction or injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention, Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. 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 their age, ability to comprehend or disability. Mental Abuse includes, but is not limited to humiliation, threats of punishment or deprivation.

Based on interview and record review, the facility failed to monitor and provide effective supervision to ensure that a resident with a history of alcohol abuse was able to get access to alcohol while in the facility. This affected one resident (R143) reviewed for supervision and monitoring. This failure resulted in R143 being able to obtain alcohol on two separate occasions in the resulting hospitalizations. [NAME], [NAME] (143) OLADINI, BOSEDE (32338) - Hazards/SupervisionR1's records show the following:Face sheet shows that R143 was admitted to the facility on [DATE] with diagnoses which include but are Alcohol Abuse, Opioid Abuse, Bipolar Disorder, Schizoaffective Disorder, Hypertension, Acute Kidney Failure, And Acute Respiratory Failure.Progress notes dated 6/6/25 at 6:55pm written by V13(LPN/Licensed Practical Nurse) states: While writer was passing medications, she heard a loud noise from 2204 from the CNA (Certified Nurse Assistant). On getting there, CNA told writer that resident was almost on the floor and that he assisted him back to chair. Upon assessing resident, he was drowsy and disoriented. the room was in disarray, everything was on the floor. resident v/s taken, wnl. as resident call light was moved closer to him to use to call for assistance writer saw an empty bottle of brandy wine on the bed. resident was asked where he got the bottle from. he became upset and annoyed, saying all kind of F word. resident came out of room to nurses station, threw one of his shoes at a staff. POA called and made aware of behavior. Administrator and nursing manager made aware. MD called order received to send resident out to the hospital for evaluation. Progress notes dated 6/7/25 at 2:56pm written by V12(RN/Registered Nurse) states in part: Resident returned to the facility on stretcher via two escorts from the Hospital where he was seen for aggressive behavior, alcohol intoxication and chronic tremors. Progress notes dated 7/3/25 at 7:30pm written by V14(LPN) states in part: Writer was informed that resident has alcohol in his room under his pillow. Writer went down to residents' room and discovered that there was a liquor bottle under resident's cover. Writer informed appropriate staff. Resident went down to his room and noticed that the bottle was gone. He then proceeded to the nurse station, where his roommate was standing and began to argue with him, shouting and cursing at him. Resident was asked to calm down to which resident refused and continued to argue with roommate.On 8/13/25 at 2:25pm, V27(Medical Director) was interviewed about residents getting access to alcohol and becoming intoxicated and being sent to the hospital two times in a row within 4 weeks interval. V27 was also asked about the possible effects on the residents. V27 stated They notified me about the situation. When we find out, we ensure that the resident is monitored more closely. V11 added Alcohol intake will affect the resident's medications like antipsychotics and blood pressure medications. Not only a resident, but anyone also who gets intoxicated with alcohol. The person will also be at high risk for falling, and the risks of intoxication. We try to get the resident to attend AA (Alcohol Anonymous), and we do closer monitoring.On 8/13/25 at 1:30pm, V29(Social Services Director) was asked about the interventions as listed on the alcohol abuse care plan for R143. V29 stated that R143 has a serious alcohol abuse issue and has been having 1:1 therapy session with a Licensed Clinical Social Worker, and the staff will continue to monitor R143 closely.R143's other records:Care Plan dated 6/16/25 states in part that resident has a history of substance abuse/chemical dependency related to: Resident has a diagnosis of opioid abuse and alcohol use Intervention states: Work with the resident to establish a verbal or written behavioral contract specifying what is and what is not allowed. Make sure the resident is aware of rules prohibiting use of alcohol, illicit substances & intoxication.Face sheet shows diagnoses which include but are not limited to Major Depressive Disorder, And Generalized Anxiety Disorder.BIMS (Basic Interview for mental status) score dated 6/16/25 shows 15(Cognitively Intact).Community Survival Skills assessment dated [DATE] states in #4 that resident appears to be able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. Correct commendations and outcomes states that the resident appears to be capable of outside past privileges at this time.On 8/12/25 at 12:38pm, V1(Administrator) was notified about the concern that a resident at the facility had access to alcohol and got intoxicated, almost falling, and was sent to the hospital, and that this same resident was found with a bottle of alcohol that was provided by a staff member without doctor's order just 4 weeks later. V1 responded that now, if a resident is found with alcohol, or drugs, they would take their pass away.On 8/12/25 at 12:00pm, V7(Assistant Administrator) stated that's the facility did not know how the resident got the alcohol that intoxicated him on 6/6/25, but that the bottle of alcohol that was found on him on 7/3/25 was purchased for him by a staff member and that the staff members had since been terminated after investigation. V7 later presented the documents titled Corrective Action dated 7/8/25.R143's hospital records dated 6/7/25 written by V8 (Hospital Physician) shows a diagnosis of alcohol intoxication, aggressive behavior, and chronic tremor. The hospital physician further stated that the patient's aggressive behavior was related to alcohol intoxication.R143's hospital records dated 7/9/25 shows admission diagnoses of Aggressive Behavior, Alcohol Intoxication, Chronic Tremor, Hypertension, Hypothyroidism, And COPD (Chronic Obstructive Pulmonary Disease).Facility's Contraband Items list shows that Glass Bottle and Rubbing Alcohol are on the list of Contrabands.Facility's document titled House Rules #6 states: Drug and Alcohol use are strictly prohibited while living at the facility. Residents should not use drugs or alcohol while out on pass or living at the facility. #7 states: Illegal or non-prescribed drugs or alcohol may not be brought into the facility premises.

Based on observation, interview and record review, the facility failed to clean and maintain the dryer lint screens thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 161 residents at the facility.Findings include:Facility census, dated 8/11/25, documents 161 residents residing at the facility.On 8/12/2025 at 10:57am, during a tour of the laundry area with V19 (Housekeeping Supervisor), three dryers were observed. V19 opened the lint compartment dryer #1. The lint compartment floor was clean however the lint screen was fully covered with lint. V19 opened the lint compartment dryer #2. The lint compartment floor had loose lint on the floor and the lint screen was fully covered with lint. V19 opened the lint compartment dryer #3. The lint compartment floor had a large amount of loose lint on the floor and the lint screen was fully covered with lint. V19 said, This (lint) needs to be cleaned up right away. They (lint screens/compartments) are cleaned out every shift. Not cleaning the lint out can cause a fire.On 8/13/25 at 11:30am, V2 (Director of Nursing/DON) acknowledged that failure to regularly clean dryer lint compartments poses a significant fire hazard and jeopardizes the safety of residents, staff, and the facility. V2 said, The dryer lint should be cleaned out, just like home, after each load.Facility policy titled, Laundry Services, revised date 8/17/23, documents, in part, . Note: It is the responsibility of the Laundry Staff to maintain cleanliness of the laundry room and its equipment. Machines should be cleaned and disinfected minimal daily. Facility policy titled, Resident Rights, dated 11/18, documents, in part, . Follow instructions, policies, rules, regulations in place to support quality care for residents and a safe environment for all individuals in the facility.

Based on observation, interview, and record review, the facility failed to ensure the required daily nurse staffing information was accurately completed and consistently posted. These failures have the potential to affect all 161 residents residing in the facility.Findings include:On 08/11/25 at 9:20 AM, upon entry into the facility, surveyor observed the Daily Nurse Staffing information posted near the receptionist area. The most recent posting was dated 08/06/25, indicating that accurate and current staffing data had not been posted for five consecutive days. The facility's daily nursing staffing also lacked the required unit-specific information. This prolonged lapse reflects a failure to maintain essential information required for public review and resident rights.On 08/11/25 at 11:30 AM, V2 (Director of Nursing) confirmed that the facility is required to post accurate and up-to-date daily staffing information each day. V2 stated, It (daily nursing staffing) needs to be posted daily.Record review of the facility's Daily Nursing Staffing form posted on 8/11/25, documents in part, (Name of facility); Date: 8/06/25, showed that it not only reflected an incorrect date but also lacked unit-specific information, further indicating a failure to ensure completeness and accuracy of the required posting.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based on observation, interview, and record review, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services in the facility's kitchen by failing to: remove ice from the ice machine, clean the visible dirt on the ice machine, clean the food mixer, and failing to clean the debris left on the floor of the kitchen by the grease trap backing up from under the kitchen floor. These failures have the potential to cause food borne illness in all 159 residents that receive food from the facility's kitchen.Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen.On 8/11/25 between 10:10am and 10:41 am during kitchen observation, the following were observed with V6(Dietary Manager):The floor of the kitchen close to the wall was observed with debris left on the floor of the kitchen from the grease trap backing up from under the kitchen floor. V6 stated that this happens frequently, and Maintenance has been aware of this for a long time. When the surveyor observed that there were only 2 staff working in the kitchen with V6 and asked V6 to be sure that the floor was cleaned as soon as possible because grease trap back-up is like sewer back up and that was an unsanitary condition in the kitchen, V6 explained that there should have been 3 staff working with her (V6), but someone had a scheduled sick-day off. V6 stated that the kitchen was running behind but that she would ensure that the floor was cleaned.The ice machine was observed with visible dirt on the left, right and front sides. The ice machine also was overflowing with ice and the cover (which V6 stated had been broken for a while) was observed on the wet blankets placed on the floor to catch the water dripping from the ice. V6 stated that staff should have emptied the ice into the ice cooler this morning and taken it to the 1st floor and 2nd floor for residents. Inquired from V6 why there were only 2 staff working with her(V6) in the kitchen, V6 stated that a staff member had a sick day off that had been requested for a while and on the schedule; V6 later showed the surveyor the schedule. V6 explained that she(V6) was working the position of the staff who is off and that usually, the ice machine should have been almost empty after taking ice to the floors. The food mixer that was covered with transparent plastic wrap was observed to have accumulated food particles. V6 stated that it should have been cleaned before being covered but they were running behind due to her (Dietary Manager) functioning in the position of absent staff. V6 stated that she would ensure to clean the food mixer.On 8/12/25 at 10:30am, it was observed that 4 staff were working in the kitchen. The kitchen was clean without blankets on the floor to catch water/grease trap leaks, and the ice machine was not overflowing to the floor with ice and water and there was no wet blanket on the floor of the ice machine.On 8/12/25 at 11:34am, V6 stated Today, we have enough staff and everything is going smooth.On 8/13/25 at 11:30am, V7(Assistant Administrator) presented the Dietary staff Job Description for the staff that works 6:30am-3:00pm. This document shows that the Dietary Aide was supposed to Make sure all hydration stations are filled. The Job Description for the AM [NAME] that works 5:30am to 2:00pm includes cleaning the cook area.Facility's policy on dietary services states in #8f: All food equipment, utensils, dishes, steam tables, should be cleaned and sanitized daily. #8h: Ice machines are used and maintained in a manner that eliminates contamination during ice manufacture, storage, and dispensing. #8L: All floor surfaces should be cleaned daily and as appropriate using appropriate cleansers.

Based on observation, interview, and record review, the facility failed to ensure that refrigerated milk cartons are stored at a temperature to protect against food spoilage(below 41 degrees), failed to clean the air vent/vent return above the food prep table, failed to clean the ice machine, failed to clean the food mixer, and failed to clean the debris left on the floor of the kitchen by the grease trap backing up from under the kitchen floor. These failures have the potential to cause food borne illness in all 159 residents that receive food from the facility's kitchen.Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen.On 8/11/25 between 10:10am and 10:41 am during kitchen observation, the following were observed with V6(Dietary Manager):The floor of the kitchen close to the wall was observed with debris left on the floor of the kitchen from the grease trap backing up from under the kitchen floor. V6 stated that this happens frequently, and Maintenance has been aware of this for a long time. When the surveyor observed that there were only 2 staff working in the kitchen with V6 and asked V6 to be sure that the floor was cleaned as soon as possible because grease trap back-up is like sewer back up and that was an unsanitary condition in the kitchen, V6 explained that there should have been 3 staff working with her (V6), but someone had a scheduled sick-day off. V6 stated that she would ensure that the floor was cleaned.The air vent/vent return above the food prep table was observed with accumulated dust. V6 stated that she(V6) would call maintenance to clean the air vents.The ice machine was observed with visible dirt on the left, right and front sides. The ice machine also was overflowing with ice and the cover (which V6 stated had been broken for a while) was observed on the wet blankets placed on the floor to catch the water dripping from the ice. V6 stated that staff should have emptied the ice into the ice cooler and taken it to the 1st floor and 2nd floor for residents. Inquired from V6 why there were only 2 staff working with her(V6) in the kitchen, V6 stated that a staff member had a sick day off that had been requested for a while and V6 later showed the surveyor on the schedule.The food mixer that was covered with transparent plastic wrap was observed to have accumulated food particles. V6 stated that it should have been cleaned before being covered.The milk cooler temperature thermometer showed 55 degrees Fahrenheit. V6 stated that the milk cooler did not read the correct temperature because staff have been opening and closing it so frequently. Two hours later, the surveyor and V6 used the ice point calibration method to calibrate a new thermometer brought out by V6. After the thermometer calibration, V6 brought out one carton of milk that had been supplied 4 days earlier (Thursday) and had been in the same refrigerator. V6 explained that it was better for us to check the milk that had been there for four days rather than checking the milk that was just supplied today. 2 out of the twelve 8-ounce cartons of Whole Milk (all stored in a plastic milk crate) that were received from the supplier 4 days earlier were found to be 51 F. V6 stated that the milk temperature should be less than 41 F. V6 proceeded to dump all the 12 cartons of milk in the garbage can.On 8/13/25 at 1:35 PM, V6 told the surveyor that she (V6) cleaned out the milk refrigerator and the milk refrigerator was not used the previous day and that it is now working well and maintaining the milk to the correct temperature below 41 .Facility's monthly resident council meeting minutes dated 2/27/25 and 3/27/25 both show that residents were complaining about spoiled milk. Facility's undated policy on food storage stated in part: Protect food from contamination, to ensure wholesomeness, and to prevent the spread of infections and communicable diseases. #3 states: Perishable foods shall be stored at the specified temperatures to protect against spoilage. This policy shows that dairy products and eggs are supposed to be stored at between 33 to 41 F. Facility's policy on dietary services states in #8f: All food equipment, utensils, dishes, steam tables, should be cleaned and sanitized daily. #8h: Ice machines are used and maintained in a manner that eliminates contamination during ice manufacture, storage, and dispensing. #8L: All floor surfaces should be cleaned daily and as appropriate using appropriate cleansers.Facility's policy on dietary services states in #8f: All food equipment, utensils, dishes, steam tables, should be cleaned and sanitized daily. #8h: Ice machines are used and maintained in a manner that eliminates contamination during ice manufacture, storage, and dispensing. #8L: All floor surfaces should be cleaned daily and as appropriate using appropriate cleansers.

Based on observation, interview, and record review, the facility failed to ensure that essential kitchen equipment such as the 3 Compartment sink water-drain works correctly to drain water without causing a drain back-up of grease/dirty water to the floor, failed to ensure that the milk refrigerator works efficiently to keep milk below 41 degrees Fahrenheit, and failed to fix the broken cover of the ice machine. These failures have the potential to affect all 159 residents that receive food from the facility's kitchen.Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen.On 8/11/25 between 10:10am and 10:41 am during kitchen observation, the following were observed with V6(Dietary Manager):The floor of the kitchen close to the wall was observed with debris left on the floor of the kitchen from the grease trap backing up from under the kitchen floor. V6 stated that this happens frequently, and Maintenance has been aware of this for a long time. V6 stated that she would ensure that the floor was cleaned.The ice machine overflowing with ice and the cover could not fit properly to cover the ice. V6 stated the Ice machine cover had been broken for a while. V6 was observed placing the broken ice machine cover on the wet blankets placed on the floor to catch the water dripping from the ice. V6 stated that the broken ice machine cover had been reported several times and added that the ice machine would need replacement.The milk cooler temperature thermometer showed 55 degrees Fahrenheit. V6 stated that the milk cooler did not read the correct temperature because staff have been opening and closing it so frequently. Two hours later, the surveyor and V6 used the ice point calibration method to calibrate a new thermometer brought out by V6. After the thermometer calibration, V6 brought out one carton of milk that had been supplied 4 days earlier (Thursday) and had been in the same refrigerator. V6 explained that it was better for us to check the milk that had been there for four days rather than checking the milk that was just supplied today. 2 out of the twelve 8-ounce cartons of Whole Milk (all stored in a plastic milk crate) that were received from the supplier 4 days earlier were found to be 51 F. V6 stated that the milk temperature should be less than 41 F. V6 proceeded to dump all the 12 cartons of milk in the garbage can.V6 added that the refrigerator should be cold enough to keep milk below 41 degrees.On 8/12/25 at 2pm, V10(Maintenance Director) stated that for him to fix the issue with the grease trap and prevents the back up so the kitchen floor, here we would have to open the wall of the kitchen and turn off water supply for the whole building. V10 stated that he could do that whenever it is possible to turn off water supply to the whole building.On 8/12/25 at 11:15am, with V1(Administrator) and V6 in the kitchen, V1 explained to the surveyor that the kitchen staff should not empty the three compartment sink all at the same time. V1 explained that if the whole water in the three-compartment sink is not emptied all at the same time, the grease trap under the kitchen floor would not overflow and back up on to the kitchen floor. V1 stated that he would continue to monitor how the kitchen staff empty the three-compartment sink and see whether or not the drain would back up onto the kitchen floor again. Facility's maintenance log sheets for July and August 2025 show that V6 and other dietary staff logged in several maintenance issues with kitchen equipment dated 7/3/25, 7/22/25, with kitchen equipment including the three-compartment sink leaking and Ice machine lid needs to be replaced. No evidence on the log sheet that these issues were addressed or resolved.Facility's preventative maintenance program policy says in part: to conduct regular environmental tours safety audits to identify areas of concern within the facility. #3 States preventative maintenance program will review the following areas during random rounds: #5 stats: All facility areas are kept clean and in safe condition. #17 states: Drains are cleaned and free of debris.Facility's document titled Maintenance Director- Job Description states in #2: Maintains the building in good repair and free of hazards such as those caused by electrical, plumbing, heating, and cooling systems, life safety, etc.Facility's policy on dietary services states in #8f: All food equipment, utensils, dishes, steam tables, should be cleaned and sanitized daily. #8h: Ice machines are used and maintained in a manner that eliminates contamination during ice manufacture, storage, and dispensing. #8L: All floor surfaces should be cleaned daily and as appropriate using appropriate cleansers.Facility's undated policy on food storage stated in part: Protect food from contamination, to ensure wholesomeness, and to prevent the spread of infections and communicable diseases. #3 states: Perishable foods shall be stored at the specified temperatures to protect against spoilage. This policy shows that dairy products and eggs are supposed to be stored at between 33 to 41 F.

