Every finding on record at Pleasant Meadows Senior Living

Based on observation, interview, and record review, the facility failed to adequately perform, and document required skin assessments and failed to provide assistance with daily sock changes for one (R2) of three residents reviewed for neglect related to pressure ulcers. This failure resulted in a delay in identifying skin deterioration, allowing R2 to develop an unstageable pressure ulcer to the right heel with suspected Osteonecrosis.R2's Electronic Health Record (EHR) documents that R2 was re-admitted to the facility on [DATE] following a brief hospitalization from 7/12/26 - 7/15/26. R2's hospital Discharge summary dated [DATE] documents that R2 was found to have a pressure injury of the right heel. An x-ray report dated 7/12/2026 documented articular surface collapse of R2's right foot, likely representing osteonecrosis.R2's Minimum Data Set (MDS) dated [DATE] documents that R2 has an active diagnosis of Diabetes Mellitus (DM), and Peripheral Vascular Disease (PVD). This MDS also documents that R2 is at risk for developing pressure ulcers/injuries and requires use of pressure reducing devices for R2's chair and bed. R2's MDS dated [DATE] documents R2 requires substantial/maximal assistance from staff with bathing and is dependent on staff for upper and lower body dressing including putting on and taking off footwear (put on and take off socks and shoes or other footwear that is appropriate for safe mobility).R2's Care Plan dated 12/16/2025 documents that R2 is at risk for impaired tissue integrity related to impaired tissue perfusion, impaired mobility related to left leg amputation, Peripheral Vascular Disease (PVD), and Type II Diabetes. Intervention for this problem include notifying the nurse immediately of any new areas of skin breakdown, including redness, blisters, bruising, or discoloration noted during bathing or daily care.R2's July 2026 Medication Administration Record (MAR) documented an order, initiated on 5/28/2026, for nursing staff to complete skin checks on this high-risk resident every shift (day, evening, and night). The MAR documented that skin checks were recorded three times daily throughout July, except during R2's hospitalization.On 7/20/26 at 10:27 a.m., R2 was observed sitting in a recliner with the footrest elevated. A left-below-knee amputation was noted, and R2's prosthesis was observed lying on the floor in front of the recliner. R2 appeared sad and stated R2 was feeling down following the recent death of R2's brother. R2 expressed feelings of hopelessness regarding R2's current condition, stating R2 felt confined to R2's chair, stating I'm at the point in life where I really don't give a d*** (expletive) about what happens to me. R2 stated R2 had a sore on the bottom of R2's right foot that was discovered during a recent hospitalization for a urinary tract infection. R2 stated R2 did not even know R2 had a sore on R2's right foot.On 7/20/26 at 11:11 a.m., V3 Licensed Practical Nurse, (LPN)/Infection Preventionist (IP)/Wound Nurse stated V3 was familiar with R2 and confirmed that R2 had a new unstageable pressure injury on the right heel. V3 stated the wound was first identified during an emergency room visit on 7/12/26, when R2 was evaluated for altered mental status.On 7/20/26 at 12:25 p.m., V6 Certified Nursing Assistant (CNA) stated V6 is familiar with R2 and R2's care needs. V6 stated R2 has a sore on the buttocks and requires assistance with repositioning every two hours using pillows. V6 stated staff reposition R2 from side to side to help prevent further skin breakdown. V6 further stated that CNAs do not typically assist R2 with putting on or removing the sock from R2's right foot.On 7/20/26 at 1:12 p.m., V7 Licensed Practical Nurse (LPN) with V3 LPN present, stated that R2 is sometimes noncompliant with care. V7 stated that nursing staff perform daily skin assessments and that R2 had not complained of pain in the right heel. When asked about the right heel, V7 was not able to describe assessing the area during the daily skin assessments prior to R2's hospitalization on 7/12/26.On 7/20/26 at 1:12 p.m., V3 LPN/IP/Wound Nurse stated that R2 independently applies sock to R2's right foot daily.On 7/21/26 at 9:54 a.m., V3 performed wound treatment to R2's right lateral heel. The wound size looked approximately 6 cm x 4 cm and appeared moist with white slough (dead, non-viable tissue that accumulates on the surface of a wound) present. R2 denied pain during the treatment.On 7/21/26 at 2:02 p.m., V11 Certified Nursing Assistant (CNA) stated staff assist R2 with upper and lower body dressing but do not change R2's socks every day unless R2 says they are wet.On 7/21/26 at 3:15 p.m., V14 Registered Nurse (RN), stated that nurses are responsible for completing daily head-to-toe skin assessments, including assessment of R2's right foot, if R2 allows. V14 stated that R2 sometimes refuses assessments because R2 prefers to sleep or does not want to be bothered. V14 stated that nursing staff should document any refusals.On 7/22/2026 at 10:41 a.m., V3 LPN/IP/Wound Care Nurse stated that nursing staff are expected to assess R2's high-risk areas, including areas at risk for skin breakdown, three times daily as ordered, and document any refusals. V3 was unable to provide documentation indicating that R2 refused skin assessments.On 7/22/2026 at 2:45 p.m., V24 Nurse Practitioner (NP) stated that due to R2's severe peripheral vascular disease, history of amputation, and tendency to develop wounds, staff should closely monitor R2's skin integrity. V24 stated that competent daily skin assessments, including assessment of R2's right foot, should have identified changes before the wound progressed to an unstageable pressure injury with possible osteonecrosis.On 7/23/2026 at 7:19 a.m., V13 LPN stated that V13 routinely completed daily skin assessments on R2, including assessment of the right foot, in the days leading up to R2's hospitalization on 7/12/2026. V13 stated that no unusual findings were identified during those assessments. V13 stated V13 did not take off R2's sock or assess, stating that it was the least of V13's worries at that time.On 7/23/2026 at 1:26 p.m., V2 Director of Nursing (DON) stated that nurses are expected to complete and document head-to-toe skin assessments three times daily, including assessment of R2's feet when R2 allows. V2 stated R2 is at high risk for skin breakdown due to R2's comorbidities and agreed that staff failed to identify the right heel pressure ulcer during required assessments. V2 stated that, if assessments had been completed properly, the wound should have been identified sooner. V2 further stated that R2 had never been dependent on staff for care needs during R2's years of admission at the facility.On 7/23/2026 at 2:13 p.m., V29 LPN/MDS Coordinator stated that completion of the MDS assessment includes interviews with therapy, nursing staff, and the resident, as well as review of the applicable three-day assessment period. V29 stated that R2's cognition varies and that R2 frequently declines care. V29 stated that the 6/3/2026 MDS assessment identified R2 as dependent on staff for upper body dressing, lower body dressing, and putting on and taking off footwear.On 7/23/2026 at 2:34 p.m., V30 Director of Rehabilitation/Physical Therapy Assistant stated that R2's Occupational Therapy Discharge summary dated [DATE] documented R2 was dependent on staff for lower body dressing, including putting on and removing socks.The facility's Pressure/Skin Breakdown-Clinical Protocol policy dated January 2017 requires staff to document residents' risk factors for pressure injuries; complete and document a comprehensive skin assessment, including wound location, stage, measurements, tissue characteristics, drainage, pain, mobility status, current treatments, support surfaces, and active diagnoses; identify factors contributing to skin breakdown, including comorbidities such as diabetes; and document skin assessments, signs and symptoms of infection, and the impact of comorbid conditions on wound healing.