Based on observation, interview and record review, the facility failed to provide sufficient personal protective equipment to meet the needs of residents that require enhanced barrier precautions. This failure has the potential to affect 4 residents (R5, R6, R24, R110) residents in a sample of 70 residents reviewed for infection control.Findings include:Facility document titled Enhanced Barrier Precautions (8/2025) documents in part the following residents require enhanced barrier precautions: R24 (gastrostomy tube), R110 (wound), R5 (wound), and R6 (wound).On 8/11/2025 at 10:58 AM, observed signage indicating enhanced barrier precautions on R5, R6, R24's, R110's room door. The signage indicated that gloves and gown were required when performing resident care. One isolation bin was observed within the 2400 and no gowns were noted within the bin. No other PPE was noted within the 2400 unit. V25 (Certified Nursing Assistant) affirmed that V25 is assigned to care for the residents within the 2400 unit. V25 observed the PPE bin and affirmed that there were no gowns for the unit for residents that require enhanced barrier precautions. V25 stated, I (V25) wouldn't be able to care for the residents properly without a gown and gloves. It (enhanced barrier precautions) requires a gown and gloves to provide care to the resident. On 8/13/2025 at 10:34 AM, V2 (Director of Nursing) affirmed that the facility's expectation is that personal protective equipment is readily available for staff as indicated for resident needs.Facility policy titled, ENHANCED BARRIER PRECAUTIONS (revised 9/2023) documents in part, Purpose: Recommendations from CDC to protect residents from multidrug resistant organisms. Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of acquiring MDRO .

Based on observation, interview and record review, the facility failed to refrigerate medications as instructed, failed to destroy discontinued narcotic medications, and failed to label medications with an appropriate open/expiration date in accordance with accepted professional standards. This failure affects 6 residents (R42, R51, R70, R107, R136, and R137) in a sample of 70 residents reviewed for medication storage.Findings include:On [DATE] at 11:14 AM, observed R136's Lorazepam Injection Solution 2 mg/mL within the controlled substance narcotics drawer in the medication cart unrefrigerated. A sticker on the packaging of the medication instructed staff to keep the medication refrigerated. V13 (Licensed Practical Nurse) observed the Lorazepam and its packaging and affirmed that the Lorazepam should be kept in the refrigerator per the manufacturer's instructions to maintain the medication's patency.R136's physician orders document in part that the Lorazepam Injection Solution 2 mg/mL was discontinued on [DATE].On [DATE] at 11:21 AM, observed R137's Lorazepam Oral Concentrate 2mg/ML within the controlled substance narcotics drawer in the medication cart unrefrigerated. A sticker on the packaging of the medication instructed staff to keep the medication refrigerated. V23 (Licensed Practical Nurse) observed the bottle of affirmed that the Lorazepam should be kept in the refrigerator per the manufacturer's instructions to maintain the medication's patency.R137's physician orders document in part that the Lorazepam Oral Concentrate 2mg/mL was discontinued on [DATE].On [DATE] at 11:25 AM, the following medications were observed in the medication cart with V23 (Licensed Practical Nurse) without an open date or an expiration date: R70's opened Humalin solution vial, R42's opened Humalog vial, R51's opened insulin lispro vial. R107's opened vial of Insulin Aspart was noted with a discard date of 7/23. V23 affirmed that all multi-dose insulin vials and pens are to be labeled with the open date and discard date to ensure the insulin remains potent. V23 stated that insulin is good for 28 to 30 days after opening. V23 stated that R170's insulin is expired and removed R170's insulin from the medication cart.On [DATE] at 10:36 AM, V2 (Director of Nursing) affirmed that the facility expectation is that liquid lorazepam is stored in the refrigerator and that all multi-use insulin containers are labeled and dated when opened. V2 stated that when medications are discontinued, they should be removed from the cart.Facility policy titled, Labeling/Dating Meds (8/2018) documents in part, Purpose: to ensure that medications are being used timely in accordance to manufacturer's recommendations .the following medications MUST be dated when first opened: Insulin - opened date - expiration date (generally 28 days) - nurse initials .Facility policy titled, 3.1: MEDICATION STORAGE IN THE FACILITY (7/2017) documents in part, .11. Medications requiring refrigeration or temperatures between 36 and 46 degrees Fahrenheit are kept in a refrigerator . 14. Outdated, contaminated or deteriorated drugs and those in containers which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists .

Based on observation, interview and record review, the facility failed to follow physician orders and care plan for enteral feeding; failed to follow physician's order and resident's care plan to ensure that hip abduction pad is applied to a post hip replacement resident; failed to follow physician orders related to continuous oxygen use; failed to obtain physician orders/consultation for podiatric care and failed to provide podiatric care. These failures affect 4 residents (R6, R39, R75, R150) in a sample of 70 reviewed for quality of care. Findings include:On 8/11/2025 at 11:21 AM, observed R39 lying in high fowlers position sleeping in bed. R39's gastrostomy tubing (g-tube) was connected to an enteral feeding pump that was turned off. Approximately 250 mL less of tube feeding was observed in the feeding bottle in comparison to the total volume of the carton (1000 mL). Additionally, the tube feeding was dated for 8/11/2025 at 5:00 AM, indicating that the tube feeding had been started on 8/11/2025 at 5:00 AM. R39's physician orders documents in part an order for two times a day Glucerna 1.2 85 mL/hr x 20 hours until 1700 mL is infused. Up at 4pm, down at 12 pm. Based on this physician order and the date/time of the tube feeding administration, approximately 510 mL of tube feeding should have been infused from the bottle and the tube feeding should have been on at the time of the observation. On 8/11/2025 at 11:25 AM, V24 (Wound Care Nurse) observed R39's enteral feeding pump and tubing and affirmed that the pump was off. V24 observed the tube feeding bottle, dates/times and affirmed that 250 mL of tube feeding had been administered. V24 accessed and reviewed R39's electronic health record and stated, no it (the tube feeding) should be on right now. It doesn't get turned off until 12. There is no reason why it is off right now. V24 accessed R39's enteral feeding pump and resumed the feeding at 85 mL/hr. R39's enteral feeding care plan (12/29/2023) documents in part R39's tube feeding is unavoidable and the only source of (R39's) nutrition and hydration. Additionally, the enteral feeding care plan documents in part an intervention, Infuse feeding as ordered on the POS (Physician Order Sheet). Findings include: R6's face sheet documents an initial admission date of 3/20/25, with diagnoses that include but are not limited to type 2 diabetes mellitus and muscle weakness. R6's Minimum Data Set (7/15/25) documents, in part, that R6 has a brief interview of mental status summary score of 7, indicating that R6 has cognitive impairment. R6's care plan, revised date 4/7/25, documents, in part, The resident (R6) has Diabetes Mellitus, with interventions that document, in part, Check all of body for breaks in skin and treat promptly as ordered by doctor; Monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs and symptoms) of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. R6's care plan, date initiated 3/21/25, documents, in part, Resident (R6) is at risk for muscle weakness and rigidity R/T: Parkinson's Disease, with interventions that document, in part, Monitor for need of assistance with ADL's (activities of daily living). On 8/11/25 at 10:34am, R6 was observed lying in bed, on R6's right side. R6 said, My (R6) major concern is my (R6) feet. They (feet) hurt so bad. I (R6) think my (R6) toenails are digging in my skin. Especially my (R6) right baby toe. And the bottom of my feet just throb all day. There is something going on and I (R6) have asked the nurses for the past 3 months since coming here to have the doctor look at them, but nothing. They (staff) just worry about my butt sore. On 8/11/25 at 10:41am, V16 (Licensed Practical Nurse/LPN) removed R6's socks during foot and skin observation. Upon removal, a significant amount of dry, flaky skin was noted within the socks and on the resident's bed linens. Examination of both feet revealed all toenails to be markedly overgrown, thickened, and discolored with a brownish hue. The nails exhibited sharp and irregular edges. Further assessment of the plantar surfaces revealed the presence of multiple areas of concern: the right foot exhibited two quarter-sized and one nickel-sized areas of hardened, dry, and scaly skin, while the left foot presented with a nickel-sized area of similar characteristics. V16 said, The podiatrist comes here (to the facility) once a month. R6 chimed in stating, That's a lie. I've (R6) been here 3 months, and no one has looked at my (R6) feet. V16 said, Let me check to see when (R6) was last seen by the podiatrist. Upon checking R6's EMR (electronic medical record), V16 stated, I (V16) just put an order for (R6) to see the podiatrist. There was never an order placed for podiatry. Yes, (R6) most definitely needs to see a podiatrist to address her (R6's) toenails and callouses. She (R6) will be seen at the next visit. On 8/12/25 at 10:20am, V17 (Medical Records Coordinator) said, I'm (V17) the contact person for the podiatrist. He (podiatrist) works on his own list, and I (V17) add residents to the list when staff tell me (V17). The next time the podiatrist is coming here (facility) is 8/27 (8/27/25), but I (V17) still don't see her (R6) on the list. I (V17) honestly don't know. I'm (V17) going to call them and find out. On 8/12/25 at 10:55am, V17 (Medical Records Coordinator) said, I (V17) called podiatry and was told she's (R6) not in the system. They (podiatry) just need a consent form and face sheet, and she (R6) will be added to the podiatry list for 8/27 (8/27/25). On 8/13/25 at 11:30am, V2 (Director of Nursing/DON) confirmed that any concerns regarding a resident's feet—particularly for residents with a diagnosis of diabetes—should be addressed promptly, with the resident being evaluated without delay. Record review of R6's most recent MDS (Minimum Data Set), 7/15/25, failed to document existing skin conditions—specifically hard, dry, and patchy areas—present on both of R6's feet, as required in Section M: Skin Conditions. R6's MDS and care plan did not reflect the need for skilled foot care, nor were there documented interventions in place to mitigate the risk of complications related to poor foot condition. Despite the identified risks associated with diabetes and foot conditions, there was no evidence in the medical record of a podiatry consult, referral, or treatment plan. Interviews with staff confirmed that podiatry services had not been scheduled or provided for R6. R6's physician order, ordered date 8/11/2025, documents, in part, Needs podiatrist consult. R6 did not have an order to see a podiatrist until surveyor brought concerns to R6's nurse (V16/LPN/Licensed Practical Nurse). Facility policy titled, Activities of Daily Living (ADLS), dated 4/14, documents, in part, Grooming: Maintaining personal hygiene, including planning the task and gathering supplies, combing and/or styling hair, face and hands, brushing teeth, shaving or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and/or application of deodorant or powder. Facility policy titled, Resident Rights, dated 11/18, documents, in part, Policy: Employees shall offer all residents privacy and treat all residents with respect, kindness and dignity. To provide an environment of care that supports a positive self-image. Follow instructions, policies, rules, regulations in place to support quality care for residents. Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, . Your facility must provide services to keep your physical and mental health, at their highest practical levels. Findings include: R150 is [AGE] years old admitted to the facility on [DATE], past medical history includes, but not limited to hyperlipidemia, Alzheimer's disease unspecified, unspecified fracture of right femur initial encounter, presence of right artificial hip joint, etc. Per record review, R150 complained of pain to the right leg on 6/15/2025, X-ray revealed right femur fracture, resident was admitted to the hospital, underwent surgical intervention on 6/19/2025 and was readmitted to the facility on [DATE]. Active physician order for R150, reads as follows: Hip Abductor: Place device in place when in bed, Remove during ADL care and prn. Care plan initiated 6/24/2025 states, resident needs Hip Abductor due to limited ROM to RLE r/t Hip Fracture. Goal: Resident will wear abductor daily until next review date. Interventions: Abductor should be placed at hip to ankle level. Staff to ensure device is clean. Staff to ensure straps on each leg are not with tight fit but with and able to place finger in place. 08/11/2025 11:25AM, R150 was observed in bed sleeping on his back, a big mattress was noted on the right side of the bed, resident did not have any hip abduction pad. 08/12/2025 12:15 PM R150 was observed in his room in bed, alert, and oriented x 1 to 2, stated that he is doing okay. Resident did not have any abduction pad between his leg, when asked where his abduction pad is he said that he does not have one. Surveyor asked resident if he ever have a pillow since his surgery and he said no. On 8/13/2025 at 9:35A, R150 was observed again in his room with V21 (C.N.A) who just finished providing resident ADL care. Survey asked V21 about resident's abduction pad and she said, I don't know, resident have not had it for a while, and I cannot say the last time he had it on. At 9:45AM, surveyor presented this observation to V22 (Restorative) who sad that resident no longer need the adduction pad, it was discontinued the last time he went to the doctor. V22 added that he forgot to discontinue the order in the system and to remove it from his care plan. Surveyor requested to see the discontinuation order, and none was presented. At 1:48PM, V22 (Restorative) said that he could not find an order to discontinue the resident's hip abductor, he called the doctor and received an order today. R75 is [AGE] years old and have resided at the facility since2023, past medical history includes chronic obstructive pulmonary disease, encephalopathy, obstructive sleep apnea, hyperlipidemia, etc. Per record review, R75 have the following active physician order dated 7/2/2025, Oxygen 3LNC continuously. 08/11/2025 10:55AM, R75 was observed in his room, awake and alert and stated he is doing okay. R75 on 3 liters of oxygen via nasal canula, a portable oxygen tank also noted at the bedside. 08/12/2025 12:31PM, R75 was observed in the dining room eating lunch with other residents, did not have any oxygen. 08/12/2025 2:00PM, surveyor followed up with resident who was not in his room and, oxygen concentrator and the portable oxygen tank was still set at 3 liters and was on, portable oxygen tank was at bedside, but the resident was not in the room. Surveyor asked V13 (LPN) where the resident is, and she pointed at him in the still in the dining room. Resident was observed still without oxygen. Surveyor presented this to V13 (LPN) who said that the resident's oxygen is supposed to be continuous, she does not know why the C.N.A did not put it on him. V13 then went to resident's room, bought out his oxygen tank to the dining room and applied oxygen to resident. Oxygen therapy policy (undated) presented by V2 (DON) states in part: to administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Procedures #8. States; Administer oxygen per physician order.