Based on observation, interview and record review, the facility failed to assess residents for risk of entrapment from a bedrail and failed to calibrate an alternating air flow mattress setting for a resident's weight. These failures resulted in R12's mattress becoming overinflated which caused R12 to fall into the bedrail and to the floor. During the fall R12's arm became entrapped in the bedrail and R12 was unable to reposition R12's head and neck away from the bedrail which resulted in neck and sternum injuries. These failures affect eleven of eleven residents (R4, R6, R7, R10, R12, R13, R27, R28, R29, R30, and R31) reviewed for side rails and accidents on the sample list of 31.The Immediate Jeopardy began on 03/05/26, when the facility added bed siderails and a low air loss mattress to R12's bed, without completing a side rail assessment for safe use. V1 Administrator was notified of the Immediate Jeopardy on 6/17/26 at 12:10 pm. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 6/18/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:1. According to the United States Consumer Product Safety Commission's current official website: cpsc.gov, There are risk involved in using adult portable rails, however, including injuries from falls, or entrapment, or death by asphyxiation from head, neck, or chest entrapment. In fact, CPSC (Consumer Product Safety Commission) data show that 90 percent of injuries associated with adult portable bed rails are from entrapment of the head, chest and neck.R12's Current Diagnoses Sheet documents the following: Unspecified Dementia Unspecified Severity with Agitation, Osteoarthritis Unspecified Site, Age-Related Osteoporosis with Current Pathological Fracture Left Femur (History of), Subsequent Encounter for Aftercare with Routine Healing, Muscle Weakness (Generalized), Unsteadiness on Feet, Need for Assistance, and Abnormalities of Gait and Mobility,R12's Minimum Data Set (MDS) dated [DATE] documents R12 has severe cognitive impairment and is totally dependent on physical staff assistance with all activities of daily living which include bed mobility and transfers.R12's Fall Risk assessment dated [DATE] is completed. The score is not identified on the 3/9/26 assessment. The corresponding 3/9/26 Fall Risk Assessment list in R12's electronic medical record documents R12 had a score of 18, which indicates R12 was at high risk for falls due to a score greater than 10. R12's Care Plan dated 5/26/26 documents R12 requires a full body mechanical lift for transfers. R12's same Care Plan documents on 3/5/26 the following interventions were implemented: Bed Mobility: Inform (R12) about the plan and clarify what is expected of her. Use both verbal and visual cues, instructing her to use her enabler bars to assist with rolling from side to side and completing bed mobility tasks safely. (R12) depends on staff to help her reposition every two hours and as needed to relieve pressure and ensure her comfort. She (R12) uses a low-air-loss mattress for precautionary measures, with the dial set to the third position. Date Initiated: 03/05/2026There is no documentation in R12's medical record that R12 has had a side rail assessment to determine R12's risk for entrapment/safety.R12's Nursing Note dated 5/15/2026 at 2:16 am documents the following: Note Text: Resident (R12) was found by CNA (V27, Certified Nursing Assistant) sitting on floor with her (R12's) face and arm by the side rail. Resident (R12) was assessed. Bruising noted to left and right side of neck and right breast/sternal area. Three small abrasions/tears noted to left side of neck and one small abrasion/tear noted to right side. Resident A&O x1 (alert and oriented to self only). VS WNL (vital signs within normal limits). Resident was assisted back to bed, and call light within reach. Fall mat placed. NP (V10, Nurse Practitioner) and DON (V2, Director of Nursing) notified.R12's Nursing Note: dated 5/15/26 at 2:44 am documents R12's personal bed alarm did not sound when R12 fell from her bed.R12's Fall investigation report dated 5/15/26 at 1:45 am documents the following: Predisposing factors: Fall alarm. R12's same Fall investigation report also documents the following: (V27, / CNA): resident (R12) slid off side of bed, unwitnessed found resident on floor with head resting on guardrail. Intervention/Root Cause: low air loss mattress /appears resident rolls out of bed -- bed is in lowest position/floor (air mattress) position set to 340 lbs. (pounds) - resident weighs 96 lbs. Intervention: air mattress at correct settings, restorative programs updated, PT/OT eval (Physical Therapy/ Occupational Therapy evaluation).R12's same Fall investigation report documented above does not document the side rail involvement was identified as part of the root cause related to R12's injuries and therefor does not include an intervention.R12's Bruise assessment Wound report, with pictures only documents one measurement and location. R12's bruise assessment documents the location of the bruise being measured was on R12's chin. The measurements were recorded as 10.0 centimeters (cm) length, 7.0 cm width and 0.10 cm depth. The pictures of the bruise were of R12's neck and spanned over the center and both sides of R12's neck. There was no picture of R12's sternum. The same wound report documents skin intact though R12 had skin tears on the bilateral neck (noted in the nurses note above). The skin tears were not measured. The same wound report does not describe the color of the bruise and surrounding tissue for swelling, redness or signs of infection in accordance with standard of practice.R12's Physical Therapy - PT Evaluation & Plan of Treatment dated 5/18/26 (three days post fall) directs staff to remove R12's bed siderails and also documents the following: Current Referral Reason for Referral/Current Illness: Pt (Patient R12) is a (specific stated age) referred to skilled PT following a recent fall w/o (without) ER (Emergency Room) visit w/ (with) acute injuries. Pt was found sitting on the floor w/ (with) her face and arm by the side rail, bruising noted to L and R (left and right) side of neck and R (right) breast sternal area, 3 small abrasions/tears noted to L (left) side of neck and one small abrasion/tear noted to R (right) side. She (R12) presents to therapy with contractures on BLE (bilateral lower extremities), 2 assist dep (dependent) for bed mobility, (full body mechanical lift) for transfers, bed/chair bound, total dep (dependence) for all ADLs (Activities of Daily Living), nonverbal, ongoing agitation and confusion, but no acute behavioral disturbances or distress. Pt's fall prevention measures include a bed alarm, a low bed precaution, a bedside floor mat to cushion, and a body pillow. Therapy recommends removal of pt's bed rail at this time due to pt's cognitive decline/ confusion and poor safety awareness. Pt is also in good restorative program for passive rom (Range of Motion), dressing/bathing/ grooming and feeding. DC (discharge) skilled PT (Physical Therapy) at this time as pt (patient R12) is functioning at baseline w/o (without) any significant decline.On 6/3/26 at 1:30 pm V2, Director of Nursing (DON) and this surveyor walked to the nurse's station. R12 was seated in a geriatric wheeled chair, and was confused. R12 had three pencil eraser sized light white scar-like areas on her neck. Surrounding the scar like areas on R12's neck was a faded yellow bruise area approximately two inches wide going down approximately two inches down the center of 12's neck. There was a red dry skin patch noted on R12's chin. A full visual assessment was not conducted at this time due to resident's cognitive status and the resident was seated in a common area. V2, DON confirmed R12's scar-like areas are healed skin tears and the discolorations are faded bruises from when R12 fell on 5/15/26. V2, DON reviewed the details of R12's 5/15/26 fall out of bed. V2, DON stated the facility does not complete a side rail assessment to determine the residents' risk of entrapment and does not consider a consent is needed for side rail use when the side rail is an enabler not a restraint. As V2, DON reviewed R12's Fall investigation, V2, DON stated (R12) would have been bounced around like she (R12) was in a bounce house, because the air mattress had been hyperinflated for a person weighing 340 pounds, and (R12) only weighs 96 pounds. V2, DON then stated I have educated the CNAs. They were hyperinflating (R12's) mattress when they changed her (R12). It creates a firmer surface to change (provide incontinence care) and reposition her (R12). We have put a stop to that. Only the nurses can change the setting (on the air mattress inflation).On 6/3/26 at 3:42 pm V27, Certified Nursing Assistant (CNA) stated when he (V27, CNA) found R12 seated on the floor next to R12's low bed, R12's right arm was stuck in the right-side rail. R12's arm was protruding from the inside of the bed, through the right siderail opening. R12's hand was suspended over the floor, and outside the bed rail. R12's buttocks were on the floor. R12's back was against the bed, R12's neck and head were leaning at an angle, and up against the side rail. V27, CNA stated (R12) couldn't move her head and neck, because her arm was caught in the side rail. It (arm caught in the side rail) was holding her in that position up against the side rail. V27, CNA also said R12 had skin tears on both sides of her neck, and bluish colored bruising to her neck and chest. I am not sure how long she was stuck. It was my first round of bed checks. I came in to work that night at 10:00 pm. I had been in her (R12's) room to get a bedpan to her roommate (R15) about 1:00 am. (R12) could have fallen any time after I (V27, CNA) provided the bed pan to her (R12's) roommate (R15), and when I found her around 1:45 am to 2:00 am. Her bed alarm was not turned on or I would have known right away that she fell. I really don't know how long she was on the floor like that. One of the nurses (unidentified) came and said the air mattress was turned too high (hyperinflated) causing (R12) to be pushed into the side rail. V27, CNA also stated (R12) is dependent on staff for repositioning in bed and does not use the side rail for repositioning.On 6/4/26 at 12:55 pm V36, Certified Nursing Assistant (CNA) stated (R12's) bruises I saw a couple days after she fell out of her (R12) bed. They said she (R12) rolled out of bed because her (R12's) air mattress was turned too high. She (R12) did have side rails, but I have never seen her use them. She (R12) has Dementia and doesn't understand even simple directions. She (R12) can't roll on her own that's why they think the air mattress shifted and rolled her off the bed that is all I heard about the fall. When I first saw a band aid on (R12's) chin, I (V36 CNA) also saw, all around her neck, she had a big green and faded yellow bruises. She had a fading bruise in the middle of her chest, too.On 6/5/26 at 8:20 am V3, Medical Director (MD) confirmed R12 is cognitively impaired and totally dependent on staff. V3, MD acknowledged R12's fall from a hyperinflated air mattress, a bed with side rails that were not properly assessed for safety to prevent entrapment, and a bed alarm that did not activate are all the issues of concern. V3, MD was non-committal to identify the potential risk for serious injury or death when R12's side rails were in use with an air mattress and without a side rail entrapment assessment. 2. R4, R6, R7, R10, R13, R27, R28, R29, R30, and R31's medical records do not include side rail assessments.On 6/23/26 between 12:15 pm and 1:15 pm, V2, Director of Nursing (DON) and V7, Licensed Practical Nurse (LPN)/Wound Nurse went from resident room to resident room with this surveyor. R4, R6, R7, R10, R13, R27, R28, R29, R30, and R31 all had air mattresses and bed siderails on their beds.During the same observations noted above, V2 DON and V7, LPN confirmed the facility had not completed side rail assessments prior to originally installing side rails for R4, R6, R7, R10, R13, R27, R28, R29, R30, and R31, for risk of entrapment and safety.The facility policy Proper Use of Beds and Bed Mobility Systems- effective 04/25/15 documents the following: PurposeThe purpose of these guidelines is to ensure the safe use of all beds and bed mobility systems as resident mobility aids.DefinitionMobility Systems are defined as any mechanical, material or equipment attachment devices that are used to assist and increase the resident's functional status with ADLs (Activities of Daily Living) as determined by the interdisciplinary team. All such devices must be in compliance with state and federal guidelines. Mobility Systems include, but are not limited to, trapeze, Halos, side rails, and poles. The facility presented an initial abatement plan to remove the immediacy on 6/17/26 at 3:53 pm. The survey team reviewed the abatement plan. The abatement required revisions to remove the immediacy.The facility presented a first update to the abatement plan to remove the immediacy on 6/18/26 at 11:59 am. The survey team reviewed the first updated abatement plan. The abatement required revisions to remove the immediacy.The facility presented a second update to the abatement plan to remove the immediacy on 6/18/26 at 1:21 pm. The survey team reviewed the second update to the original abatement plan and accepted the abatement plan on 6/18/26 at 1:57 pm.The Immediate Jeopardy that began on 3/05/25 and was removed on 6/18/26 when the facility took the following actions to remove the immediacy.1. R12 received a new low bed on 5/15/26 with side rails removed on 5/18/2026.2. R12's alternating air flow mattress was adjusted to the correct setting air mattress inflation level to the manufacturer's recommended settings and verified proper functioning on 5/15/2026.3. V3, Medical Director, V10, Nurse Practitioner and V34, R12's Family Member were notified of the incident and care plan revisions were completed by V1, Administrator and V2, Director of Nursing on 5/15/2026.4. R12 was assessed for injury, entrapment risk, pain, skin impairment, and psychosocial effects by V2, Director of Nursing and V7, Wound/ Licensed Practical Nurse. Completed on 6/17/26.5. R12's Care Plan was updated to reflect current interventions which include a low bed, Physical and Occupational Therapy evaluation, Neurological checks and updated low air mattress setting to appropriate to weight. Completed by V2, Director of Nursing and V46, Minimum Data Set Coordinator /Care Plan Coordinator on 5/15/26.6. A facility wide audit was conducted regarding air flow mattresses by V2, Director of Nursing and completed on 5/15/26.7. A facility wide audit was conducted on side rails completed by V2, Director of Nursing and V7, Wound/Licensed Practical Nurse on 6/17/26.8. R4, R6, R7, R10, R12 (side rails removed post assessment), R13, R27, R28, R29, R30, and R31, were assessed for bed safety and risk for entrapment and care plans were updated as needed. Completed by V2, Director of Nursing and V7, Wound/Licensed Practical Nurse and V46, Care Plan/Minimum Data Set Coordinator on 6/18/26.9. Training was provided to V1, Administrator and V2, Director of Nursing on the policy dated 4/25/15 titled; Proper Use of Beds and Bed Mobility Systems completed by V38, Director of Clinical Services on 6/17/26.10. Training was provided by V2 DON/designee to Nurse Managers (MDS, IP and Fall/Restorative nurses), Housekeeping/Laundry Supervisor and Interim Maintenance Director on 6/18/26 on assessing the risk of entrapment before bed rails are placed on residents' bed and on Bed Rail Use and Bed Inspection. Initiated 6/18/26 and ongoing.11. V2 DON updated orders for resident's (R4, R6, R7, R10, R12, R13, R27, R28, R29, R30, and R31) Electronic Medication Administration Record with air flow mattresses to check every shift for accurate settings. Completed by V2, Director of Nursing on 6/17/26.12. V2 DON/designee provided training to nurses on ensuring assessments are completed for bed rails on admission, quarterly and/or change in condition to ensure resident safe utilization. The DON/designee called all nurses and provided verbal education. Don/designee will provide an Inservice to all new nurses prior to first shift worked. Initiated by V2, Director of Nursing on 6/17/26 and ongoing.13. V2, Director of Nursing and V44, Licensed Practical Nurse/Fall Nurse will audit: five residents with bed rails twice weekly for four weeks to verify completion of bed rail assessments and care plan accuracy, five residents with air flow mattresses twice weekly for four weeks to verify proper mattress settings based on manufacturer's guidelines. Initiated on 6/17/26. Audit findings will be reviewed through the facility Quality Assurance and Performance Improvement (QAPI) Committee.