Based on observation, interview, and record review, the facility failing to provide care in a manner that promotes the resident's right to dignity as evidenced by failing to cover urinary catheter drainage bags, failing to ensure residents had access to clothes when in public areas/view, failing to draw a privacy curtain when dressing a resident and failing to provide feeding assistance in a manner that promotes dignity. These failures affect 5 residents (R6, R7, R10, R24 and R129) in a sample of 70 residents reviewed for dignity. Findings include: R6's face sheet documents diagnoses that include but are not limited to pressure ulcer of sacral region, unstageable. R6's Minimum Data Set (7/15/25) documents, in part, that R6 has a brief interview of mental status summary score of 7, indicating that R6 has cognitive impairment; requires substantial/maximal assistance with personal hygiene; R6's Physician Order (8/11/25) documents in part Catheter Type: (urinary)/Indwelling; Catheter Care: change (urinary) cath as needed for blockage, leaking or malfunctioning. On 8/11/25 at 10:34am, R6 was observed lying in bed, on R6's right side, with an uncovered urinary drainage bag hanging from the R6's bed frame. Approximately 1500 ml of dark amber urine, with large amounts of sediment, was observed in R6's urinary bag. R6 said, Sometimes the nurses put a cover my bag (urinary bag) and sometimes they (nurses) don't. On 8/11/25 at 10:41am, V16 (Licensed Practical Nurse/LPN) observed that R6's urinary catheter bag was not covered. V16 confirmed that the bag lacked a privacy cover and acknowledged that urinary catheter bags should be stored using a privacy bag or other appropriate method to uphold resident dignity and maintain privacy. R7's Minimum Data Set (7/16/25) documents, in part, that R7 has a brief interview of mental status summary score of 6, indicating that R7 has cognitive impairment and R7 has an unhealed pressure ulcer. R7's Physician Order (8/11/25) documents in part Catheter Type: (Urinary)/Indwelling, 16 Fr/30 ml. Dx Wounds; Catheter Care: change (urinary) cath as needed for blockage, leaking or malfunctioning. On 8/11/25 at 10:52am, R7 was observed lying in bed, on R7's left side, with an uncovered urinary drainage bag hanging from the R7's bed frame. Approximately 300 ml of straw colored urine was observed in R7's urinary bag. When asked about R7's uncovered urinary bag, R7 replied, I (R6) don't know. R10's face sheet documents diagnoses that include but are not limited to legal blindness. R10's Minimum Data Set (7/19/25) documents, in part, that R10 has a brief interview of mental status summary score of 3, indicating that R10 has cognitive impairment and requires substantial/maximal assistance with eating. R10's care plan, revised date 7/21/25, documents, in part, (R10) has a Self-Care Deficit and requires assistance with ADL's (activities of daily living) to maintain the highest possible level of functioning. following limitations and potential contributing factors: Impaired Cognitive Status, Requires Limited to Extensive Assistance with most ADL's, with interventions that document, in part, . Provide assistance with all ADL's as required per the residents need dependence: Eating, Transferring, Bed Mobility, Bathing, Dressing, Personal Hygiene, Ambulation and Personal Hygiene. On 8/11/25 at 12:10pm, V18 (certified nursing assistant/CNA) was observed standing over and feeding R10 while R10 was seated in the dining area. V18 was not positioned at eye level with R10 while assisting R10 with eating. On 8/11/25 at 12:18pm, V18 (Certified Nursing Assistant/CNA) acknowledged that, when assisting residents with eating, they should be seated at eye level with the resident to promote a respectful and dignified interaction, and to support the resident's individuality, dignity, and comfort. V18 said, I (V18) know I (V18) should be sitting with (R10), but I (V18) am also the sitter for the 2 residents over there (putting to another table). On 8/13/25 at 11:30am, V2 (Director of Nursing/DON) affirmed that urinary drainage bags must be stored in accordance with practices that promote and preserve resident dignity and privacy. V2 said, They (residents) should have a privacy bag even when in their room. V2 confirmed that staff should be seated at eye level with residents during assisted feeding in order to promote a respectful and dignified interaction. V2 said, Staff should be sitting at eye level with residents when assisting with meals. Facility policy titled, Urinary Catheter Care, dated 5/14, documents, in part, . 19. The catheter drainage bag will be marked with the date inserted or when changed and stored in privacy bag. CNAs (certified nursing assistants) may change the drainage and/or leg bag. Facility policy titled, Feeding and Assisting Residents to Eat, revised date 6/14, documents, in part, . Nursing personnel assisting should be positioned/seated at eye level with the resident to provide a relaxed and comfortable environment, and to avoid a standing over image. Facility policy titled, Resident Rights, dated 11/18, documents, in part, Policy: Employees shall offer all residents privacy and treat all residents with respect, kindness and dignity. To provide an environment of care that supports a positive self-image. These rights include the residents' rights to:. n. Privacy and confidentiality. ee. The right to an environment that preserves dignity and contributes to a positive self-image. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. Findings include: R24's minimum data set (6/9/2025) documents in part a brief interview of mental status (BIMS) summary score of 14, indicating that R24 is cognitively intact. On 8/11/2025 at 10:46 AM, observed R24's buttocks/genitals from the hallway. R129 (R24's roommate) was observed with no pants on, sitting in his wheelchair within the room from the hallway. R129's incontinence brief was fully exposed. No privacy curtain or other devices/interventions were used to maintain dignity. R24 utilized a thin blanket to cover himself and stated, Please I really need to talk to you. I don't have any clothes. Yesterday, I had to go to the nurse's station naked because I have no clothes. I have to walk around the facility naked all the time because there are no clothes for me. It just makes me look stupid having to be naked—I want to wear clothes. No clothing was observed in R24's room. On 8/11/2025 at 10:57 AM, V25 (Certified Nursing Assistant) was observed physically assisting R129 with dressing and putting on pants. No privacy curtain was pulled, and the assistance provided could be seen from the hallway. V25 affirmed that V25 was assigned to care for R24 and R129. V25 affirmed that R24 was currently only wearing a blanket and was naked without clothing under the blanket. V25 explained that R24 does not have clothes and when V25 is assigned to R24, V25 has to go to laundry where there are spare clothes to find clothing that might fit R24. V25 did not know why R24 did not have clothes. V25 pulled pants, a shirt, and a incontinence brief from the linen cart and placed them on R24's bed. Facility policy titled, Dignity (1/2015) documents in part, Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .1. Residents should be treated with dignity and respect at all times; even cognitively impaired residents .10. Staff shall promote, maintain and protect resident's privacy, including bodily privacy during assistance with personal care and during treatment procedures .

Based on observation, interview and record review, the facility failed to ensure that handrails were secured along the resident corridors. This failure has the potential to affect 21 residents that reside within the 2400 unit.Findings include:Facility provided census documents in part that 21 residents reside within the 2400 unit.On 8/12/2025 at 9:39 AM, observed the handrail near the elevator in the 2400 unit detached from the wall and hanging down approximately 6 inches. A hole approximately 4 inches long was observed where the handrail was anchored to the wall. When pressure was applied to the bottom and top of the handrail, the handrail was loose and was able to move approximately 6 inches. V3 (Assistant Director of Nursing) observed the handrail and affirmed that the handrail was not secured to the wall. V3 stated, it (the handrail) could be tightened, I'll call maintenance.On 8/13/2025 at 10:33 AM, V2 (Director of Nursing) affirmed that the expectation of the facility is that handrails are securely affixed to the walls in case a resident needs assistance with ambulation.Facility policy titled, Preventative Maintenance Program (4/21/21) documents in part, Purpose: To conduct regular environmental tours/safety audits to identify areas of concerns within the facility. 5. All facility areas are kept clean and in safe condition. 8. Are hand rails present and in working condition.

Based on observation, interview, and record review the facility failed to ensure the call lights in 2 out of 3 shower rooms on the second floor were functioning properly. This deficient practice has the potential to affect all 91 residents that reside on the second floor of the facility.Findings include:Facility census, dated 8/11/25, documents 91 residents residing on the third floor.On 8/11/25, at 11:08 a.m., during an observation of the second-floor shower rooms conducted with V13 (Licensed Practical Nurse/LPN), it was identified that the call lights in 2 of the 3 shower rooms were nonfunctional. V13 confirmed the issue, stating, Maintenance is working on fixing them (call lights in the showers). Any of the shower rooms can be used by any of the residents on this (second) floor. They (call lights in the showers) haven't been working since Friday (8/8/25). Yes, the call lights are important for patient safety. On 8/13/25 at 11:20am, V10 (Maintenance Director) stated that an external company had been contacted to repair the inoperative call lights in the second floor shower rooms. V10 was unable to confirm the duration for which the call lights had been nonfunctional.On 8/11/25 at 11:30am, V2 (Director of Nursing/DON) said, It wasn't long since the call lights in the second floor shower room weren't working. Like 2 or 3 days. An outside company was had to be called out to fix them. V2 affirmed that the call lights must be operable and functioning properly in the event a resident requires immediate staff accessibility.Facility policy titled, Call Light, dated 4/14, documents, in part, Purpose: To respond to residents' requests and needs in a timely manner. 3. Bathroom lights should be viewed as emergencies and immediate attention should be give. 6. Call bell system defects will be reported promptly to the Maintenance Department for servicing. Facility policy titled, Resident Rights, dated 11/18, documents, in part, . Follow instructions, policies, rules, regulations in place to support quality care for residents and a safe environment for all individuals in the facility.

Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 3 medication errors out of 25 medication opportunities resulting in an 11% medication error rate. This failure affected two residents (R47 and R52) of five residents reviewed for medication administration. Findings include:On 8/12/2025 at 8:30AM, observed medication administration with V20 (LPN) on the first floor of the facility. The first resident observed was R47, a [AGE] year-old female who have a diagnosis of polyneuropathy among others. V20 administered 10 medications to R47, among the medications given was:Gabapentin Oral Tablet 600 MG (Gabapentin) 1 tablet by mouth.Active physician order for R47 shows the following. Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy; reducing dose due to weight gain. Gabapentin Oral Tablet 100 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy give in addition to 600mg=700mg TIDUpon medication reconciliation, V20 signed the gabapentin 100mg as given in the medication administration record (MAR), though she only gave 600mg, not 700mg as ordered.8/12/2025 at 8:50AM, V20 also gave medications to R52 who is [AGE] years old and have a diagnosis of essential primary hypertension among others.V20 took a blood pressure for R52 which read 101/63, heart rate of 97.V20 administered 5 medications to R52 and held the Chlorthalidone 25 mg oral tablet due to the systolic blood pressure of 101. Review of active physician order for R52 showed the following:Chlorthalidone Oral Tablet 25 MG (Chlorthalidone) Give 1 tablet by mouth one time a day for htn Hold if SBP<120.Valsartan Tablet 40 MG Give 2 tablet by mouth one time a day for HTN 2 tabs=80mg: HOLD IF SBP<110Amlodipine Besylate Tablet 5 MG Give 5 mg by mouth in the morning for hypertension 1 tab=5mg: HOLD IF SBP<110.Per medication reconciliation, a review of medication administration record showed that amlodipine 5mg ad Valsartan 40mg were both signed out as given by V20, with a documented blood pressure of 101/63. Both medications were omitted during medication administration observation and should have been held due to resident's blood pressure as ordered.On 8/13/225 at 11:35AM, V2 (DON) said that her expectations from nurses during medication administration is to the five rights of medication administration, (right resident, right medication, right time, right route, and right order) as well as maintaining proper hand hygiene and resident's privacy.Medication administration policy (undated) presented by V2 (DON) states in part that only a licensed nurse is permitted to administer medications to residents.Medications should always be prepared, administered, and recorded by the same licensed nurse.Documentation of medication administration is recorded in the medication administration record (MAR) or treatment record and includes date, time and initials of the licensed nurse who administered the medication.Under administration, the policy states tin part that medications must be administered in accordance with a physician's order, e.g. right resident, right medication, -------, and right time.

Based on interview and record review the facility failed to have a system in place to prevent unauthorized and unsupervised leave from the facility. This failure resulted in one resident's (R1) elopement from the facility without staff knowledge who has documented assessments related to elopement/wandering behaviors.This was identified as an immediate jeopardy which begin on 07/17/25 at 8:55pm when R1 eloped from the facility without supervision and authorization.V1 (Administrator) was informed of the immediate jeopardy and a template was presented on 07/28/25.On 08/04/25 acceptable removal plan was received after revision of the original plan submitted on 7/28/25.The Immediate Jeopardy was removed on 08/04/25, however, the non-compliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of in-service training.On 08/06/25 the surveyor confirmed by observation, interview, and record review that the removal plan was initiated, and Immediate Jeopardy was removed on 08/04/25. However, the non-compliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. FINDINGS INCLUDE:R1 medical report admission Record showed that R1 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Schizophrenia, hyperlipidemia, cerebral infarction and bilateral primary osteoarthritis of knee.V1 (Administrator said R1 placed in the facility due to being aggressive towards family.On 07/17/25 at approximately 8:55pm/9:00pm, R1 eloped from the facility unauthorized and without staff supervision. R1's police report dated 07/18/25 documents when reported by the facility as 01:23:27 07/18/25, time of occurrence 21:00:00 07/17/25 and 01:23;53 07/18/25. Offense codes listed as A433 missing Adult.R1's hospital emergency room record dated 07/18/25 showed that diagnosis includes but not limited to Dementia, PTSD (Post Traumatic Stress Disorder) schizophrenia and aggressive behavior. R1's medical record electronic physician order did not have a physician order documentation allowing him to go out independently without any supervision.R1's medical record MDS (Minimum Data Set, dated [DATE] showed R1's BIMS (Brief Interview for Mental Status) score of 11 indicating that cognitively R1 is moderately impaired.R1's previous (MDS) section C dated 12/04/2024 and 2/26/2025 scored R1 BIMS as 15 and 14 indicating that cognitively intact. Showing that R1 has decline cognitively. R1's medical record Elopement Risk Review dated 03/19/24 timed 18:48 (6:48pm) documented under comments that resident (referring to R1) is confused, voicing that he is trying to go home. Resident does actively engage in themed behavior and is a new admit. Resident will be placed on elopement protocol and will be monitored.R1's medical record recent Elopement Risk Review dated 07/21/25 four days after the incident of 07/17/25 documented that R1 is presently at risk for elopement and should be placed on elopement risk protocol. Comments documentation read R1 left from the building on 07/17/25 without authorization to go home. R1 can make his own decisions. Resident stated he knew what to do and where to go. Resident has history of hallucinatory behaviors but does not display those behaviors currently (currently). Resident is not able to live at home due to him showing aggression towards family. V13 (Receptionist) presented facility visitor registration log dated 7/17/25 that showed no documentation that R1 signed self out to the community or that the family member visit or sign out R1 to the community.V2 and V4 ADON (Assistant Director of Nurses) stated that any unusual occurrence should be documented The facility video monitor showed R1 walking around the nurse's station on the 1st floor at 8:55pm but did not show the front exit door. V1 stated that the video did not show the rest of the night footage because it has been discarded. R1's hospital visit record showed documentation that R1diagnosis includes but not limited to Dementia, PTSD (Post traumatic stress disorder, schizophrenia and aggressive behavior. R1 was treated on 07/18/25 with medications that includes Haloperidol lactate (Antipsychotic) at 3:26am and Midazolam (Versed) at 3:27am. On 07/23/25 at 2:00pm, interview conducted with V2 DON (Director of Nurse's) regarding the event of 07/17/25 with R1. V2 stated that R1 is one of our vets (veterans). Alert and oriented times 3, delusional, able to verbalize needs, needs re-direction constantly, has good days and bad days, needs supervision and cues from the staff. On the day R1 went out (referring to 07/17/25), I was on vacation I hardly took time off, but I was off. I did not do any investigation, V1 (Administrator) did the investigation so I could not tell you what happened. When asked about potential risk that could have happened to R1, V2 said Any-thing could have happened to (R1). Safety issues, accident can happen. R1 wants the son to get out of his home and that is part of why he (R1) is in the facility I think they V1 said they are in court, but he (V1) does not have the paperwork (court document) yet. V2 explained that the facility exits (in the facility) have alarms especially the front door, so if staff or resident goes through without proper code the alarm goes off to alert every-one in the building. The alarm is loud enough that everyone can hear it. When a resident is missing or eloped, the facility policies should be followed. The surveyor then asked whether it is normal occurrence for the facility residence to walk out of the facility without staff's knowledge. V2 said It is not normal for any of our resident to walk out of the building without anyone knowing about it. R1 is here (facility) to be cared for and monitored. On 07/23/25 at 3:23pm, V22 (Family) stated that I am the son, (R1) left the nursing home (facility) during the night of 07/17/25. (R1) walked back to his home which is about 4hours walk because they said he left around 9:00pm. V22 said I call the facility to ask about him, they (facility staff) did not know he was gone. V22 stated that he called the facility at 12:30am on 07/18/25 when R1 showed up at their house at 12:20am, so he called the police, they arrive with an ambulance and was advice to send R1 to the hospital. V22 stated that R1 did not recognize him was calling V22 by his brother's name, he was confused. Using the address V22 gave the surveyor R1 had walked approximately eight miles from the facility unsupervised and unauthorized to V22 home.On 07/23/25 at 3:51pm, V15 CNA (certified Nurse's Aide) stated that she was the 2nd shift CNA for R1 on 7/17/25. V15 stated that during her shift R1 was observed in the dining room socializing with peers. She made her last round at about 9:00pm 10:00pm and R1 was in the building then between 13:30am and 1:00am on 07/18/25 the facility staff called asking about R1's whereabout because he was missing. V15 stated that R1 is not capable of going out in the community without supervision, so R1 should not be out there without supervision of staff or family. He knows what time to come for medicine and dinner time, independent at times but still need staff to re-direct him.On 07/23/25 at 4:07pm, during interview with V23 RN (Registered Nurse) assigned to R1 on 11:pm to 7am shift 07/17/25, V23 stated that when I clocked in at the facility (timecard preview showed V23 clocked in at 11:09pm). V23 stated in part that V17 LPN (Licensed Practical Nurse) was at the nurse's station with V27 (RN), I got the shift change report from V17 that nothing was going on. The surveyor asked what V23 meant by nothing going and she said, to mean everything was normal with the residents assigned to her (V23). V23 stated that V17 (LPN) that worked 3pm to 11pm did not report that R1 eloped or has gone out unauthorized. V23 stated that it was after V22 (family) called the facility around 12:30am that the staff started looking for him. V1 (Administrator) was notified, and he came into the facility asked for the police be called. When the police called, he (V22) told them that he had his father, and he is on the way to the local hospital to get evaluated. V23 could not explain or give account of how R1 eloped with the door alarm on because the front door alarm goes off when coming in or out then you will have to put the code in to stop it. V23 stated in part that every staff knows the code to get in or out and the alarm did not sound on my shift. On 07/24/25 at 3:33pm, V25 (Maintenance Director) stated that all the exit doors in the facility are in working condition, the front exit door is always working. The alarm goes off when staff or resident goes through the door without the code. After 8:00pm the receptionist set the code so no one can go in or out without the alarm not going off, the staff knows the code to reset the alarm not the residents.On 07/24/25 at 4:37pm, V18 NP (Nurse Practitioner) stated that she is not the direct NP for R1 but in cases where a resident has dementia and MI (Mental illness) diagnosis these types of residents need constant supervision and are not capable of going out without someone supervision, family or staff. They should be monitored closely. If the resident has a MI (Mental Illness) diagnosis schizophrenia, takes his/her medicine and in a stable mind may be go into the community. The surveyor then asked V18 that in your professional opinion what are the risk this type of resident might face? V18 stated that they can be in a danger to self or orders, and they should be monitored /supervised.On 07/28/25 at approximately 10:23am, V27 RN (Registered Nurse) confirmed that R1 was not in the facility at the start of her shift and none of the staff was aware of R1 missing until V22 (family) called at 12:45am 07/18/25 and the staff started looking for him. When asked whether it is safe for R1 to be out there in the community at that time of the night, V27 stated that it is not safe for R1 to be out in the community at that time of the night stating No, it is not safe because we don't know where he could be, and anything could have happened to him. On 07/28/25 at 3:35pm, V36 (Physician) for R1 stated that she is familiar with R1, was made aware of R1 leaving the facility unsupervised. V1 (Administrator) called me right away after the event cannot recall what time. V36 said she talk to V1 immediately believed R1 was taken to the hospital to get him fully evaluated and to have drug test done because he was out of the facility. The surveyor asked whether V36 have seen R1 since he returned to the facility, V36 said No, I am out of the country now but when I returned, I will see him. The surveyor asked is it appropriate for R1 to go out without authorization / supervision? V36 said It shouldn't be safe for anyone in the nursing home even if they are alert and oriented because he was able to make his own decision to get to his son. The surveyor then clarifies from V36 Are you saying it is okay. V36 said I am saying is not okay, I would not want any of the resident at that time (of the day) to go out in the dark. The surveyor also asked V36 about what are the risk for R1 going out at that time without supervision and authorization, V36 said The risk can be fall like any one being at risk, there is traffic, loose your way. V36 added that R1 is alert times three knows what he was doing with BIMS of 15 at the time (tie of incident). The surveyor informed V36 that at the time of the incident R1's BIMS score was 11 and not 15. V36 stated that I don't know how they get 15 that is what I was told, R1 needs assistance and supervision to be out (out of the facility).On 07/21/25 at 1:32pm, V11 PRSC (Psychiatrist Rehabilitation Service Coordinator) assigned to R1 stated that R1 is alert oriented times three, R1 has some delusion and hallucinations, hard to redirect because he wants to do want to do against the facility policy. V11 stated she is aware about R1 going out of the facility without any supervision, I was informed on Friday (7/18/25) that (R1) left the building at 9:00pm on 7/17/25. He walked home rang the doorbell and his son answered the doorbell and then took him to the hospital for evaluation. The hospital released R1 back to us (Facility) on Friday and at that time my shift was over. V11 stated that R1 left the building because is fully aware of what he was doing, cognition is intact he wanted to go home, and he executed his plan. The receptionist leaves at 8pm, He (R1) waited till the front door was closed and left out of the building. When asked how she knows all these, V11 said V1 told her. The surveyor asked about how the residents are monitored /supervised to make sure the residents did not just go out without a pass/supervision. V22 said When the receptionist leaves there should be nurses and CNAs to redirect the residents. When asked about her professional opinion if R1 is able cognitively to go out of the facility without supervision/monitoring. V11 stated I want to say yes and no. Cognitively he was intact depending on his mental status at the time. When he is medication compliant, he is on right mind but when he refuses his medication that's when he delusional and hear voices. V11 stated I did not see him until today because he came back after the end of my shift.On 07/21/25 at 2:10pm, V12 SSD (Social Services Director) stated that she is familiar with R1, he is one of our veterans, alert but can be delusional, not easy to re-direct. I did talk to V1 (Administrator), he mentioned that R1 left the facility, but he did not give me any details of how it happened, this morning around 9am (7/21/25), V1 said the care plan should be updated. I asked V11 to do a wellness visit on (R1) and document on him. V11 stated that R1 has been on elopement risk since admission because he did not want to be here at the facility and was voicing it. R1 is at risk for elopement and need staff supervision. He hears voices, talk to himself. When asked about pass privilege, V12 stated that R1 is not on independent pass because he must be supervised either by family or staff. Family must sign him, before going into the community unless he is going with staff on appointment. The front door has an alarm, and I have his picture on the list of our residents on elopement risk at front desk (receptionist desk). On 07/23/25 at 1:58pm, V4 ADON (Assistant Director of Nurses) stated in part that the facility policy is that the CNAs are supposed to make rounds every two hours and as needed. The facility visitation is over at 8:00pm unless the administrator makes exceptions, the only time the resident can go out is if they have independent pass. R1 is ambulatory and sits in the dining room most of the time at night. When asked whether she is aware that R1 went out of the facility without supervision of staff and the reason for him been moved to another floor. V4 said I don't have the details about it the (V1) Administrator did not discuss the detail with me, so I don't know any detail about that. I just know he was coming from the hospital and need to be moved; I will have to discuss with V1 to know why he was moved. The surveyor V4 as the ADON and in her professional opinion is R1 cognitively capable of going about in the community without supervision? V4 said Hun-hum, prior to that day (7/21/25), I will have to get back to you on that one, I was told he called for a ride to come and get him.On 07/21/25 at 4:14pm, V17 LPN (Licensed Practical Nurse) stated that the last time she saw R1 was around 8pm. When asked how the staff know when the resident tries to leave the facility without supervision/ unauthorized and whether she would let any of the resident go into the community without supervision, unauthorized and unaccompanied during the night. V17 stated that No she will not allow any resident to go out; that the receptionist leaves at 8pm, the alarm on the door exit will sound if any of the resident tries to leave. V17 stated that R1 cannot function without staff supervision or family supervision in the community. Families normally will have come and sign out the residents with social services or V1 authorization. V17 stated that rounds are made every two hours the CNAs at even hours and nurses at odd hours.Facility Pass Privilege policy presented dated 7/16 documents in part that this nursing facility emphasizes and expects respectful, mature conduct from each resident both within the facility and the outside community. Some individuals admitted to the facility have history of psychiatric problems. Because of a combination of mental health, physical problems and irresponsible behavior certain residents may not be fully capable of negotiating safely in the community. Procedure listed includes but not limited to persons who demonstrate consistent maladaptive and problematic behaviors may not be candidates for independent privileges. Decisions regarding pass privileges, including, independent privileges or being accompanied by responsible individual are determined by physician orders and social services assessments. As appropriate, pass privileges may be discussed at care plan meetings which the resident is encouraged to attend. The resident is responsible for making staff aware of his/her desire to receive an independent pass privilege. Pass privilege levels listed, Level1 (Supervised Pass), Level 2 (Restricted Pass), Level 3 (Independent Pass) and resident may only move up one level at a time.Facility policy titled Unauthorized Absence dated 8/14 documents that the purpose of the policy is to ensure the ongoing health and safety when a resident has eloped/ and or is otherwise unable to be accounted for during occurring times of the day. An unauthorized absence is one that the resident is unable to be accounted for upon the scheduled return from home pass, while out on community pass, at a day treatment program and/or other similarly situated times. If a resident has eloped and / or otherwise absent from the facility without prior permission of notification, the facility is to take the following measures. The facility Elopement Risk Assessment policy presented dated 5/14 documents that the policy purpose is to identify residents who may be potentially at risk for elopement and at risk for harm. To use as a baseline to maintain a secure resident environment. Listed under Responsibility is the Social Services Department. Equipment to be used listed as the facility approved form. Procedure listed includes but not limited to a Social Service department will conduct the elopement assessment during the admission process, when there is a significant change in mood or behavior(s), and quarterly. Risk factors that will be assessed includes but not limited to verbalization of wanting to leave the facility and/or go home, inability or refusal to follow instructions diagnosis that includes but not limited to dementia and schizophrenia. In event the assessment was initiated because of an elopement (where the resident's whereabout were unknown), the elopement will be reported in accordance with the facility's Accident/Incident Unusual Occurrence Policy.Facility Incident/Accident Reports presented dated 9/14 documented in part that all accidents or incidents where there is potential for injury the report must be completed. An accident is defined as any happening, unintended event not consistent with the routine operation of the facility, that can result in bodily injury other than abuse. Listed incident / accident that report will be completed includes all accident/ incidental unusual occurrences , all unexpected events that occur that cause actual or potential harm to a resident and leaving premises without authorization (elopement).the administrator, Director of nursing, Assistant Director of nursing or Nursing supervisor must notify the following The incident/accident report is to be completed by RN (Registered Nurse) or LPN (Licensed Practical Nurse) and is to include date and time of the incident or accident., and the IDPH (Illinois Department of Public Health) The facility Supervision and Safety policy dated 3/15 presented documents that our policy strives to make environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. Our facility -oriented approach to safely addresses risk for groups residents such as wanderers, behavior, aggressiveness, confusion etc. (And so on). Staff to make visual rounds on residents minimally every two hours and more often I necessary based on resident's assessment.(CNA) saw R1 standing in the front lobby at 8:00pm, R1 told the (CAN) that he was waiting for his ride, re-directed R1 back into the facility without making the staff on 3-11pm aware on the 1st floor. The facility Discharge Against Medical Advice (AMA) documented that the purpose of the policy is to define the facility's responsibility when a resident and /or legal guardian voluntarily discharges him/herself from the facility without the consent of or an order from the attending physician. It is the policy of the facility to acknowledge the right of a resident to sign him/herself out of the facility without the consent of or an order from the attending physician providing that the resident has the decisional capacity to do so. If it has been determined that the resident is able to make his/her own decisions and chooses to exercise this right, he/she will be discharged from the facility Against Medical Advice (AMA). Procedure listed includes but not limited to prior to leaving the facility, the resident and/or guardian will be provided with explanation of the potential risks of such a discharge and alternatives to the same, any resident or legal representative choosing to discharge or be discharge without the consent of or an order from the attending physician is expected to sign AMA form. In the event the resident is signing him/herself out AMA, his /her legal representative and/or family member will be notified by facility personnel.On 08/06/25, the surveyor made observations, conducted interview, and received documentation to confirm the following removal plan was initiated. 1. R1 was reassesses by social services for elopement risk starting 07/21/25 and ending 07/28/25.2. All nine residents identified as potential to be affected by the same deficient practice were reassessed starting 7/18/25 to 7/28/25.3. The facility began re-educating the staff on elopement precaution and prevention that includes the facility elopement policy, exit door alarm system testing, system alarm response. Elopement binders.4. The facility made available elopement binders with identified resident's picture on every nurse's station starting 07/28/25.5. The facility staff are re-educated on supervision of identified wanderer/exit seeking residents starting 07/28/25 at least every-one hour. 6. The facility re-educate staff on pass privileges starting 7/28/25.7. The facility Maintenance Director re-testing all door alarm for proper functioning starting 7/18/25 to 7/28/25 as safety measures.8. All activity staff, nursing and social services will supervise the facility patio outings for elopement risk residents.9. V1 (Administrator) V2 (DON), V3 (Assistant Administrator), V4 (ADON), and V12 (SSD) re-educated on reporting incidents of elopement to proper authorities including IDPH (Illinois Department of Public Health) on 07/28/25). 10. Review of Quality Assurance Quality improvement Team monthly meeting will discuss and re-evaluate interventions in progress and if further interventions are needed it will be added and implemented.

Based on interview and record review the facility failed to revise a comprehensive care plan, failed to develop care plan with measurable goals, objectives and individualized interventions to meet the need for increased supervision in preventive interventions for one resident (R1) reviewed for elopement in the sample.Findings include:R1 medical report admission Record showed that R1 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Schizophrenia, hyperlipidemia, cerebral infarction and bilateral primary osteoarthritis of knee.R1 eloped from the facility on 07/17/2025 without authorization and without facility staff being aware that R1 was missing until the V22 (family) called the facility staff on 07/18/2025 at approximately 12:30am to inform them of R1 whereabout.R1's V22 (family) with the local police department advice sent R1 to the hospital for evaluation.R1's hospital emergency room record diagnosis includes but not limited to Dementia, PTSD (Post Traumatic Stress Disorder) schizophrenia and aggressive behavior.R1's medical record MDS (Minimum Data Set, dated [DATE] showed R1's BIMS (Brief Interview for Mental Status) score of 11 indicating that cognitively R1 is moderately impaired.R1's previous (MDS) section C dated 12/04/2024 and 2/26/2025 scored R1 BIMS as 15 and 14 indicating that cognitively intact. Showing that R1 has decline cognitively. R1's medical record Elopement Risk Review dated 03/19/24 timed 18:48 (6:48pm) documented under comments that resident (referring to R1) is confused, voicing that he is trying to go home. Resident does actively engage in themed behavior and is a new admit. Resident will be placed on elopement protocol and will be monitored.R1's medical record recent Elopement Risk Review dated 07/21/25 four days after the incident of 07/17/25 documented that R1 is presently at risk for elopement and should be placed on elopement risk protocol. Comments documentation read R1 left from the building on 07/17/25 without authorization to go home. R1 can make his own decisions. Resident stated he knew what to do and where to go. Resident has history of hallucinatory behaviors but does not display those behaviors currently (currently). Resident is not able to live at home due to him showing aggression towards family. On 07/21/25 at 2:10pm, V12 SSD stated in part that she has been on vacation but worked about three hours on Friday (07/18/25). V12 said did talk to V1 (Administrator), he mentioned that R1 left the facility, but did not give me any details of how it happened. This morning around 9am (7/21/25). V1 said the care plan should be updated. During the same interview with V12, V12 stated in part that R1 has been on elopement risk since admission because he did not want to be in the facility and R1 was voicing it.R1 plan of care for elopement with initiated date of 3/19/2024 with revision date of 07/21/25 documentation that showed that this care plan was not revised until 07/21/25 five days after the incident on 07/17/25 and four days after R1 had returned to the facility with no new intervention put in place until 07/28/25.The facility Elopement Risk Assessment policy presented dated 5/14 documents that the policy purpose is to identify residents who may be potentially at risk for elopement and at risk for harm. To use as a baseline to maintain a secure resident environment. Listed under Responsibility is the Social Services Department. Equipment to be used listed as the facility approved form. Procedure listed includes but not limited to a Social Service department will conduct the elopement assessment during the admission process, when there is a significant change in mood or behavior(s), and quarterly. Risk factors that will be assessed includes but not limited to verbalization of wanting to leave the facility and/or go home, inability or refusal to follow instructions diagnosis that includes but not limited to dementia and schizophrenia. In event the assessment was initiated because of an elopement (where the resident's whereabout were unknown), the elopement will be reported in accordance with the facility's Accident/Incident Unusual Occurrence Policy.