Based on observation, interview and record review the facility failed to maintain complete and accurate medical records for three residents (R2, R5, and R20) out of four reviewed for safety/medical records on the sample list of 31. Findings include: 1. R5's Current Medical Diagnoses Sheet documents the following diagnoses: Alzheimer's Disease, Unspecified, and Unspecified Dementia with Moderate Agitation.R5's Minimum Data Set (MDS), dated [DATE], documents that R5 has severe cognitive impairment, a history of falls, and is dependent on staff for assistance with all activities of daily living.The facility's Incident Description report, dated 5/21/26 (untimed), inaccurately documents that R5's right breast and rib cage bruises were identified on 5/21/26.According to the witness text message documented below, V51, Certified Nursing Assistant (CNA), identified R5's right breast and rib bruise on 5/20/26.The facility's Incident Description report, dated 5/21/26, failed to document a complete assessment of R5's bruise. Standard nursing practice requires documentation of the bruise's color, warmth, swelling, and pain.The facility's report also measured R5's bruise without identifying the orientation of the measurements. The report documents, DON (V2, Director of Nursing) and Wound Nurse (V7, Licensed Practical Nurse) measurements noted to be 7 cm x 4 cm (assumed but not documented as length by width), no open area present and bruising present to right nipple, witnessed event with (V26, Registered Nurse) RN present at time of injury.As documented in V26's interview below, V26, Registered Nurse (RN), did not witness the event.The same Incident Description report documents the following summary: (On) 5/21/2025 spoke with (V26, RN) nurse, (R5's) breast was pinched during transfer. No concerns for abuse. Bruising occurred during transfer. Plan of care ongoing.On 6/5/26 at 3:20 p.m., V26, Registered Nurse (RN), reviewed R5's Incident Description report dated 5/21/26. V26 stated, I don't know why this report says I witnessed the injury. That is not what I told (V7, Wound Licensed Practical Nurse) or the (V2, Director of Nursing) DON. V26 further stated she had lowered R5 to the floor approximately one week before the bruises were discovered. V26 acknowledged she did not document lowering R5 to the floor or complete documentation of a post-event skin assessment.The same Incident Description report documents that V32, R5's family member/Power of Attorney (POA), was notified of R5's bruising on 5/21/26 at 9:00 a.m.On 6/17/26 at 3:20 p.m., V32, R5's family member/Power of Attorney, stated, I was not notified of any bruising. I would expect them to have called. I have had to emphasize this repeatedly. I need to be informed.There is no documentation in R5's medical record that the bruise was identified on 5/20/26 or 5/21/26. There is also no documentation that V26 transferred R5 from the toilet or that R5 pinched her breast during the transfer.V2, Director of Nursing (DON), provided a printout of text messages dated 5/21/26 at 8:43 a.m. The correspondence between V2 and V51, Certified Nursing Assistant (CNA), concerned R5's bruise.The text messages document the following:V2 texted, (R5) has significant bruising, new and old, to right breast and rib cage area. Are we using sit to stand on her?V51 replied, I reported that (R5's bruise) last night (5/20/26) to the nurse (unidentified) when she (R5) was put in the shower. No one has informed myself (sic) that she requires a mechanical stand lift for transfers, and I have never seen one used on her. It (bruise) was on her left breast (later corrected to right breast), and I was told when I reported it that she had a fall.On 6/2/26 at 5:00 a.m., V20, Licensed Practical Nurse (LPN), stated, (R5) has a big bruise that is fading now, for the most part. It was an injury of unknown source. At first, we thought it could be from a fall. There was nothing documented about a fall.There is no documented physician order, treatment order, or nursing documentation indicating R5's bruise was monitored.On 6/5/26 at 1:30 p.m., V10, Nurse Practitioner, stated she expected facility nurses to follow the standard of practice when assessing a bruise. V10 stated, A bruise that size needs to be monitored closely for swelling, warmth, and pain.On 6/5/26 at 2:20 p.m., V1, Administrator/Abuse Prevention Coordinator, confirmed there was no documentation in R5's medical record of the bruise, a recent fall, a recent incident, or an improper transfer that could explain the cause of R5's bruise identified on 5/20/26 or 5/21/26.2. R2's Care Plan, dated 11/20/24, documents that R2 exhibits exit-seeking behavior.R2's Elopement Risk Assessment, dated 3/6/26, documents that R2 is at risk for elopement.The facility investigation, provided by V1 and dated 5/1/26, documents that R2 exited the facility, entered a staff member's automobile, and was resistant to leaving the automobile and returning to the building.R2's comprehensive medical record contains no documentation regarding R2's exit from the building on 5/1/26 or notification of R2's family or physician.On 6/5/26 at 2:20 p.m., V1, Administrator, stated R2's exit from the building on 5/1/26 was not documented in R2's electronic medical record and should have been. V1 stated the elopement was documented in the facility's risk management section and confirmed surveyors do not have access to that portion of the electronic record. V1 further stated an investigation had been conducted regarding the incident.On 6/16/26 at 10:44 a.m., V1 confirmed R2's exit from the building on 5/1/26 had not been documented in the medical record. Only the second exit incident, which occurred on 5/2/26, was documented. V1 further stated no investigation was conducted regarding the 5/2/26 exit because Activity staff accompanied R2 during that incident.The facility's Charting and Documentation policy, dated 2006, documents that all observations and incidents must be documented in the resident's clinical record, including the date, time, and notification of the family and physician.3. R2's Physician Order Sheet, dated 6/17/26, directs nursing staff to monitor R2's Wanderguard (electronic monitoring device) each shift to ensure it is in place on R2's right ankle.R2's Treatment Administration Record (TAR) for May 2026 and June 2026 through 6/17/26 documents nursing staff electronically initialed that the Wanderguard was checked and remained on R2's right ankle. The June 2026 TAR also documents the order was rewritten on 6/2/26 to include the Wanderguard identification number while continuing to direct staff to monitor the device on R2's right ankle.On 6/16/26 at 10:53 a.m., R2 was observed lying in bed with the Wanderguard on the left ankle.On 6/23/26 at 3:53 p.m., R2 was seated in the dining room with the Wanderguard on the left ankle. V29, Certified Nursing Assistant, observed and confirmed the Wanderguard was on R2's left ankle.4. R2's Physician Order Sheet, dated 6/17/26, directs nursing staff to monitor R2's Wanderguard each shift to ensure it is in place on R2's right ankle.R2's Treatment Administration Record for May 2026 documents nursing staff failed to electronically document Wanderguard monitoring on six occasions: day shift on 5/5/26; day and evening shifts on 5/6/26; and evening shifts on 5/22/26, 5/24/26, and 5/27/26.R2's Treatment Administration Record for June 2026, through 6/16/26, documents nursing staff failed to electronically document Wanderguard monitoring on four occasions: night shift on 6/4/26; day and evening shifts on 6/10/26; and evening shift on 6/15/26.The facility's Charting and Documentation policy, dated 2006, requires all observations to be documented in the resident's clinical record, including the date, time, and the care provider's name and title.5. R20's Physician Order Sheet, dated 6/17/26, directs nursing staff to monitor R20's Wanderguard (electronic monitoring device) every shift to ensure it is in place on R20's left ankle.R20's Treatment Administration Record for June 2026 documents nursing staff electronically initialed that the Wanderguard was checked and remained on R20's left ankle.The facility's undated List of Residents Utilizing a Wanderguard documents R20's Wanderguard is to be placed on the left ankle.On 6/16/26 at 1:47 p.m., R20 was observed seated in a recliner in her room with the Wanderguard on her right ankle. At 3:20 p.m., R20 confirmed the Wanderguard was on her right ankle.On 6/24/26 at 11:56 a.m., V52, Licensed Practical Nurse, while conducting a function check of R20's Wanderguard, observed and confirmed the Wanderguard was on R20's right ankle.

Based on observation, interview and record review, the facility failed to notify a resident's Power of Attorney/ Family Representative of a significant torso bruise. This failure affects one of three residents (R5) reviewed for injuries of unknown origin/family notification on the sample list of 31. Findings include: The facility's Incident Description report documents, 5/21/2026: Resident (R5) presents to admin (V1, Administrator/Abuse Prevention Coordinator) front office with CNA (V36, Certified Nursing Assistant). Upon dressing resident this morning, bruise noted to right breast nipple area radiating to right armpit area. Admin (V1) requests presence of DON (V2, Director of Nursing), bruising noted, and investigation completed.R5's Incident Description report also documents that V32, R5's family member/Power of Attorney (POA), was notified of R5's bruising on 5/21/26 at 9:00 a.m.R5's medical record did not document the above-described bruise. Therefore, R5's medical record also does not document that V32, R5's family member/Power of Attorney, was notified of the bruise.On 6/2/26, V2, Director of Nursing, stated the Incident Description report is an internal tool the facility uses to investigate incidents that occur in the facility. V2 stated the Incident Description report does not become part of a resident's medical record.On 6/17/26 at 3:20 p.m., V32, R5's family member/Power of Attorney, reviewed her phone records during the interview and stated R5's last fall was in April 2026 and that V32 was notified of the fall on 5/3/26. V32 also stated she was not told by the facility that her mother had pinched her breast or that she had a large bruise on 5/21/26. V32 stated, I was not notified of any bruising. I would expect them to have called. I have had to emphasize this repeatedly. I need to be informed.The facility's Notification of Resident Change in Condition Policy, dated October 1, 2019, documents the following:Policy: It is the policy of this facility to promptly notify the residents, their legal representative(s), and attending physicians of changes in the residents' health condition.Policy Specifications: To establish guidelines for assuring residents, their legal representatives, and attending physicians are informed of changes in the resident's condition.The same policy documents, 3. Clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings, and care plan review. Review of high-risk clinical issues such as skin breakdown, falls, weight loss, dehydration, and others are conducted on a daily basis.The same policy also documents, 12. Resident representative(s) notifications and attempts will be made promptly and documented in the nurse's notes. In the event the licensed nurse is unable to contact the resident's representative after a reasonable time period, the Director of Nursing will be notified.