Based on interviews and record reviews, the facility failed to implement resident-centered interventions on a resident with behavior of agitation and limited mobility on upper extremities in preventing injury for one (R3) of four residents reviewed for accidents. This failure resulted in R3 experiencing pain, swelling, and bruising to left upper and mid arm which requires emergent transfer to the hospital and was found to have an oblique displaced fracture through the proximal diaphysis of the left humerus. Findings include: R3 is a [AGE] year-old, male, admitted in the facility on 02/04/2020 with diagnoses of Bipolar Disorder, Unspecified; Other Reduced Mobility; Stiffness of Unspecified Joint, Not Elsewhere Classified; Weakness; and Limitation of Activities due to Disability. MDS (Minimum Data Set) dated 12/24/24 recorded that R3 has BIMS (Brief Interview for Mental Status) score of 14 which means no impairment in cognition. His MDS also recorded that he needs substantial/maximal assistance for upper body dressing. R3 has impairment on both upper extremities. According to progress notes dated 02/20/25, while R3 was getting assistance with ADLs (activities of daily living) by CNA (Certified Nurse Aide), a pop sound from his (R3) left shoulder was heard. An Xray was ordered. R3's Radiology report dated 02/20/25 recorded: No recent fracture or dislocation. Incident report dated 02/26/25 documented that R3 was noted with swelling and bruising to his left upper and mid arm. R3 previously had a stat (immediately) Xray on the left shoulder done on 02/20/25 after a pop sound was heard as staff were assisting with pulling off his shirt. R3 was sent to the hospital for further evaluation and management. Hospital records dated 02/26/25 documented: R3 presented for evaluation of left upper extremity swelling. R3 states that earlier today aide at nursing facility was pulling patient's arm out of his shirt when he felt a snap and developed severe pain in his left shoulder. R3 continued to have left arm pain and swelling and thus was brought to ER (emergency room ) for further work-up. Hospital records also indicated that an Xray of the left humerus was performed showing R3 sustained an oblique displaced fracture through the proximal diaphysis of the left humerus. No focal geographic bony abnormality to suggest pathologic fracture. On 03/20/25 at 3:09 PM, V6 (Licensed Practical Nurse, LPN) was asked regarding R3 and incident on 02/20/25. V6 stated, On 02/20/25, it was V5 (CNA) who notified me to come to his (R3) room because he (V5) and V7 (CNA) were trying to assist him (R3) back to bed after dinner. I went to his (R3) room, he (R3) was agitated with them, said his left arm hurts, because they were trying to put him in bed. I did my assessment, no bruise, no open area. I called V14 (Nurse Practitioner), stat X-ray was ordered. I was off for 3 days, when I came back, I asked and was told that there was no fracture. Two to three days after, we got him up, V14 was trying to examine him and he couldn't move his (R3) arm, so he was sent out as ordered. V6 was asked if R3 has any limitations on his arms. V6 replied, Both arms are a bit contracted, unable to move his arms freely. He is dependent on staff for ADLs. He can still lift his arms a little. On 03/20/25 at 3:36 PM, V5 was interviewed regarding R3's incident on 02/20/25. V5 stated, I was one of the CNAs, I was helping V7. We were doing the care, taking his (R3) clothes off, and as we were taking his shirt off, he pulled away and that is when we heard a pop in his arm. He became agitated and that is when the pop came from his arm. I was the one taking his shirt off. Once I heard the pop, I immediately called the nurse. He did not complain of any pain. He was not agitated at first, he became agitated when I attempted to remove his shirt. This was the first time I worked with him (R3) and it happened. V5 was asked on how he removed R3's shirt. V5 continued, I tried to pull the shirt from the back when that didn't work, I grabbed the sleeve from his arm. I was holding his arm and I pulled the sleeve from his wrist and pulled it out. And that is when he became agitated and that's when the pop noise happened. On 03/20/25 at 3:47 PM, V7 was also asked regarding R3. V7 stated, We (V5 and me) were trying to take his (R3) sweater off. He kind of pulled back and we heard his arm popped and we go to get the nurse. It was the left that popped. He is alert and oriented. I don't know if his arms were contracted or not, that was my first time working with him. R3's Restorative Nursing Review Notes dated 12/24/24 recorded the following: Range of Motion: 2. Left shoulder - severe loss/less than 50% of norm 4. Left elbow - severe loss/less than 50% of norm 6. Left wrist and fingers - severe loss/less than 50% of norm Muscle strength and loss of functional movement: left shoulder, left elbow, left wrist - poor On 03/25/25 at 12:33 PM, V11 (CNA) was asked regarding R3 and range of motion. V11 stated, He has contracted upper extremities. He has stiffening on both arms, can bend elbows but shoulders are stiff. He is unable to move the upper extremities wide enough. If he gets agitated during dressing, depending on his mood, for the most part, he will kick his bed, [NAME] from side to side, he'll tell us to leave him alone. We will leave the room and come back later, otherwise he will not stop screaming. We will give him time to cool down and then attempt again later. When he gets agitated, he is not combative, he [NAME] from side to side and will scream. When we remove his shirt off, we don't hold the hand or arms. We will lay him in bed, we'll pull the shirt off by turning him from one side to another. When the shirt is on the upper chest, we will slide it over the head and slide out from the arms. We don't extend his arms at full length. For the most part, every CNA has had experience with him, knows how to do ADL care on him. On 03/25/25 at 1:01 PM, V12 (Licensed Practical Nurse, LPN) was interviewed regarding R3. V12 replied, He is alert. His upper extremities are contracted. He required total care; he is a feeder. He does not use his arms and hands; he could move them a little but not able to fully extend it to the sides or front. When we do ADL care, when removing shirt on R3, slide the shirt off from the back to head then slide it out from the sleeves. No need to pull or hold the hands. On 03/25/25 at 2:50 PM, V13 (Restorative Nurse) stated during interview, R3 had limitations to his bilateral shoulder. He could only extend his shoulders like less 50% of the norm. And any type of hyperextension, he cannot do it. His arms and shoulder cannot rotate. He usually wears loose fitting clothes. When you take his shirt off, pull the shirt off from the back, slide it over the head, slide it out to the arms, one arm at a time. You don't need to hold or grab his arms because his clothes are loose fitting and easy to take off. It is not necessary to hold his arm, just slide it off. He can be a little agitated especially when he wants something to do and he cannot do it, he become frustrated and agitated. He has a behavior of waddling himself and kind of pulling back, so any type of joint movement and when you are holding his hand or shirt can cause some resistance, and it could potentially lead to some type of pain or injury. That is why, when you are taking his shirt off, just let it slide off. He is alert enough to tell you what was going on. V3 (Director of Nursing) was also interviewed on 03/25/25 at 2:20 PM regarding R3. V3 stated, With the incident on 02/20/25 for R3, he pulled back while CNA was removing his shirt off from his left arm. The CNA said he had gotten agitated, resistive at that point. Whenever a resident gets agitated, let him cool down by not touching the resident, get another staff member involved, calm resident down. In other words, do not continue providing the care. V3 was also asked on how to remove R3's shirt. V3 verbalized, R3 is one of the residents with limited movements. His arms cannot go all the way up. He can move it to certain extent but not all the way. If you have a resident with contracted arms, you will pull the shirt off over the head first before pulling the shirt out to the arms. You don't have to hold the arm when pulling off the sleeves. If a resident has an impairment on one side, start with the normal side then to the impaired side. You should not hold the hand or arm when removing the shirt off. Let the sleeve slide out from the arms. On 03/25/25 at 11:38 AM, V9 (Social Services Director) was asked regarding R3's behavior. V9 stated, He is alert, oriented, no aggressive behavior, not overly delusional, gets agitated at times when refusing care, like he does not want to take shower or get out of bed. But not being difficult during assistance in ADL care, not that I am aware of. He is usually cooperative and compliant with care. He'll have those days that are not pleasant but most of the time, he is pleasant and cooperative. R3's care plan documented: Self-care deficit and requires assistance with ADLs to maintain the highest possible level of functioning as evidenced by the following limitations and potential contributing factors: limited bilateral shoulder and elbow range, poor bilateral hand grasp and dexterity, shoulder pain (revision dated 12/08/22) Intervention (02/05/2020) Explain all tasks prior to performing the ADL assistance. Use task segmentation and verbal cues as needed. Further review of R3's care plans showed that there were no interventions addressing behavior of agitation especially during ADL care and any special instructions on how to perform ADL care related to dressing. On 03/26/25 at 11:01 AM, V14 was asked regarding R3 and expectations on staff related to injury prevention during provision of care. V14 stated, R3 has limited mobility in his upper and lower extremities. I was notified that he had swelling and pain on the left arm and I sent him out to the hospital for further evaluation and treatment. I was told by V3 that when they were trying to dress him, he was resisting during ADL care, and they heard a pop. He was pulling away. He was resisting them while changing clothes and he pulled away. Usually, staff walks away or bring another staff member, give him a few minutes to calm down and try again. I expect staff to take into account what his behavior at the moment and how he respond, if not, step away and come back at a later time, give him time to cool down, this is the key in order to make him safe. He has some mental issues, in a minute they appeared to be cooperative then in a second they snap, behavior change, staff has to step back or redirect him. Facility's policy titled Behavioral Management for New or Worsening Behavior Symptoms dated 4/14 documented in part but not limited to the following: Purpose: To determine the cause of the behavior To prevent the resident from harming self or others To establish guidelines for reducing or preventing behaviors when possible Policy: It is the policy of the Nursing Department to determine the cause of behaviors when possible and initiate interventions to reduce, control, or prevent identified behaviors. Facility's policy titled Activities of Daily Living dated 4/14 stated in part but not limited to the following: Purpose: To preserve ADL function, promote independence and increase self-esteem and dignity. Implementation of Mobility Programs: Develop individualized care plan utilizing resident-centered goals. Provide special instructions and precautions. There was no other policy presented by facility related to prevention of accidents during ADL care or during provision of care upon request.

Based on interview and record review, the facility failed to follow their abuse policy by not preventing a resident to resident physical assault. This affected two of three residents (R2, R3) reviewed for physical abuse. This failure resulted in R2 being punched in the face, falling backwards, and being transferred to the hospital with a diagnosis of right frontal maxillary process fracture (upper jaw) Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, dementia, weakness and age-related physical debility. R2's brief interview for mental status dated 11/19/24 documents a score of 4 which indicates severe cognitive impairment. R2's Screening for indicators of aggressive and/or harmful behaviors under abuse factors dated 8/20/24 documents a high risk for abuse due to the following: History of abuse prior to admission; factor increasing residents vulnerability(dementia, confusion, poor insight/poor judgement, poor communication, poor ambulation, frailty/weakness, history of exploitation, heavy care needs, unable to make needs known, psychotropic medications; psychiatric history; resident admits to history of mistreating others. R2's progress note dated 11/4/24 documents: Resident was walking in the hallway pushing his wheelchair when R3 went up to him and struck him on the right side of the face causing him to fall to the floor on his buttocks before staff could intervene. Laceration noted to R2's right inner eye/side of the nose. On 11/26/24 at 11:43AM, R2 who was alert and oriented at time of R2 said he got hit in the nose, lip and right eye by R3. R2 said R3 hit him unprovoked and from behind. R2 said the hit caused him to fall backwards and he had to go to the hospital. R2 was angry that R3 hurt him and wanted to hurt R3 back. On 11/26/24 2:37PM, V1(administrator) said he assisted with investigation for R2 and R3 altercation. R3 came out of the small dining room and approached coffee cart to serve himself coffee at breakfast. Staff stopped him and instructed him to wait for staff to serve the coffee. R3 became upset and swearing at staff. R2 was near R3 at this time. R2 thought R3 was swearing at him and swore back. R3 got upset and hit R2 in response. R2 sustained a maxillary fracture that did not require any further intervention. V1 said the incident was substantiated. R2 did not hit R3. R3 sucker punched R2 and then kept walking. R2's facility reportable witness statements from R3 dated 11/4/24 documents: R3 asked staff for a cup of coffee, and they told me to wait until breakfast. I got irritated and swore at staff. R2 swore at me so R3 said he hit R2 in the face. R2's progress note dated 11/11/24 documents: Abuse investigation concluded regarding 11.4.24 altercation. Abuse by R3 substantiated. R2's hospital records dated 11/4/24 documents: R2 for evaluation of facial injury status post assault. Per emergency medical tech R2 was punched in the face by another resident causing him to fall backwards. CT scan documents: right sided nasal soft tissue swelling. Mildly depressed right frontal maxillary process fracture. Facility abuse prevention program undated documents: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property and involuntary seclusion. This facility therefore prohibits the mistreatment, neglect and abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting.

Based on interviews and record reviews, the facility failed to prevent or determine how an injury of unknown origin occurred for 1 of 3 residents (R1) reviewed for resident injuries in a total sample of three. This failure resulted in R1 suffering an acute left femur fracture that was discovered at an outside ortho appointment. Findings Include: R1 is an [AGE] year old with the following diagnosis: fracture of the right femur, aftercare following joint replacement surgery, dementia, and vitamin D deficiency. R1 was unable to be interviewed due to no longer residing at the facility. A Nursing note dated 9/27/24 at 11:20 AM documents R1 left the facility and went to the hospital for an appointment with an escort. The Veteran Visit Summary dated 9/27/24 documents R1 was admitted to the hospital for a new hip fracture. An acute left hip fracture was noted on x-ray. A Nursing note dated 9/27/24 at 7:25 PM documents the escort reported to the nurse that R1 was admitted to the hospital for evaluation. R1 was determined to have a left hip fracture. The Hospital Records dated 9/27/24 document R1 presented to the ortho clinic today with a left hip fracture. R1 presented to the ortho clinic today for a follow up of a right hip arthroplasty that occurred in July 2024. R1 complained of left hip pain and was given a left hip x-ray which revealed an acute left femoral fracture. R1 had decreased mobility in the left hip joint also. R1 was admitted for possible surgical intervention. On 10/29/24 at 10:17AM, V2 (R1 Family Member) stated staff notified V2 of R1 falling in 08/2024 but denied R1 having any injuries. V2 reported R1 went to a follow up ortho appointment at the end of September where a new left hip fracture was identified via x-ray. V2 stated R1 now is wheelchair bound after not having another surgery because it was too risky. On 10/29/24 at 1:07PM, V4 (Nurse) stated R1 had a history of falling and was a high fall risk. V4 reported R1 had a hip fracture, but V4 did not know how R1 fractured R1's left hip. V4 was not able to answer what protocols the facility has in place when a root cause to a fall cannot be determined. V4 stated an injury of unknown origin is when someone gets injured but staff can't say how it happened. On 10/29/24 at 1:23PM, V5 (Nurse) stated V5 sent R1 out to a follow up ortho appointment and R1 did not return to the facility. V5 reported R1 did have a fracture but V5 did not remember where the fracture was. V5 stated R1 did have numerous falls in August but was unable to say how many. V5 denied being aware of R1 having any falls near the time when R1 was sent out to the ortho appointment. V5 reported R1's last fall was at the end of August and R1 did not have any injuries. V5 was not able to define an injury of unknown origin. The surveyor then defined an injury of unknown origin to V5. V5 stated the new fracture would be an injury of unknown origin due to the facility not being able to identify a cause. On 10/29/24 at 4:03PM, V8 (Former Nurse) stated R1 had more than three falls while residing at the facility but R1 did not suffered any injuries from the falls. V8 reported R1 was a high fall risk due to being confused and an unsteady gait. V8 denied knowing what an injury of unknown origin is. The surveyor then defined injury of unknown origin and V8 stated the new fracture should be considered and injury of unknown origin due to not being able to find a cause. On 10/30/24 at 12:04PM, V10 (Restorative/Fall Nurse) stated R1 was a high fall risk on admission due to unsteady gait. V10 denied being aware of any injuries with any falls. V10 denied having any record of R1 falling in September. V10 reported being notified R1 had a new fracture during a morning meeting. V10 stated staff try to determine a root cause of each fall but they weren't able to determine a caused of the fracture. V10 reported a fracture would be a serious major injury. V10 stated managements talks to staff to see who was the last person to see R1 and establish how the fall occurred to the best of their ability what happened. V10 stated in this case there was nothing to say how R1 got the hip fracture and it can be classified as an injury of unknown origin. On 10/30/24 at 2:34PM, V11 (CNA) stated V11 escorted R1 to the ortho appointment and no accidents occurred during transport. V11 reported after R1 took x-rays, V11 was told by hospital staff that R1 would be admitted to the hospital. V11 denied being aware of any new fracture. On 10/30/24 at 2:45PM, V12 (DON) stated during the investigation, it seemed as though an accident happened when R1 was out on pass with family because R1 didn't have any falls in September. V12 reported R1 came back from the visit with pain but it was not investigated further. V12 stated the fracture cause was not able to be determined during the investigation. The Hospital Admission Records dated 7/24/24 documents R1 admitted to the hospital after falling and breaking the right hip and femur. R1 is alert and oriented times one. The plan is to discharge R1 to a rehab facility. A Nursing note dated 8/1/24 documents a loud noise was coming from R1's room and staff found R1 on R1's knees. R1 admitted to trying to walk. R1 was assessed in an abrasion to the left knee was found. An x-ray of the knee was performed and was negative. No other injuries were noted. A Nursing note dated 8/18/24 documents R1 fell and a head to toe assessment was completed with no apparent injury noted. R1 was able to move all extremities. A Nursing note dated 8/22/24 documents R1 attempted to stand on assisted and walk back to the wheelchair and fell . A head to toe assessment was completed and no major injuries were noted. R1 sustained minor skin tear to the right knee with minimal bleeding. R1 was able to move all extremities. A Nursing note dated 8/25/24 documents R1 was noted on the floor across the hall from our room. R1 was laying on the right side and had redness to the lower back. When asked what happened, R1 replied that R1 walked over to the other room. R1 complained of low back pain and medication was given. The physician ordered to send R1 out to the hospital for evaluation. R1 returned back to the facility with no new orders. The x-ray results were negative. The Hospital Records dated 8/25/24 document R1 presented to the emergency department after an unwitnessed fall. R1 is alert and oriented times one at baseline. An X-ray of the pelvis was completed. A right hip arthroplasty was noted to be in alignment. No other fractures in the right or left hip or noted at this time. R1 was sent back to the facility. A Nursing note dated 9/5/24 at 11:15 AM documents R1 went out on pass with family and left and stable condition. R1 is due to return tonight. A Nursing 9/5/24 at 6:15PM documents R1 returned from being out on pass with family. R1 complained of pain all over R1's body. R1 denied falling and denied being bumped. R1's family was called and asked if anything happened while out on pass and the family denied any injuries. The Medication Administration Record dated 09/2024 documents R1 rated pain a 10 out of 10 and was given Tylenol. The pain assessment scores were reviewed and documented as zero for each entry. The complaint of pain on 9/5/24 after returning from an outside pass is new onset pain. No complete pain assessment or further assessment of the pain was documented after the medication administration. The physician was also not notified of the new onset pain. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as a five (severe cognitive impairment). Section GG of the MDS documents R1 has an impairment to one lower extremity and uses a wheelchair as a mobility device. R1 is a substantial/maximal assist with most ADL care. R1 is a supervision or touching assist with bed mobility and a partial/moderate assist with transfers. Walking was not attempted during this assessment. The Facility Unusual Occurrence 24 Hour Report Form dated 10/3/24 documents R1 went to the hospital for an ortho. Follow up appointment. X-rays were completed at the appointment and a left hip fracture was noted. R1 is alert and oriented times one with confusion. Before the appointment, R1 showed no signs of pain or discomfort. R1 had no new redness, bruising, deformities, or changes in behavior. Upon investigation, no report or knowledge of any falls or other incidents or noted. At this time, the cause of the injury is unable to be determined. R1 remains in the hospital. Based off the progress notes, R1 has an extensive history of falls and a new onset of pain on 9/5/24 that had was never further assessed nor was a physician notified. The facility was unable conclude when or how an injury occurred. ' Since R1 had an x-ray of the pelvis on 8/25/24 that was negative, the injury had to occur some time fro 8/26/24 to 9/27/24 when the injury was discovered. The policy titled, Abuse Prevention Program Facility Policy, dated 2012 documents, .An injury should be classified as an injury of unknown source' when both of the following conditions are met: The source of the injury was no observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because the extent of the injury of the location of the injury.

Based on interviews, observations and record review, the facility failed to provide adequate supervision to 1 (R4) of 3 (R1, R3 and R4) residents and the physical enviornment review for accidents, this failure resulted in R4 gaining access to the laundry room, that should have been locked, and once R4 gained entry to the laundry room, the facilty's lack of supervision allowed R4 to gain access to a laundry detergent that spilled on his right foot causing a chemical burn that required treament at the local hospital. Findings include: R4's electronic medical record indicated resident admitted to facility on 05/01/2023 and has a past medical history not limited to: bipolar type schizoaffective disorder, depression, anxiety, burn of unspecified degree of right foot, iron-deficiency anemia, and age-related physical debility. Facility final incident report dated 06/29/2024 indicated R4 reported to nurse that he had blisters on his right foot. R4 complained of a burning sensation to his right foot after some detergent fell on his shoe while washing some items. R4 was rendered first aide at facility, then sent to a local emergency room and later returned to facility with diagnosis of a chemical burn to his right foot with treatment orders and follow-up to a burn clinic. Hospital records dated 06/23/2024 indicated R4 presented to local emergency room from facility with complaint of spilling powered bleach onto right foot. R4 was seen by V12 (Medical Doctor) for a burn follow-up/wound check and was diagnosed with a chemical burn. His foot was irrigated, dressed with wet to dry dressing, then transported back to facility with orders to follow up with primary vision and burn clinic in two days. Care plan last revised on 06/24/2024 indicated R4 has altered skin integrity related to chemical burn to right great toe tip extending to medial aspect and right medial forefoot extending to dorsal aspect of toes. Same care plan with revision date of 06/25/2024 indicated a focus for R4 to engage in vocational activities with goal to perform duties as discussed with V1 (Administrator) and appropriate department head 5 days per week. Interventions included but not limited to: observe resident during program, and minimize risk factors through interventions such as assessment, team consultation, supervision, observation, structured environment, and peer-buddy system. Burn outpatient preliminary report dated 06/25/2024 indicated R4 presented to burn clinic for evaluation of chemical burn sustained at facility on 06/23/2024 while working in laundry department where his shoes and socks became covered with powdered bleach when it was wasted onto his wet shoes and R4 sustained burn wound to the dorsal, medial foot, and dorsal toes of his right foot with dead skin overlying the burned area. (Report incorrectly indicated left foot.) Treatment was rendered, wound cleaning and healing ointments both applied (see treatment orders below), then covered with gauze dressing and orders to return to the burn clinic in one week. Treatment orders for R4 with print date of 07/01/2024 showed an order to apply a debridement ointment (removes damaged/dead tissue to promote wound healing) to right great toe tip and right medial foot after normal saline cleanse, then apply an antimicrobial cream to gauze and lay over wound bed and cover with dry dressing daily and as needed. On 07/01/2024 at 12:06 PM, V4 (Assistant Director of Nursing) said on 06/23/24, R4 went into the laundry room behind the kitchen area on the first floor, but was not allowed to be in this room unsupervised. She also said that she believed the laundry aide was on duty but wasn't present at the time that R4 had entered the laundry room. V4 (ADON) then said R4 saw some detergent in a box on the floor, so he opened the packet and had spilled some onto his shoe when he later felt his foot burning and saw some blisters on his foot. She added that R4 was sent out and returned same day with treatment orders and to follow-up with the burn clinic. V4 added that she was unaware of what specific detergent caused the chemical burn to R4's foot but indicated that V1 (Administrator) was aware of the name. On 07/01/2024 at 12:48 PM, V1 (Administrator) said R4 was allowed to participate in an activities/vocational training program to deal with his anxiety by doing simple tasks that included: scraping plates after meals then taking trays to the doorway of kitchen, mop up a spill on the floor, pick up trash from offices and take the trash to the back door. He added that all chemicals in use for R4 are premixed for him, such as with a cleaning product and water. V1 (Administrator) then said on day of incident (06/23/2024), R4 went into the laundry room per self, saw some detergent stored in a box, opened the box and removed a packet of detergent from the box, and then tried to put the detergent into the washing machine when he spilled some on his foot. V1 added that this occurred at approximately 3:00 PM but R4 did not report the incident and/or the blisters on his feet to his nurse until approximately 4:30PM who sent R4 out for further treatment and evaluation. V1 (Administrator) then said that the detergent was determined to be a whitening detergent that their vendor wanted the facility to try and wasn't previously used by facility. V1 added that the laundry product that caused the burn to R4's foot was in a box near the washers but was removed from the building after incident and will not be used by facility. V1 provided the product safety data sheet (SDS) for review. Safety data sheet with issue date of 01/26/2024 that indicated the laundry product was a multi-purpose stain blaster reserved for industrial and professional use with no dilution information provided that may cause skin irritation, allergic skin reaction, and/or serious eye damage. SDS sheet indicated to wear personal protective equipment including gloves/clothing/eye and face protection and to store the product locked up. On 07/01/2024 at 1:24 PM, V6 (Social Services Director) said R4's cognition is always intact, but he can be anxious at times so facility explored therapeutic interventions and activities that were appropriate for R4 to perform. She added that R4 enjoyed cleaning, so she referred him to the appropriate department heads who only inquired about R4's mental state/cognition and did not include V6 in the planning. V6 (SSD) then said she has never been done this type of intervention/activities in the past with any other resident and indicated that no type of safety contract was initiated for R4 related to the activities/duties he would be performing. On 07/01/2024 at 1:51 PM, R4 said that he takes himself into the laundry area because the laundry doors are not locked and there's no code to unlock the door. R4 added that he's washed clothes and operated the machines before to help the laundry staff. R4 said on day of incident, there was no one present of working in the laundry room. He then said after loading the washer with soiled white linens and incontinence pads, he saw a box filled with packets of a bleach detergent, opened it, then spilled some to the top of his right shoe when he tried to add packet into the washer. R4 then said that he felt a burning sensation to his right foot, so he had removed his shoe, took off his sock, then put his shoe back on. R4 added that he stayed in the laundry room for a while longer to finish what he was previously doing and at no time did any staff come to the laundry room while he was there. R4 then said a few hours later, he informed his nurse during medication administration about the incident and of the burning sensation. He said the nurse (V9) put a dressing on his foot and said R4 had to be sent to local hospital. R4 said he went to the emergency room , they cleaned his foot, applied a dressing then sent him back to the facility. R4 added that he followed up with the burn clinic on the next day and has a second appointment on 07/02/2024. R4 said at times, he still feels a burning sensation to his right foot that comes and goes. On 07/01/2024 at 2:24 PM, observed V10 (Wound Care Nurse) provide wound care to R4's right foot prior to applying a new dressing. During wound care, observed open areas to tip of great toe and lateral side extending to medial aspect. Also observed open area to top of foot from medial base of great toe through dorsal aspect (fourth toe) and noted edema throughout R4's right foot. V10 said the areas are considered two wounds, with one cluster extending from great toe to fourth toe and from side of great toe and around to front. She added that R4's wounds are documented as full thickness wounds with slough, with red smooth areas throughout wounds. On 07/01/2024 at 2:50 PM, toured laundry area that is across from dietary department in back hallway with V1 (Administrator). Observed a lock on laundry doorknob and the door propped open with an armchair placed in the doorway. Upon entering the laundry room, a laundry staff member removed the chair from the doorway and placed it against the wall next to door. V1 then said the laundry door should always be locked when no staff is present. On 07/02/2024 at 10:51 AM, V2 (Assistant Administrator) said the laundry department is closed from 2:00 PM until 4:00 PM so on the day of R4's incident, the laundry department was closed. Reviewed working schedule and hours worked provided by V2 that showed no laundry staff were working on day of incident (06/23/2024) between the hours of 1:30 PM through 4:13 PM. On 07/02/2024 at 11:31 PM, V3 (Director of Nursing) said R4 he was not allowed to be in the laundry room because this is not included on his list of activities to do. V3 added that no resident is allowed in the laundry room, and the door should be locked if no staff is present. She also said that no door should be propped open at any time. On 07/02/2024 at 11:38 AM, V9 (Licensed Practical Nurse) said at approximately 8:30 PM on day of incident, he was preparing medications when R4 came to the nurse's station and said something fell on his right foot. V9 said he and R4 went to his room, R4 removed his shoe and sock to his right foot and V9 saw what looked like blisters to his first four toes, were not fluid-filled. V9 added that R4 complained of a burning sensation to the foot that did not look like a recent injury. R4 informed V9 (LPN) that some bleach fell on his gym shoe while he was in the laundry room. V9 called the treatment nurse, manager on duty and the administrator then cleaned R4's wound with normal saline and applied a wet to dry dressing. He then spoke to the physician and received order to send R4 to the hospital where he stayed for a few hours then returned with a dressing in place and orders to follow up with the burn clinic. On 07/02/2024 at 01:32 PM, V1 (Administrator) said no one stands over R4 to watch him perform his duties that have since been discontinued post R4's incident. V1 then said that R4 was able to access the laundry room because it was found during investigation that the lock to the laundry room door was not functioning properly and required the lock to be changed out with new keys reissued to laundry staff. Reviewed vendor sales receipt dated 06/24/2024 that showed the purchase of a new lock system and copies made for four additional keys. Reviewed supervision and safety policy dated 03/15 that reads in part: policy strives to make the environment as free from hazards as possible. Safety risks and environmental hazards are identified on an ongoing basis through employee training conducted upon hire, annually and as needed. Resident supervision is a core component to resident safety. Staff to make visual rounds on residents minimally every two hours and more often if necessary based on resident's assessment needs.

Based on interviews and record reviews, the facility failed to prevent or determine how an injury of unknown origin occurred for 1 of 3 residents (R2) reviewed for resident injuries This failure resulted in R2 being found with an old fading bruise and a right proximal humerus fracture at the surgical neck. Findings Include: R2 had the diagnosis of Dementia, Hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting unspecific side. Minimal data set section C (cognitive skill for daily decision making) dated 4/4/23 documents: a score of three which indicated severe impairment (never/rarely made decisions). Section G (functional status) documents: R2 required extensive assistance with two person physical assist with transfers and extensive assistance with one person physical assist with bed mobility. On 6/27/23 at 2:34PM, V3 (don) said, R2 was observed with yellow and green discoloration. R2 reported she tried to get up. R2 twisted her arm attempting to get up from bed which resulted in a fracture due to osteopenia. Staff did not report any incidents, falls or anything else. On 6/28/23 at 2:26PM, V12 (restorative aide) said, while doing range of motion with R2, taking off R2's gown. R2 yelled/hollered out and moaned stating her right arm was sore/hurt. R2. R2 couldn't lift it up her arm. R2 is a Hoyer lift, total care and cannot turn and reposition self. R2 can move her legs. R2 cannot move/lift her upper body. On 6/28/23 at 2:59PM, V15 (cna) said, R2 complained of pain during, ADL care, R2 said, she was trying to get out the bed and go to bathroom. On 6/28/23 at 3:56PM, V17 (medical doctor) said, the nurse reported R2 was getting out of bed and twisted her shoulder. R2 verbalized pain. R2 had swelling. On 7/6/23 at 10:15AM, V25 (orthopedic doctor) said, R2's injury did not occur by twisting. R2 fracture was associated with a fall. Event dated 4/21/22 documents: Reported by certified nursing assistant, resident (R2) complained of pain to right shoulder which was noted with slight discoloration with mild swelling and warm to touch. Level of pain: face grimacing and tense body language. Mental status: oriented to person, confused/disoriented. Predisposing Physiological Factors: Impaired memory, weakness, decreased safety awareness and delusions. No witnesses found. Progress noted dated 4/21/23 documents: Residents (R2) right shoulder noted with mild swelling and old fading bruising. R2 complained of discomfort to site. Progress noted dated 4/22/23 documents: R2 was sent to the hospital. R2 was diagnosed with a right shoulder fracture. R2 had not fallen or anything. ED paperwork dated 4/22/23 documents: Per nursing staff, R2 had an Xray today showing a nondisplaced fracture and was sent here for repeat imaging and re-evaluation. R2 is nonverbal at baseline and did not contribute to this history. R2 arrived in a make shift sling. Right upper extremity held adducted, internally rotated with elbow flex at ninety degrees with contractures to hand/fingers with normal capillary refill. Bruising to proximal right upper extremity. Shoulder immobilizer applied. Imaging result dated 4/22/23 documents: R2 had a right proximal humerus fracture at the surgical neck. Mild displacement. Ambulatory progress note dated 5/11/23 document: Patient (R2) states she was trying to get out of bed and injured her right arm. Etiology of a Humerus fracture: Humeral neck fractures are caused by a fall on the outstretched arm or the elbow, often in elderly, osteoporotic women. If the fracture is through the surgical neck of the humerus, it can be classified in three distinct categories; unimpacted, angulated impacted, and comminuted.