Based on observation, interview, and record review, the facility failed to protect residents from potential abuse by failing to appropriately recognize, investigate, and respond to an injury of unknown origin before concluding there were no concerns for abuse for one of three residents (R5) reviewed for bruises/injury of unknown origin, on the sample list of 31. Findings include: R5's Current Diagnoses Sheet documents the following medical diagnoses: Alzheimer's Disease Unspecified, and Unspecified Dementia with Moderate Agitation. R5's current Physician Order Sheet (POS) documents the following blood thinning medications: Eliquis (Apixaban) Oral Tablet 5 milligrams, Give 1 tablet by mouth two times a day for Atrial Fibrillation. The same POS, and Correlating Medication Administration Records and Treatment Administration Records does not document an order to monitor for bruising related to the blood thinner medication (which is standard of practice confirmed with V10, Nurse Practitioner interview below). R5's Minimum Data Set (MDS) dated [DATE] documents the following: R5 has severe cognitive impairment, has had no behaviors directed towards self or others, and no behavior of rejection of care: R5 uses a manual wheelchair with partial assistant from staff for short distance mobility and is totally dependent on staff for long distance mobility. R5 is Dependent on two or more staff to complete the following: Toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. R5 requires substantial/maximal assistance for toilet and tub transfers. R5's Care Plan dated 4/22/26 documents the following: (R5) is at risk for a psychosocial well-being problem/issue r/t (related to): diagnosis of Alzheimer's Disease and Dementia with impaired cognitive function, wears glasses to assist with vision and are labeled with name, will remain long term in the facility, at risk for exit seeking and wears a wander-guard for monitoring, moderate risk for abuse r/t dependent on others, psychiatric history, anxiety and displays behaviors, is dependent on staff to provide activities, has verbal and physical aggression towards staff other residents at times, and past history of homicidal ideations. (R5 name) will remain free from abuse. (R5) has potential/actual impairment to skin integrity. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The facilities Incident Description report dated 5/21/26 (untimed report) documents the following regarding R5: Nursing Description: Right breast/rib cage, CNA (Certified Nursing Assistant) noted during dressing that AM (witness statement documented below, confirms the bruise was identified the night before on 5/20/26, when providing a shower). DON (V2, Director of Nursing) and Wound Nurse (V7, Licensed Practical Nurse) measurements noted to be 7cm x 4 cm (assumed but not documented, length by width per standard of practice), no open area present and bruising present to right nipple, witnessed event with (V26, Registered Nurse) RN present at time of injury. Resident Description: Resident Unable to give Description Was this incident witnessed: Y (Yes) (V26, RN denies in interview below that she witnessed R5 being pinched). The same Incident Description report documents the following summary: (On) 5/21/2025 spoke with (V26, RN) nurse, (R5's) breast was pinched during transfer. No concerns for abuse. Bruising occurred during transfer. Plan of care ongoing. The same Incident Description report documents the following: (On) 5/21/2026, Investigation reflects that during transfer off (the) toilet to wheelchair, right breast pinched between toilet arm riser and wheelchairs (sic plural). (On) 5/21/2026 Resident (R5) presents to admin (V1, Administrator/Abuse Prevention Coordinator) front office with CNA (V36, Certified Nursing Assistant) upon dressing resident this morning bruise noted to right breast nipple area radiating to right armpit area. Admin (V1) requests presence DON (V2), bruising noted, and investigation completed. V26, RN's interview documented below denies the detail in the above report and confirms the injury was of unknown origin. R5's same Incident Description report documents V32 R5's Family Member Power of Attorney (POA) was notified of R5's bruising on 5/21/26 at 9:00 am. (POA denied being notified in her interview documented below) On 6/17/26 at 3:20 pm V32, R5's Family Member/Power of Attorney reviewed her phone calls while being interviewed. V32 stated R5's last fall was in April and R32 was notified on 5/3/26. V32 stated she was not told by the facility that her mother had pinched her breast, or that she had a large bruise on 5/21/26. I was not notified of any bruising. I would expect them to have called. I have had to emphasize this repeatedly. I need to be informed. R5's medical record did not document the finding of the bruise on 5/20/26 or 5/21/26. There was no fall documented since 4/27/26. The fall note on 4/27/26 documents R5 fell trying to get up from a recliner chair, and R5 had no injuries from that fall. There were no incident reports or nursing notes that document V26, RN transferred R5 from the toilet and R5's breast got pinched. V2, Director of Nursing provided additional information she had not included in R5's bruise investigation or witness statement. V2, DON provided a printout of a text dated 5/21/26 at 8:43 am. The correspondence was between V2, DON and V51, CNA was regarding R5's bruise. The texts are documented as follows: V2, DON texted (R5) has significant bruising new and old to right breast and rib cage area. Are we using sit to stand on her? V51, CNA texted I reported that (bruise) last night (5/20/26) to the nurse (unidentified) when she (R5) was put in the shower. No one has informed myself (sic) that she is (requires) a (mechanical stand lift to transfer) and I have never seen one used on her. It (bruise) was on her left breast (corrected later in text to be right breast) and it was told to me when I reported it that she had a fall. V2, DON texted: Nothing was in the chart so now I have to back track V2, DON texted: Who told you it was a fall? V51, CNA texted: It (bruise) wasn't reported to me, I found out last night assisting her (R5) into the shower when I took off her shirt. I told (V20, Licensed Practical Nurse/ LPN) she (R5) had an enormous bruise on her right breast, and she (V20, LPN) told me she (R5) had a fall and they (nurses) knew (about the bruise) and I went back into the shower room. V2, DON texted: Why wasn't it (bruise) reported on day shift (5/20/26) when they put a shirt on her (R5)? V51, CNA texted: The bruise I saw was purple and turning yellow, it was huge, couldn't have been missed. Funny, I am being asked about it, when I reported it. On 6/2/26 at 11:35 am V13, CNA and this surveyor entered R5's room. R5 was lying on her back in bed. V13, asked R5 if V13 could show this surveyor her bruise. R5 was pleasantly confused, smiled and said okay. V13, CNA raised R5's shirts. R5's right breast was completely covered with a dark purple/black bruise (identified on 5/20/26). R5's bruise measured approximately the diameter of a standard soda pop can. R5 also had diffused yellow and faint green faded bruised areas under her right breast that measured approximately three inches, down the lateral aspect of her right torso and extended approximately five inches, and under her right axillary that measure approximately three inches wide and included R5's upper back. On 6/2/26 at 5:00 am V20, Licensed Practical Nurse (LPN) stated (R5) has a big bruise that is fading now for the most part. It was an injury of unknown source. At first, we (unidentified facility staff) thought it (the bruise) could be from a fall. There was nothing documented about a fall. I know they (unidentified) did an investigation, and I reported the bruise to (V10, Nurse Practitioner). It was big and was so purple it looked black. It covered one of her breasts, down to her waist, and wrapped around her back. It looked like somebody may have transferred her with the (mechanical stand lift) with the sling on too tight. Generally, the CNA's (Certified Nursing Assistants) don't use a sit to stand on her. On 6/2/26 at 6:25 am, V5, Certified Nursing Assistant (CNA) stated I know (R5) has a bruise across her chest, under her armpit and ribs. I heard it had already been reported when I saw it. I heard someone fastened the (mechanical stand lift) belt too tight. At least that is what I was told. That is what it looked like to me. Somebody else said her (R5's) breast was pinched in a transfer off the toilet. I can't imagine a bruise that bad, coming from a pinch on her wheelchair. That is just what I was told it last. On 6/2/26 at 5:35 am V16, CNA stated I do know about a resident with a seriously large bruise. (R5) has a black and blue bruise on her breast that extends all the way down her side to her hip. You could tell it was fresh. It was on my last round (resident checks) about 5:00 am (5/21/26). It was not there when I worked a few days before. It was definitely new. It wrapped around her torso from about the middle of her chest, over her (breast,) rib cage, across her stomach, under her arm, and even spread around to her back. She did not even act like it hurt, but you know it had to. I reported this to (V26, Registered Nurse) and she reported it to the Administrator (V1, Administrator/Abuse Prevention Coordinator). I believe they investigated it. Nobody called me or had me write a statement. I heard later it happened from the (mechanical stand lift) during a transfer. I have never transferred her with a (mechanical stand lift), but that is what it looked like. It has faded a lot, but you can still see where it was. Her (R5's) (slang for breast) is still black, the rest of it is more yellow and faded now. On 6/2/26 at 5:55 am V21, CNA stated I do know about (R5) having a bruise. It was unbelievable. It was so dark and so big. It was in a pattern like she had on a (mechanical stand lift) sling that was too tight. (V16, CNA) and I both work over there with (R5) her, the night it was found, (V26, Registered Nurse) came and looked at it. She was going to see if maybe (R5) had a fall. I assumed she would report it to the Administrator (V1, Administrator/Abuse Prevention Coordinator) if she couldn't figure out what happened. I haven't worked over there for a while. I had not seen it (bruise) recently, until tonight. The bruise is still there but has faded a lot. On 6/5/26 at 1:30 pm V10, Nurse Practitioner (NP) said she was not notified of R5's bruises until (V2, Director of Nursing) told V10, NP later, when V10 NP came into the facility 5/21/26. V10 NP also said R5's bruises found overnight 5/21/26 were likely reported to V3, Medical Director (MD) because he was on call. V10 NP stated (V3, MD) would have provided an order to monitor the bruise as well. V10, NP said That is the standard of practice, when there are no other symptoms present. A bruise that size needs to be monitored closely for swelling, warmth, and pain. On 6/5/26 at 2:20 pm V1, Administrator/Abuse Prevention Coordinator stated V1's understanding was that V2, Director of Nursing and V7, Licensed Practical Wound Nurse had found V26, Registered Nurse witnessed R5 pinch her breast during transfer. The facility did not have to report to Illinois Department of Public Health or go any further with the investigation, that the information had been accurate and confirmed with additional information. V1 then confirmed there was no documentation in R5's medical record that documents R5's bruise, neither a recent fall nor a recent incident or a report of an improper transfer that caused R5's bruise on 5/21/26. V1, acknowledged R5's injury of unknown origin investigation should have gone on further to find supporting evidence of the cause to rule out abuse. On 6/5/26 at 3:20 pm V26, Registered Nurse (RN) reviewed the facilities Bruise/Discoloration report dated 5/21/26, regarding R5's bruise. V26 RN stated I don't know why this report says I witnessed the injury. That is not what I told (V7, Licensed Practical Wound Nurse) or the (V2, Director of Nursing) DON. The twins (V16 and V21, Certified Nursing Assistants) came and told me. I went and assessed (R5's) bruise. There was no witness to any pinch that I knew of. They (V16 and V21 CNA's) did not know what happened and neither did I. (V2, DON) asked me if (R5) could have pinched her breast during a transfer. I said she could have, but the bruise was much worse than what a pinch on her nipple would have caused. That was my expert opinion. Even though she is on blood thinners, this was a massive bruise. It covered part of her sternum, right breast, ribcage, and axillary. It was fresh and deep purple, almost black. It was an injury of unknown origin. We did not have a clue what happened to her. It looked more like a (mechanical stand lift) sling was adjusted too tight. If you put the sling on her (R5), I guarantee it would line up exactly. The CNA's and I all thought the same thing. (R5) does not use a (mechanical stand lift) stand transfer. (V2, Director of Nursing) asked me if I was aware of any recent falls. I remembered about a week prior, I saw (R5) standing in the bathroom, I intervened because I know she (R5) was on blood thinners. She was very unsteady on her feet. I assisted her right away and lowered her to the floor. It was a smooth transition with her buttocks on my leg. Once she was safe on the floor, I got two CNAs to help transfer her to bed so I could do an assessment. I checked all her skin. There was nothing on her skin at all. The bruise surely would not have been from that. Me lowering her to the floor was about a week prior to finding it. If anything, she would have a bruise on her buttocks. I did not see her pinch her nipple. I wish they would not write stuff, I did not say. V26, RN then reviewed R5's electronic medical records notes and stated, I see I did not document when I lowered (R5) to the floor. I should have documented that. Had I documented it, you could see her bruise didn't happen from me lowering her to the floor the week before the bruise was found. V26, RN then stated, When the Administrator (V1, Administrator/Abuse Prevention Coordinator) got here that morning (5/21/26), (V36, CNA) took (R5) up and reported the bruise as an injury of unknown origin, because that is what it was. On 6/23/26 at 2:50 pm V21, Certified Nursing Assistant (CNA) stated that she received report around 6:00 pm on 5/20/26, (the night before R5's injury of unknown origin was reported to the Administrator/Abuse Prevention Coordinator) when coming on to work the night shift. The day shift CNA (later identified as V51) had found a bruise while giving R5 a shower. V21 stated She (V51) did not say how big or how bad it was. I would have looked immediately and reported it. (R5) was asleep, in night clothes when I went in her room after shift change. It was not until 5:00 am rounds that I actually saw (R5's) bruise. It was so big. As soon as I pulled up her night shirt, it was obvious. Overnight rounds we are just changing incontinent briefs when they're soiled. At night residents don't want their blankets or clothes removed for skin assessment. We leave their covers on their upper body or I would have seen it sooner. I told (V20 and V26, Registered Nurses), they looked at it and did not know what happened. They were going to see if it was documented and report to the administrator if it was an injury of unknown reason. The facility Abuse Prevention Program policy dated October 2022 documents the following:Establishing a Resident Sensitive Environment This facility desires to prevent abuse, neglect, exploitation, mistreatment, deprivation of goods and services by staff, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following:Concern Identification and Follow-up: Resident and family concerns will be documented, reviewed, addressed, and responded to using the facility's concern identification or grievance procedures. Residents and families will be informed of the facility's concern identification or grievance procedures. An essential element of customer satisfaction is a timely response back to the family or residents to concerns expressed. At least quarterly, the reported concerns from residents and families, and the facility response, will be reviewed by the facility Quality Management committee to assure that individual concerns are being addressed and to assess any patterns that might indicate needed changes in facility practices.V. Internal Reporting Requirements and Identification of AllegationsEmployees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence.The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration, or pain.VII. Internal Investigation1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected.2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.3. For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. 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 not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over lime.If classified as an injury of unknown source,' the person gathering facts will document the injury, the location and time it was observed, any treatment given and notification of the resident's physician, responsible party. The Department of Public Health will be notified. Time frames for reporting and investigating abuse will be followed. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interview able. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents.