Based on interview and record review, the facility failed to prevent a resident (R1) from obtaining a severe burn from a radiator heater connected to the wall when R1's bed was pushed against the wall for one out of three residents reviewed for accidents and incidents in a total sample of four. This failure resulted in R1 suffering second and third degree burns to the left leg requiring a hospitalization where R1 received a debridement and skin graft surgery. The Immediate Jeopardy that began on 3/19/23 was removed on 3/21/23 when the facility removed the heater on the wall from R1's room. The administrator was notifed on 04/14/23. This past non-compliance occurred from 03/19/23 through 03/21/23. Findings Include: R1 is a [AGE] year old with the following diagnosis: peripheral venous insufficiency, cerebral infarction, and weakness. R1 admitted to the facility on [DATE]. A Nursing note dated 3/19/23 documents upon doing rounds, R1 was heard, moaning and complaining of left leg pain. The nurse helped turn R1 from the left side to the right side. A burn was then observed on the left lateral lower leg. The burn appeared red with a blister, when I asked what happened, R1 stated that the bed was close to the heater attached to the wall and the heat was too warm and burned. R1's leg. The burn was cleansed and left to air dry. The physician was called and orders were received to apply a burn cream twice a day and a burn wound consult. R1 denied any pain or discomfort. A Nursing note dated 3/20/23 documents the nurse practitioner evaluated R1's left leg wound and gave verbal orders to send to the burn specialist to evaluate the left leg burn wound. A Nurse Practitioner note dated 3/20/23 documents R1 was assessed due to a new wound. Per R1, R1 was sleeping with the leg up against the heater on the wall when R1 noticed the leg beginning to hurt. R1 called the nurse and that is when the nurse noted R1 had a wound on the left leg, as it was lying on the heater on the wall. R1 was repositioned immediately to get the leg off the heater and a burn was identified. After coordination with the wound team and a complete assessment, it was decided to send R1 to the hospital for further evaluation and treatment, which requires a higher level of care. The wound to the left leg extends from the thigh to below the knee. The wound is red and dry at the proximal portion of the wound. There is darkness to the middle portion of the wound. There is a large serous filled blister at the distal portion of the wound just below the knee. A Nursing note dated 3/20/23 documents R1 was admitted to the hospital with a diagnosis of a full thickness, third-degree burn to the left leg. R1 is scheduled to have surgery in the morning. A Nursing note dated 3/23/23 documents R1 had a debridement to the left leg burn site with a skin graft. The Final Investigative Report Form dated 3/19/23 documents R1 was lying in bed and complained of pain to the left leg. Upon assessment, the left leg was noted with redness and a clear fluid filled blister area. The doctor was made aware and treatment orders were received, as well as a consult for a burn wound. The next morning, the nurse practitioner and the wound care nurse assessed R1's leg. The nurse practitioner gave orders to send R1 out to the hospital for a burn consult. R1 was admitted to the hospital and remains in the hospital this time. The Hospital Records dated 3/20/23 documents R1 presented to the emergency room with a burn. R1's bed was next to the radiator. R1 had pain to the left knee where the burn was but endorse it has improved. The physical exam shows left knee erythematous (redness) with evidenced of a popped blister with cream over line. The left medial knee has a palm size blister. Plastic surgery/burn physician was consulted. The assessment from the burn physician indicated R1 sustained a full and partial thickness burn to the left lower extremity. R1 reported sleeping in R1's bed, which is next to the radiator when R1 felt the radiator burn R1's leg. The burn is 2% total body surface area to the left distal thigh, knee, and proximal lower leg. The central portion of the burn is full thickness with edges of partial thickness. A large blister is noted distantly. R1 was admitted to the burn intensive care unit. On 3/23/23, a fascial excision (excision of the full thickness and subcutaneous tissue to create a reliable bed for skin grafting) of the burn and autograft placement was performed with the donor site being from the left thigh. On 3/31/23 at 1:56PM, this surveyor went to make observation in the room where R1 stayed. The radiator heater previously attached to the wall was removed. There is an empty space on the wall where the radiator used to sit. The empty space shows the radiator heater was attached to the wall about 1 foot from the floor and was approximately 6 feet long down the length of the wall. At 2:01PM, R2 walked in the room and was interviewed. When asked what happened to R1, R2 stated R1 burned R1's left leg on the heater that used to be on the wall. R2 endorsed that night R1 was making noises causing R2 to wake up and that is when everyone started coming in the room to check on R1. R2 denied R1 screaming out for help but was moaning and saying Ouch. It hurts. R2 reported seeing the burn the next morning and described it starting from the lateral, mid-thigh and extending to the just below the lateral knee with a fluid filled blister the size of a golf ball. R2 also stated the wound was red in color. R2 stated R1 went to the hospital the next day because the blister got larger. On 3/31/23 at 2:50PM, V3 (Nurse) stated, I came in on Monday morning and the burn looked really bad. I thought to myself R1 needs a burn unit. We got orders to send R1 to a hospital burn unit. There was a heater on the wall, and R1's bed was pushed against the wall. R1 turned that way towards the wall in bed, and R1's leg came off the bed and was touching the heater. The heater was like an old radiator type of heater. R1 had kind of two spots of where the burn was. Then below the knee R1 had a very large blister. I would say it was about the size of a fist. There was another blister on the side of the knee that had popped. You could tell a blister was there. R1's pretty much total care but R1 can turn. R1 is overall weak. R1 does have venous insufficiency, so R1 probably couldn't feel what was burning R1 because of the lack of blood flow. R1 might not have been strong enough to get his leg back over after it was touching the heater, or R1 might have been in too much pain to lift it off alone. On 3/31/23 at 3:39PM, V4 (Maintenance Director) stated, I don't really have anything to do with the heaters. We only check those when they're broken. It's a hardwired space heater. The ones that are mounted to the walls are in working condition. Only the rooms at the end of the halls have the heaters connected to the wall because they are right next to a stairwell so it could be colder in their rooms from some drafts. I did not check any temperatures in that room of the heater that I can remember. I know there's a dial on there with three different settings that the residents can access if they want to. I don't check the knobs. If you left your skin on there for too long, it would probably burn. No, I still don't have to check any temperatures of the heaters. On 3/31/23 at 3:46PM, V5 (Nurse) stated, I answered the call light and R1 was complaining of heat coming from the heater that was attached to the wall. R1 asked to be pushed away from the wall because R1 was too hot. I pushed the bed away and R1 moaned in pain. R1 started talking about R1's left leg hurting. It was covered with a blanket, so I couldn't see it. When I took the blanket off to look at it, I saw the skin was off superficially, and R1 had a small blister. The blister was on the left lower lateral leg near the knee. The red area went all the way up on the lateral side of the thigh. It didn't go all the way up the side, but probably to the middle of the thigh. I would say the blister started off as a golf ball size then got a little bit bigger. No, I did not tell anyone when it got bigger. That's usually what blisters do. I went into check on R1 for my first round around 11PM and R1 was sleeping. R1 wasn't complaining of anything so that did not prompt me to do anything. R1 can turn from side to side. R1 uses a wheelchair to get around. R1 couldn't really say what happened or why R1 kept R1's leg there. I don't know all the diagnoses of the residents so if R1 does have a diagnosis of that (PVD), then that could be a reason R1 kept R1's leg there. R1 might not have felt it getting hot. R1's bed was up against the wall when I came in but because the blanket was covering R1. I could not see if R1's leg was on the heater the first time I rounded on R1 so I didn't do anything then. I can't really remember exactly what time it happened but I want to say it was between 2 and 3 AM. On 3/31/23 at 4:28PM, V6 (CNA) stated, I first saw R1 around 10PM when I came in and did my first rounds. R1 was sleeping then. The nurse (V5) came in around 11PM and she did her first rounds and saw R1 sleeping too. I can't remember what time it happened but I saw R1 again still sleeping after midnight. I was doing my rounds again and the nurse called me into R1's room to show me the burn. R1 had a burn on the side of R1s knee with a blister just below the knee. It was probably a little bit bigger than a gold ball. R1 is able to turn by himself in bed. I think when R1 turned R1 was just sleeping on the heater and didn't realize it until R1 was burned. When I went into R1's room to check on R1, it looked like R1 was just sleeping under the blankets. I saw R1's bed up against the wall but I couldn't see R1's leg touching the heater because the blankets were touching it. I don't know why R1's bed was against the wall. I don't remember R1's bed being against the wall before. On 3/31/23 at 4:40PM, V7 (Nurse) stated, I worked the evening shift the day before it happened. R1 didn't complain of anything to me that shift when I was leaving. I do remember R1'ss bed was up against the wall, but I didn't think R1 could touch the heater. I didn't ask R1 why R1's bed was against the wall. The burn was a big red area on the side of his leg. It went from the thigh to a little below the knee. It was probably as thick as the top part of the heater. There was a blister on it too. It was probably the size of a golf ball. On 4/3/23 at 4:17PM, V8 (Burn Unit Physician) stated, R1 had both second and third degree burns to the left leg. Second degree means it goes partially through the dermis which is the second layer of skin under the epidermis. A third degree burn is a full thickness burn which goes all the way through the epidermis and dermis. This burn was more complicated because it was near a joint. A third degree burn around a joint can cause a contracture. R1 ended up needing a skin graft to assist in healing the area. Skin grafts are the main course of treatment for extensive, more serious burns. It would take much longer to heal and a greater risk for infection if no skin graft was done. For a burn that is second or third degree, it would need to be something 108 degrees or higher that touches the skins for about 2 - 3 minutes. I can't say exactly how long he had his leg on the heater, but most people have the instinct to immediately remove their body from something that feels hot. We know he at least had it on the heater 2 - 3 minutes if it was 108 degrees. Yes, he does have a history of peripheral vascular disease so that could have distorted his perception of how hot the heater really was. PVD causes decreased sensation because of the decrease of circulation and the narrowing of the blood vessels. Any burn with a blister that is growing in size should be seen as soon as possible. A burn is considered an open wound so you increase the risk of infection. Burns also cause dehydration through fluid loss. Because this was over a joint, this would be considered an area that needed to be treated immediately because of the location. With a burn around a joint, the skin, muscles, and tendons can tighten causing much more severe damage. On 4/4/23 at 10:49AM, V9 (Nurse Practitioner) stated, The burn just didn't look great. My gut said to send R1 out. It was a large wound to the left thigh that traveled down past the knee. There was a lot of redness with a blister. The blister was the size of maybe one of the cutie oranges. After speaking with the wound nurse and the floor nurse, we decided R1 needed a specialized burn unit to care for this wound. R1 told me R1 rolled over in R1's sleep and R1 felt R1's leg getting hot. R1 put on the call light to get the nurse to help R1 and they found the burn on R1's leg. On 4/4/23 at 11:03AM, V10 (Wound Care Nurse) stated, I saw R1 when I came in on Monday. I measured the area and assessed R1. I was told R1 laid R1's leg on the heater. The wound was an open red area from the thigh all the way down past the knee a little. I was on the lateral side. R1 also had a blister on the wound closer towards the bottom. It was big. I would say probably the size of a grapefruit. On 4/4/23 at 4:00PM, V2 (DON) stated, We found the cause of the burn was the bed being against the wall. R1 told me it made R1 feel more secure when R1 was moving in the bed. R1 was mostly independent with bed mobility. R1 just wasn't able to transfer alone. We don't know why R1 kept R1's leg there long enough to get burned. Doing more thorough rounds would help prevent or decrease injuries like this. On 4/6/23 at 11:08AM, This surveyor walked in the room mid-dressing change to the left leg. There were 2 sites noted. The wound to the top of the left thigh was the donor site. It is pink and a rectangle shape. The second site was the graft site which is located about inch above the lateral left knee to about the middle of the calf. That wound is red with dark red edges around the whole wound. The thigh was treated with Silvadene, xeroform, and a dry abdominal pad. The lateral knee was treated with xeroform and a dry abdominal pad. R1 has a purple discoloration completely around both legs starting from the ankle extending up the leg about 3-4 inches. The surveyor questioned V11 (Outside Facility Wound Care Nurse) what the discoloration was on the legs and V11 stated, R1 has PVD. That can cause discoloration to the legs because of the lack of circulation. On 4/6/23 at 11:16AM, V11 stated, The wound to the top of the thigh is the donor site. That is 10.5cm x 16cm. The lower leg is 22cm x 13.5cm. The wound to the top of the thigh has gotten smaller R1 admitted to us, but the graft site has remained the same. R1 admitted to us on 3/30/23 from the hospital burn unit. R1 is not able to roll himself when we do the dressing changes. R1 can assist in helping us turn, but R1 can't do it alone. On 4/6/23 at 11:22AM, R1 stated, I went to bed that night sometime between 9 and 10PM. The CNA (V12) put me to bed that night. While V12 was putting me to bed, V12 pushed my bed against the wall. I don't know how it happened or why V12 did it. I didn't ask for that. I don't remember having my bed against the wall before. I didn't feel it right away but when I was trying to go to sleep, my leg was hot. I knew I was touching the heater then. I had a blanket under my leg so I thought I would have been ok. I didn't think I was going to burn myself. The pain kept getting worse and I couldn't take it anymore so I put on my call light. The nurse (V5) came in my room and helped me. I told V5 to push my bed away from the wall because I was too hot. When V5 moved me, I told V5 my leg really hurt. V5 looked at it and told me I was burned on me leg. I had my leg on the heater probably about an hour or a little more than that. I know it wasn't very long after V5 got there that I called for help. I tried to sleep but I was sleeping on and off because my leg was so hot. I didn't move my leg off the heater. The nurse had to do it for me. I can't move my legs too good with the blankets on top of them. I guess I'm not strong enough. I use a lift to get in my wheelchair and that is how they put me back in bed that night. I sometimes need help adjusting in bed. I can use my arms good and push myself up a little, but my legs don't work so good anymore. I didn't go back to that facility because after this happened there is too much danger there. This burn made me realize I don't feel safe with them taking care of me. On 4/6/23 at 1:36PM, V12 stated, I put R1 to bed around 8:30 - 9PM. I put R1 in with a lift. We use that because R1's unstable on R1's feet and unsteady with R1's gait. That night, R1 asked me to scoot R1's bed against the wall because R1 wasn't feeling well. R1 said R1 wanted R1's bed against the wall, and R1 was afraid of hanging out of the bed a little bit. No, I didn't tell anyone R1 was feeling this way. I just did what R1 asked. R1 never asked me to do that before. I did my last round about 10:15 PM and R1 was sleeping. I walked over and I watched R1 breathe and R1 didn't say he had any problems then. R1 did have the blanket covering R1's body. I didn't let anyone know I pushed the bed against the wall. I didn't think he could touch the heater. The Treatment Nurse Initial Skin Alteration Review dated 3/20/23 documents R1 has a full thickness wound to the left knee extending to the lower left leg. Per this assessment, a full thickness wound is defined as skin loss with extensive destruction, tissue necrosis, or damage to underlying structures, such as muscle, tendon, or bone. It may present as a deep crater and may even tunnel into surrounding subcutaneous tissues. The size of the wound is documented as 26 cm x 10 cm. It is 30% slough tissue, 40% red (smooth), and 30% clear fluid filled blister. There is a small amount of serous drainage. A predisposing risk factor for developing the wound is immobility and PVD. The Side Rail Review dated 3/20/23 documents R1 needs extensive assist with bed mobility. R1 is not able to turn from side to side unassisted while in bed. The Care Plan dated 11/24/21 documents R1 has peripheral vascular disease (PVD) and is at an increased risk of skin integrity issues. R1 has potential for diminished blood flow to the bilateral lower extremities. The Care Plan dated 4/11/22 documents R1 needs a mechanical lift for transfers due to lower extremity strength, impaired range of motion of the lower extremities, and weakness. The Care Plan dated 3/24/23 documents R1 has an alteration of skin, integrity, related to impaired mobility status, decreased sensory perception, comorbidities, and PVD. The Minimum Data Set (MDS) dated [DATE] documents R1 is an extensive two-person physical assist with bed mobility and transfers. Section I of the MDS documents R1 has a diagnosis of peripheral venous insufficiency. Section M of the MDS documents R1 does not have any pressure ulcers or burns. Prior to the survey date the facility took the following actions to correct the noncomplaince. All rooms in facility, all units were visited, and beds were rearranged as necessary to ensure no beds are pushed against the walls or close to heating units on March 20, 2023. This continued March 21, 2023. Any resident who resisted received education Residents bed was immediately removed from the wall and heating unit on March 19, 2023. Physician notified and treatment and burn consult orders obtained on March 19, 2023. Attempted to call responsible family member on March 19t, 2023 without success. Sister returned call on March 20, 2023and was notified and spoke with resident via Phone. On March 20, 2023 Maintenance checked resident heating unit for proper functioning and working properly. Unit has proper protection cover in place now and at time of the incident. On March 20, 2023 and continued on March 21, 2023 Maintenance checked all heating units to ensure proper functioning and that proper protection covers are in place On March 20, 2023 the facility began educating the staff on new safety protocol. This education continued until all staff were educated which was March 21, 2023. Focus of education Abstaining from positioning the beds against the wall Abstaining from positioning the beds close to the heating units Ensuring proper functioning and protection of the wall heating units Consequences for staff noncompliance On March 20, 2023 residents injured area was visually assessed by facility wound care nure and nurse practitioner and treatment rendered per physician order. On march20, 2023 resident was sent to University of Chicago ER for evaluation and admitted on the burn unit. On march 20, 2023 a Root cause analysis (RCA} was completed. Acting medical director was notified on March 19, 2023. Education with Nurses began on March 20, 2023 and continued on March 21, 2323 with focus on: Burn assessment and documentation Physician detailed notification First aid for burns ER visit or burn consult follow up Administrator will be responsible for overall compliance to plan of correction in conjunction with Director of Nursing and Designees monitoring during routine rounds while entering every room daily. The quality assurance quality improvement team meets monthly. This event will also be brought to next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly. Completion date: March 22, 2023