Based on observation, interview and record review the facility failed to ensure residents' right to be free from misappropriation of money and blank checks. This failure affected one of seven residents (R4) reviewed for misappropriation on the sample list of 31. Findings include:R4's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicating R4 has no cognitive impairment.R4's Care Plan, dated 6/9/26, documents the following:Focus: (R4) is at risk for a psychosocial well-being problem related to: low risk of abuse related to dependence on others and anxiety/fear/anger; short-term stay; diagnosis of glaucoma and wears glasses; wears hearing aids; diagnosis of anxiety; suicidal ideations with no plan to harm self; sad mood as indicated by mood assessment; self-isolates; and (R4) is capable of participating in activities of interest.Goal: (R4) will remain free from abuse.Interventions: 1. Address all complaints/concerns promptly using the grievance policy and procedure. 2. Complete a risk for abuse/neglect assessment quarterly. 3. Observe for signs and symptoms of abuse. 4. Report any signs of abuse to the Administrator, Director of Nursing, Supervisor, and follow all Illinois Department of Public Health (IDPH) and facility protocols related to reporting suspected abuse.The facility grievance log documents that V9, R4's friend and independent caregiver prior to R4's admission to the facility, filed a complaint on R4's behalf. The grievance log documents that V43, Previous Interim Administrator, and V38, Director of Clinical Services, completed an investigation regarding the alleged misappropriation of $100.00 and four blank checks on 4/9/26. The same grievance log documents R4's money and checks were reported missing sometime between March 1, 2026, and April 1, 2026. However, as documented in V31's interview below, V31, R4's family member, stated she had been visiting from Florida and placed the money and four blank checks into R4's wallet on either March 27 or March 28, 2026.The Local Police Department report, dated 6/5/26, documents R4's allegation of misappropriation of $100.00 and four blank checks was reported by the facility on 4/1/26. The report, signed by V37, Local Police Chief/Detective, documents the police department had previously instructed the facility to provide a list of individuals who had access to R4's room and personal belongings; however, the facility had not provided the requested information. The report further states, It is also usual and customary for (the facility) to provide us (police department) with the summary of their internal investigation, but that has also not been provided. It is unlikely that our investigation can go any further, particularly if (the facility) claims it to be unfounded.On 6/3/26 at 1:55 p.m., V9, R4's friend and private caregiver, was having lunch with V35, Activities Aide. During lunch, V35 stated she had heard a rumor that R13's purse had been reported missing (later confirmed to have been found) and that two male residents' wallets had also been reported missing around the same time but were later found.V9 stated, I went to the (local dollar store) for (R4). She usually had some money, and I always brought her the change. I never knew exactly how much money she had. I only knew what she gave me to run errands. I called (R4's) daughter (V31), who lives in Florida, and told her there was a rumor of theft in the building. (V31) asked me to check her mom's purse because she had left four blank checks and cash in (R4's) wallet. I told her I would check the next time I visited the facility. It was either the next day or two days later. I went to visit (R4). I told her (V31) wanted me to see if her checks and money were still in her purse, which was in the bottom drawer of her dresser. (R4) said she would appreciate me checking. Every compartment of her purse had been unzipped. Even her makeup bag was open. She had no money or checks. I immediately reported this to (V31) and to (V2, Director of Nursing).On 6/3/26 at 2:15 p.m., V35, Activities Aide, confirmed the above interview.On 6/5/26, V37, Local Police Chief/Detective, stated he initiated the investigation regarding R4's allegation of misappropriation after the facility notified law enforcement on 4/1/26. V37 stated he requested information from the facility that had still not been provided. V37 stated he had not completed his investigation because he was waiting for the facility to provide the names and contact information of staff who cared for R4 after V31 returned to Florida and before 4/1/26, when the missing money and checks were discovered.V37 stated, I understand from (R4's) daughter (V31) that she visited during the last week of March (March 27 or 28, 2026, according to V31's interview below) and placed money and checks in (R4's) wallet. (R4's) daughter immediately stopped payment on the checks. The daughter had no concerns about (V9), the friend and previous caregiver, or the ladies from church who routinely visit (R4). My interviews also found them to be credible. At this point, the facility employees need to be interviewed. One of them would be the likely perpetrator.On 6/17/26 at 2:40 p.m., V1, Administrator/Abuse Prevention Coordinator, stated the investigation into R4's allegation of misappropriation, reported on 4/1/26, had been completed before V1 began working at the facility on 4/6/26. V1 stated she received a notification in the facility's electronic system on her first day of employment indicating the final IDPH report was due. V1 stated she submitted the final report that same day. V1 confirmed neither R4 nor V31 had been notified of the results of the investigation completed by V43, Previous Interim Administrator.On 6/23/26 at 11:50 a.m., R23, R4's friend, stated, R4 and I have known each other for years. I come here to visit her regularly. I remember several months ago R4 told me someone had taken money from her purse while she was sleeping one night. She always had her own money. I have seen her give money to our church when our friends visit. R4 is sharp and honest. If she said she had a certain amount of money, I believe her. She is almost [AGE] years old, but she is reliable. No one ever interviewed me about it. I would have told them the same thing. I probably would have remembered more details if I had been asked at the time.On 6/23/26 at 12:25 p.m., R4 confirmed R23 visits her regularly in her room. R4 stated, R23 and I have been friends for years. We went to church together. (R23) has her own money. She would never take anything from me. R4 also stated, It really bothers me that I cannot figure out who stole from me. I was hoping the facility and police could figure this out.The facility's Abuse Prevention Program policy, dated October 2022, documents the following:Establishing a Resident-Sensitive Environment This facility desires to prevent abuse, neglect, exploitation, mistreatment, deprivation of goods and services by staff, and misappropriation of resident property by establishing a resident-sensitive and resident-secure environment.Concern Identification and Follow-up Resident and family concerns will be documented, reviewed, addressed, and responded to using the facility's grievance procedures. Residents and families will receive a timely response, and concerns will be reviewed by the Quality Management Committee at least quarterly.Internal InvestigationAll incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment, or misappropriation of resident property occurred, was alleged, or was suspected.Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation.Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable. Written statements, medical records, and other pertinent documents will be reviewed. Residents to whom the accused regularly provided care, and employees with whom the accused regularly worked, will also be interviewed.The facility's Filing Grievances/Complaints policy, revised December 2004, documents: 7. The resident, or person filing the grievance on behalf of the resident, will be informed of the findings of the investigation and the actions to be taken to correct any identified problems. Such notification will be made orally by the Administrator, or designee, within five working days of the filing of the grievance. A written summary will also be provided to the resident, and a copy will be maintained in the business office.Should the resident not be satisfied with the results of the investigation or the recommended actions, the resident may file a written complaint with the local Ombudsman Program or the State Survey and Certification Agency.

Based on observations, interviews and record reviews, the facility failed to operationalize their abuse prevention policy by failing to inform a resident and resident's family representative of a misappropriation, investigation results. This failure affected one of seven residents (R4) reviewed for misappropriation on the sample list of 31.Findings include:The facility's Abuse Prevention Program policy, dated October 2022, documents the following:IV. Establishing a Resident-Sensitive EnvironmentThis facility desires to prevent abuse, neglect, exploitation, mistreatment, deprivation of goods and services by staff, and misappropriation of resident property by establishing a resident-sensitive and resident-secure environment. This will be accomplished through a comprehensive quality management approach involving the following:Concern Identification and Follow-up: Resident and family concerns will be documented, reviewed, addressed, and responded to using the facility's concern identification or grievance procedures. Residents and families will be informed of the facility's concern identification or grievance procedures. An essential element of 'customer satisfaction' is a timely response to the resident or family regarding concerns expressed. At least quarterly, reported concerns from residents and families, along with the facility's responses, will be reviewed by the Quality Management Committee to ensure individual concerns are addressed and to identify any patterns indicating the need for changes in facility practices.The same Abuse Prevention Program policy documents the following:Informing the Resident's Representative. The resident or the resident's representative will be informed of the conclusions of the investigation.The facility's investigation regarding R4's allegation of misappropriation, dated 4/7/26, documents the following Final Summary/Conclusion:Based on the investigation, the cash and four blank checks were determined to be missing but remain unaccounted for. The resident's POA (V31, Family Member/Power of Attorney) contacted the bank and canceled the checks so they could not be used.There is no documentation in the 4/7/26 investigation report indicating that R4 or V31, R4's Power of Attorney/Daughter, was informed of the investigation's conclusions after the facility completed the investigation on 4/7/26 and submitted its final report to the Illinois Department of Public Health (IDPH).The Local Police Department report, dated 6/5/26, documents that R4's allegation of misappropriation of one hundred dollars and four blank checks was reported by the facility on 4/1/26. The report, signed by V37, Local Police Chief/Detective, documents that the police department had previously instructed the facility to provide a list of individuals who had access to R4's room and personal belongings; however, the facility had not provided the requested information. The report further states:It is also usual and customary for (the facility) to provide us (police department) with the summary of their internal investigation, but that has also not been provided. It is unlikely that our investigation can go any further, particularly if (the facility) claims it to be unfounded.R4's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicating R4 has no cognitive impairment.On 6/2/26 at 1:15 p.m., R4 stated she had been missing approximately one hundred dollars and four blank checks since V31, Family Member/Power of Attorney, visited at the end of March. R4 stated, I wish the directors in this nursing home would have identified who did this. I would rest a lot easier. I have heard nothing about the investigation.On 6/3/26 at 10:50 a.m., V31, R4's Power of Attorney/Family Member, confirmed R4 had approximately one hundred dollars in her wallet on March 27 or March 28, 2026, which was discovered missing on 4/1/26. V31 stated neither she nor R4 had been informed of the results of the facility's investigation.On 6/16/26 at 4:00 p.m., V38, Director of Clinical Services, stated he spoke with R4's daughter (V31) when the allegation of misappropriation was reported on 4/1/26. V38 stated he submitted the initial report to IDPH but did not complete the investigation. V38 stated V43, Previous Interim Administrator, completed the investigation and that he did not know whether V43 informed R4 or V31 of the investigation's conclusions.On 6/17/26 at 2:40 p.m., V1, Administrator/Abuse Prevention Coordinator, stated the investigation into R4's allegation of misappropriation had been completed before V1 began working at the facility on 4/6/26. V1 stated she received a notification through the facility's electronic system on her first day indicating the final IDPH report was due and submitted the report that same day. V1 confirmed neither she nor anyone else had notified R4 or V31 of the conclusions of the investigation completed by the previous administrator.

Based on observations interviews and record review the facility failed to report an injury of unknown origin to the State Agency for one of three residents (R5) reviewed for bruises/injury of unknown origin/reporting on the sample list of 31. Findings include: The facility's Incident Description report, dated 5/21/26, documents the following, (On) 5/21/2026 Resident (R5) presents to admin (V1, Administrator/Abuse Prevention Coordinator) front office with CNA (V36, Certified Nursing Assistant). Upon dressing resident this morning, bruise noted to right breast nipple area radiating to right armpit area. Admin (V1) requests presence of DON (V2, Director of Nursing), bruising noted, and investigation completed.On 6/5/26 at 2:20 p.m., V1, Administrator/Abuse Prevention Coordinator, stated V1's understanding was that V2, Director of Nursing, and V7, Wound Licensed Practical Nurse, had determined that V26, Registered Nurse, witnessed R5 pinch her breast during a transfer. V1 stated the facility would not have had to report the incident to the Illinois Department of Public Health (IDPH) or continue the investigation if that information had been accurate (V26, RN denied witnessing R5 pinch her breast during the transfer, as documented below) and confirmed by additional evidence.V1 then confirmed there was no documentation in R5's medical record of the bruise, a recent fall, or an incident involving an improper transfer that could explain the cause of R5's bruise identified on 5/21/26. V1 acknowledged the investigation into R5's bruise, an injury of unknown origin, should have continued to obtain supporting evidence to determine the cause, rule out abuse, and report the allegation to IDPH while additional information was being obtained.On 6/23/26 at 2:50 p.m., V21, Certified Nursing Assistant (CNA), confirmed the details of V26's interview, documented below.On 6/5/26 at 3:20 p.m., V26, Registered Nurse (RN), reviewed the facility's Incident Description report dated 5/21/26 regarding R5's bruise. V26 stated she did not witness R5 pinch her breast or sustain the bruise. V26 stated V16 and V21, Certified Nursing Assistants, informed her of the bruise. V26 stated, The bruise was an injury of unknown origin. We did not have a clue what happened to her. It looked more like a mechanical stand lift sling was adjusted too tight. If you put the sling on her (R5), I guarantee it would line up exactly.The facility's Abuse Prevention Program policy, dated October 2022, documents the following:For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an 'injury of unknown source.' 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 not observed by any person, or the source of the injury could not be explained by the resident; andThe injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or because of the number of injuries observed at one particular point in time or the incidence of injuries over time.Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on observation, interviews and record review, the facility failed to recognize and thoroughly investigate an injury of unknown origin one of three residents (R5) reviewed for bruises/injury of unknown origin, on the sample list of 31. Findings include: The facilities Incident Description report dated 5/21/26 (untimed report) documents the following regarding R5: Nursing Description: Right breast/rib cage CNA (Certified Nursing Assistant) noted during dressing that AM (witness statement documented below, confirms the bruise was identified the night before on 5/20/26, when providing a shower). (The) DON (V2, Director of Nursing) and Wound Nurse (V7, Licensed Practical Nurse) measurements noted to be 7cm x 4 cm (assumed but not documented, length by width per standard of practice), no open area present and bruising present to right nipple, witnessed event with (V26, Registered Nurse) RN present at time of injury. Resident Description: Resident Unable to give Description. Was this incident witnessed: Y (Yes) (V26, RN denies in interview below that she witnessed R5 being pinched). The same Incident Description report documents the following summary: (On) 5/21/2025 spoke with (V26, RN) nurse, (R5's) breast was pinched during transfer. No concerns for abuse. Bruising occurred during transfer. Plan of care ongoing. The same Incident Description report documents the following: (On) 5/21/2026. Investigation reflects that during transfer off (the) toilet to wheelchair right breast pinched between toilet arm riser and wheelchairs (sic plural). (On) 5/21/2026 Resident (R5) presents to admin (V1, Administrator/Abuse Prevention Coordinator) front office with CNA (V36, Certified Nursing Assistant) upon dressing resident this morning bruise noted to right breast nipple area radiating to right armpit area. Admin (V1) requests presence of DON (V2), bruising noted, and investigation completed. R5's medical record did not document R5's bruise or any falls or incidents to determine the cause of R5's bruise. Therefore there was no record review to support the investigation conclusion documented above. On 6/2/26 at 5:35 am V16, CNA confirmed the details of V26's interview documented below. On 6/5/26 at 2:20 pm V1, Administrator/Abuse Prevention Coordinator stated V1's understanding was that V2, Director of Nursing and V7, Licensed Practical Wound Nurse had found V26, Registered Nurse witnessed R5 pinch her breast during transfer. The facility did not have to report, to Illinois Department of Public Health or go any further with the investigation, had the information been accurate and confirmed with additional information. V1 then confirmed there was no documentation in R5's medical record that documents R5's bruise, a recent fall, or a recent incident report of an improper transfer, that explained the cause of R5's bruise on 5/21/26. V1, acknowledged R5's bruise/injury of unknown origin investigation, should have gone on further to find supporting evidence of the cause, so as to rule out abuse. On 6/23/26 at 2:50 pm V21, CNA confirmed the details of V26, interview documented below. On 6/5/26 at 3:20 pm V26, Registered Nurse (RN) reviewed the above facilities report dated 5/21/26, regarding R5's bruise. V26 RN stated I don't know why this report says I witnessed the injury. That is not what I told (V7, Wound Licensed Practical Nurse) or the (V2, Director of Nursing) DON. The twins (V16 and V21, Certified Nursing Assistants) came and told me. I went and assessed (R5's) bruise. There was no witness to any pinch that I knew of. They (V16 and V21 CNA's) did not know what happened and neither did I. (V2, DON) asked me if (R5) could have pinched her breast during a transfer. I said she could have, but the bruise was much worse than what a pinch on her nipple would have caused. That was my expert opinion. Even though she is on blood thinners, this was a massive bruise. It covered part of her sternum, right breast, ribcage, and axillary. It was fresh and deep purple, almost black. It was an injury of unknown origin. We did not have a clue what happened to her. It looked more like a (mechanical stand lift) sling was adjusted too tight. If you put the sling on her (R5), I guarantee it would line up exactly. The CNA's and I all thought the same thing. (R5) does not use a (mechanical stand lift) stand transfer. (V2, Director of Nursing) asked me if I was aware of any recent falls. I remembered about a week prior, I saw (R5) standing in the bathroom, I intervened because I know she (R5) was on blood thinners. She was very unsteady on her feet. I assisted her right away and lowered her to the floor. It was a smooth transition with her buttocks on my leg. Once she was safe on the floor, I got two CNAs to help transfer her to bed so I could do an assessment. I checked all her skin. There was nothing on her skin at all. The bruise surely would not have been from that. Me lowering her (R5) to the floor was about a week prior to finding it. If anything, she would have a bruise on her buttocks. I did not see her pinch her nipple. I wish they would not write stuff, I did not say. V26, RN then reviewed R5's electronic medical record notes and stated. I see I did not document when I lowered (R5) to the floor. I should have documented that. Had I documented it, you could see her bruise didn't happen from me lowering her to the floor the week before the bruise was found. The facility Abuse Prevention Program policy dated October 2022 documents the following: For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. 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 not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over lime.

Based on interview and record review the facility failed to restrict an employee from working while investigating an allegation of abuse for one of 13 residents (R6) reviewed for staff behavior in the sample list of 21. The employee had access to R13-R21 during this time period. The facility's Abuse Prevention