Based on interviews and record reviews, the facility failed to prevent or determine how an injury of unknown origin occurred for 1 of 3 residents (R10) reviewed for resident injuries in a total sample of thirteen. This failure resulted in R10 being found with fractures to multiple ribs and multiple lumbar spine in various stages of healing and a hemothorax (collection of blood in the space between the visceral and pleura space) of the right lung. Findings Include: R10 is a [AGE] year old with the following diagnosis: dysphagia, catatonic disorder, and developmental disorder. R10 admitted to the facility on [DATE]. A Nursing note dated 4/10/23 at 1:04 PM documents R10 was noted with excessive drooling and is unable to swallow puree, consistency food. Speech therapy evaluated R10 and spoke with the physician. The physician ordered to send R10 to the hospital for failure to thrive and unable to swallow. A Nursing note dated 4/10/23 at 3:25 PM documents R10's family member was made aware of the bedside swallow evaluation by speech therapy. The left hand was also noted with mild edema along with left lower cheek swelling. The ambulance transportation company came to pick up R10. A Nursing note dated 4/10/23 at 10:23 PM documents R10 is admitted to the hospital with a diagnosis of fever and dysphasia. A Nursing note dated 4/11/23 documents a physician from the hospital called and reported that R10 has acute and chronic multiple rib fractures, a pleural effusion with a chest tube, and an acute pneumothorax. The physician asked if the facility suspected any abuse or not. A Social Service note dated 4/12/23 documents the facility received notification from the hospital that R10 was found to have both chronic and acute fractures of the ribs. These injuries are an unknown source in an abuse investigation has begun. A police report was attempted to be created, but the responding officer could not file the report due to R10 not being in the facility. On 4/13/23 at 1:47PM, V3 (Nurse) stated, R10 was sent out that afternoon because R10 wasn't eating. The top of R10's left hand was a little swollen too. I noticed it when I was giving R10 morning medications. R10 is total care. R10 can't do anything for herself. R10 can't even feed herself. R10 can't get back up by herself into the bed after a fall. R10 would absolutely need help. There were no reports that anything happened to R10 or that anything else was different about R10. I called the hospital to check on her and got a diagnosis of pleural effusion, pneumothorax, and acute and chronic rib fractures. I told the next nurse and then called the administrator. On 4/13/23 at 1:57PM, V18 (CNA) stated, R10 can't talk. I got nothing in report from the other CNA's or nurses that anything happened to R10. R10 cannot stand or walk around, but R10 will roll out of bed. R10 needs a lift because R10 is total care. On 4/13/23 at 2:07PM, V19 (CNA) stated, There were no accidents on any of my shifts with R10. I didn't get any reports but any thing happened to R10. R10 can't do anything for herself. R10 might try to sit up in the bed but that is it. R10 can only roll. R10 uses a lift to go from the bed to the chair because R10 can't get up herself. On 4/13/23 at 2:44PM, V5 (Nurse) stated, I gave R10 one pill in the morning before I left. R10 drank some of the shake and took the pill with no problem. I did not get any report from any other nurses or CNA's that R10 had something happen. R10 can't walk or stand. If R10 were to fall, R10 could not get back to bed by herself. It takes 3 to 4 people to get her back into the bed when R10 does fall. On 4/19/23 at 9:52AM, V20 (Hospital Nurse) stated, R10 was put on nasal cannula because R10 was satting at 93% on room air. They did a right upper quadrant ultrasound of her abdomen because her liver enzymes were elevated and that's when they discovered she had a pleural effusion to the right lung. R10 needed to have a nonrebreather place because R10 was satting in the 80s. They did a chest x-ray on 4/11, and that was concerning for bilateral lower rib fractures that were recent and a right hemothorax. In the report, it mentions that the fractures can be correlated with a history of trauma or abuse. They did another chest x-ray later that day, and it showed multiple bilateral rib fractures of the lower ribs. On 4/11 in the evening R10 had a CT of the chest/abdomen/pelvis that showed multiple rib fractures with callous formation indicating that the fractures had been there for sometime. R10 also had fractures of the lumbar spine on L1, L2, and L3. The L1 and L3 had callous formation. On the 11th and 12th rib those did not have callous formation, indicating that they were new fractures. L2 did not have callous formation. That indicated it was a newer fracture. We are not sure where the hemothorax occurred. I know with all the fractures R10 had there was a concern from doctors on if it was trauma related like a fall versus a concern for abuse. I don't see anything in R10's history that would cause R10 to have these type of fractures without some type of trauma. On 5/2/23 at 3:23PM, V2 stated We ended up sending R10 out on the 10th because R10 was having some dysphasia for a couple days. We didn't get notified of the rib fractures and hemothorax until the next evening after R10 was admitted . I know R10 did end up needing oxygen because R10's saturations were in the 80s but that wasn't until later in the evening as well. R10 didn't start showing signs until she got to the hospital later. On 5/3/23 at 9:20AM, V23 stated R10 ended up having multiple rib fractures with a hemothorax and lumbar fractures. Usually those type of fractures are from a fall or some kind of trauma. Usually symptoms start to occur 48 to 72 hours after the fracture. I've seen cases where it's taking up to a week to develop symptoms, because the bleed happens slowly. Because we aren't able to tell what happened. I cannot say exactly when this occurred. I know V1 and V2 have talked with all staff going back a couple weeks, and they have no evidence that there was any type of trauma or fall. I know R10 had a jaw fracture in December when R10 fell and that was seen on the x-rays at the current hospital and it was documented as chronic. The fractures were different varying degrees. The story just does not add up. Acute fractures mean that they are newer and they have happened within the last 4 to 6 weeks. Subacute fractures means that there's some callus formation so they have had to have happened anytime after the six weeks. R10 may have poor nutrition because of not eating well before R10 went to the hospital, but usually these type of fractures only occur with trauma or falls. The Hospital Records dated 12/11/22 documents R10 was sent to the hospital status post fall and was noted with a hematoma to the forehead and a swollen bottom lip. Imaging returned with no acute intracranial, cervical spine abnormalities, and no abnormality on the chest x-ray or x-ray of the pelvis. The CT of the face is significant for an acute fracture of the right hemi mandible. The chest x-ray report documents, no pleural effusion or large pneumothorax. No acute osseous abnormalities. There is no documentation of any fractures in the chest or spine at this time. The Minimum Data Set (MDS) dated [DATE] documents R10 does not have a Brief Interview for Mental Status score because R10 is rarely/never understood. Section G of the MDS documents R10 is a 2 person physical extensive assist for bed mobility and transfers. R10 needs a one person, extensive physical assist with dressing, eating, and locomotion on/off unit. The Physician Order Sheet documents an order for an x-ray of the left hand was placed on 4/10/23. The order was discontinued due to R10 being transferred out of the hospital. The Hospital Records dated 4/10/23 document R10 presented to the hospital for worsening dysphasia for the past 2 days. R10 has an oxygen level of 93% on room air so a nasal cannula was placed at 2L. R10 also has a fever of 100.8 F. A right upper quadrant ultrasound was performed and shows a right plural effusion. Around midnight on 4/11/23, R10 became hypoxic to 80% and was placed on a nonrebreather mask. The right chest x-ray shows complete opacification (haziness) of the right hemithorax (a collection of blood in the pleural space) and right lower rib fractures. R10 has normal respirations with no distress and is currently not requiring any oxygen, despite needing oxygen overnight. R10 has right lower flank/anterior chest tenderness on exam and R10 nods yes when I asked if in pain. There is no apparent skin erythema/edema/bruising. The facility was attempted to be contacted for questioning for possible trauma. The CT scans show bilateral rib fractures, chronic (majority) subacute, and some possible acute. There is also a right hemithorax pleural effusion and multiple chronic lumbar and subacute lumbar transverse process fractures. A chest tube was placed for the large plural effusion. The plural effusion is subacute because R10 does not have any respiratory distress, and there is no additional O2 requirement. The rib fractures are at varying degrees of healing.

Based on interview and record review, the facility failed to adhere to the decisions documented by a resident's representative by allowing the resident to leave the facility with an unauthorized individual. This failure applied to one (R4) of one residents reviewed for supervision and resulted in R4 leaving the facility without authorized supervision and not returning. Findings include: R4 is an [AGE] year old male who was admitted to the facility on [DATE] with past medical history including, but not limited to other intervertebral disc degeneration, thoracic region, other forms of scoliosis site unspecified, Alzheimer's disease, Essential primary hypertension, weakness, unsteadiness on feet, etc. As documented in medical record, R4 was brought to South Suburban Hospital d/t wandering outside a bank. He was evaluated by psych and determined not to have decision making capacity. The goal was to discharge him home with daughter who is the power of attorney (POA), but she was unable to be contacted and when discharged home she was not there, and he returned to hospital. Department of aging was contacted to request a state guardian. He was medically cleared and transferred to Pine Crest on 12/16 for medical management and subacute rehab. (Physician assist progress note dated 12/28/2021). Rehabilitation progress note dated 12/20/2021 documents the following: Resident showing signs of confusion at this time as evidenced by resident stating he wants to go home. Resident currently has a temporary case worker who explained to writer that resident is basically homeless at this time and his daughter has not contacted the hospital to inquire about resident in weeks and writer was told that resident and his daughter did not have a place to stay but were moving from hotel to hotel. Resident's daughter had POA for resident's healthcare but due to not being involved in resident's care, resident was awarded a state guardian with Office of State Guardian due to resident's inability to make decisions for himself and daughter's inability to provide care for resident. Review of court papers appointing a temporary guardian for R4 states the following: the appointment of state guardianship is required because there is no individual suitable and willing to accept the guardianship appointment, removal of the alleged disabled person from any placement is prohibited pending the outcome of plenary hearing. On 3/16/2022 at 8:44AM, V5 (State Guardian) said that he is currently the temporary POA for R4, the police are still looking for him but to his knowledge, they have not located him as of last Friday, R4 was lost, he could not find the daughter, the police were called, and they found out that the daughter was the POA, she never followed up with resident, and she was substantiated for neglect. V5 added that he spoke to the administrator and the social worker, he informed them of the court papers, and verbally told the administrator that the daughter cannot take him out and that her visitation should be restricted for now. V5 said that he submitted the court papers to the facility on [DATE]th. On 3/15/2022 at 1:16PM, V1 (Administrator) said that R4 was a client placed in the facility because of allegations of financial abuse by his family, specifically his daughter. Adult protective service placed him in the facility, he was assigned a temporary state guardian, the only restriction the facility was given is that R4 cannot be relocated from the facility, the daughter was allowed to visit resident but was not supposed to take him home. The last time she visited, she told the receptionist that she was taking him to lunch, and he never returned. At 4:10PM, V1 (Administrator) said that resident's daughter has not taken him out before, he added that families are allowed to take residents out unless there is a restriction, in that case they will leave something at the front desk, R4 did not have any restrictions so no instructions were left at the front desk. V1 added that the case is out of the facility's hand, he was supposed to notify the police if he gets any information and he have not gotten any. At 3:10PM, V4 (Receptionist) said that she was sitting at the desk when R4's daughter came in and said that she was taking him out to eat, she have not seen her in a long time but she told her that she was supposed to bring him back by 8:00PM. R4's daughter came in with a 12 pack case of pop, she went upstairs, left the pop up there and came down with two shopping bags and said she was going to do his laundry. V4 added that she had a feeling that she was not going to bring resident back but did not say anything. She asked her if she have the permission to take resident out and she said yes. V4 said that she is not aware of any restrictions on R4's daughter visiting or taking him out, usually the administrator gives family members permission and if he is not in the facility, V4 said she will give him a call, she did not call V1 on that day because she has worked in the facility for 5 years and knows pretty much who goes with who. V4 added that she did not tell the administrator when he came back to the building, did not know that resident did not come back until the following day when the administrator told her. V4 said that there is no system in place as far as residents going out with family members, she just documents it in the sheet they sign when they come in. At 12:48PM, V7 (Social worker) said that R4 is a nice old man who was confused and disoriented, he was assigned to her after he moved to the 2200 unit, she was told that they could not find the daughter and that resident has a state guardian. V7 said that when a resident is a ward of the state, staff are supposed to call the guardian for permission to do anything, she was aware that his daughter is not supposed to take him out. V7 added that the receptionist was supposed to check the book or ask somebody to do it for her, and she believe that even the administrator should talk to the guardian before giving any permission, the information should be documented somewhere, and all staff should be made aware of it. A document presented by V1 (Administrator) titled visitation policy (undated) states in part that it is the facility permits residents to receive visitors subject to resident's wishes and the protection of the rights of other residents in the facility. Under policy interpretation the document states that the above visitation of visitors .will be subject to reasonable restriction, denying access or providing limited or supervised access such as, but not limited to .visitor has been found to be abusing, exploiting, or coercing a resident, facility has obtained a judicial restraining order against a visitor.

Based on interview and record review, the Facility failed to follow their Weighing Residents Policy and failed to notify a Physician or Dietitian of weight loss and poor appetite for 1 of 3 residents (R4) reviewed for weight loss in a total sample of 10. This failure resulted in R4 being transferred to the local hospital with severe dehydration and a 15 pound weight loss in 2 weeks. Findings Include: The Nurse's Notes dated 6/21/19 documents that R4 was admitted to the facility and required extensive assistance with all activities of daily living. R4's weight on admission was 1[AGE] pounds. The Vitals Sheet documents that R4 weighed 170 pounds on 6/28/19 and 1[AGE] pounds on 7/4. The Intake Sheet for June and July documents that R4 had a poor appetite on 6/22/19 through 6/26/19 and 7/2/19 through 7/5/19. The Nurse's Notes dated 7/5/19 documents that R4 was noted with altered mental status. R4 was assessed by the Nurse Practitioner and sent to the local hospital for evlaution. Hospital Records dated 7/5/20 documents that R4 was admitted with severe dehydration, increased [MED] levels, acute kidney injury [MEDICAL CONDITION]. R1 required aggressive IVF hydration due to severe volume depletion. R1's weight on admission 165lbs. R1 was sent to ICU and a gastric feeding tube was inserted for nutrition. On 1/31/20 at 12:35pm ,V11 (Physician) stated This is not a desirable weight loss. I would expect to be contacted. The weight loss was pretty significant. The Nurse Practitioner was contacted on 7/5/19. I was not aware prior to this date. It looks like the resident is not eating if the resident is losing that much weight and something would've been done. I would've talked with the family, suggested a feeding tube, check for malignancies, things like that. On 1/31/20 at 1:50pm V12 (Dietary Supervisor) stated I rely on restorative to weigh the residents and to notify the department if there are changes throughout the month. I was not aware of R4's poor eating or appetite and I was not aware of the continued weight loss. I would have reached out to the resident or the family, increased the portion sizes or changed the preferences. We also notify the Dietitian of weight loss when they come to the facility. On 1/31/20 at 2:35pm V13 (Restorative Aide) stated After I weigh the resident, if there's a significant weight loss I notify the DON or the ADON. I weighed R4, I wrote the weights down and took it to the office for review. I can't remember if I gave it to the DON or the ADON at the time, but they were notified of the weight loss. On 1/31/20 at 3:00pm V3 (DON) stated I was never notified of the resident having weight loss. I had just started this position. I am unaware of the Dietitian being notified. The Weighing Residents Policy documents that Each resident is weighed on admission and in accordance with Physician orders [REDACTED]. A re-weight should be taken as soon as possible after an unanticipated weight reading is noted and prior to callings the Physician and recorded usually within 24 hours. Staff should conduct a thorough nursing assessment, and consult with Dietitian if weight gain or loss is excessive.

Based on interview and record review, the facility failed to prevent a resident (R2) from being injured by another resident. This failure resulted in one (R2) of four residents reviewed for abuse being struck in the face resulting in a laceration requiring sutures. Findings include: R2's [DIAGNOSES REDACTED]. R2's (2/17/15) care plan includes; [DIAGNOSES REDACTED]. Intervention: If resident goes in a peers' room redirect the resident. Resident is disoriented to place and time, used to be a boxer and has the potential to strike out at others. R2's (12/19/19) final investigation report includes; original allegation date: 12/15/19. Per staff interview (R3) stated he struck (R2) in the face because he wouldn't get out of his room. (R3) stated (R2) struck him in the groin so he struck him in the face. Scant amount of bleeding noted to laceration on left side of his face with slight bruising. R2 returned from emergency room with 2 sutures. On 12/30/19 at 10:34am, V4 (Certified Nursing Assistant) stated (on 12/15/19) R2 was bleeding from his face. R2 stated He beat me up however was unable to provide further details. On 12/30/19 at 10:45am, R3 stated (on 12/15/19) R2 Hit me in by b***s, my reflexes responded and I hit him back. On 12/30/19 at 12:22pm, V1 (Administrator) stated R2 is a wanderer and needs to be redirected. On 12/30/19 at 12:43pm, V4 stated staff have to keep an eye on and redirect R2 all the time. On 12/30/19 at 1:48 pm, V6 (Licensed Practical Nurse) stated R2 gets confused and needs to be redirected often. V2 (Director of Nursing) stated R2 was moved to a different room where staff can visualize him better if he wanders to the wrong room. The (2/7/17) abuse prevention policy includes; staff supervision: supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs.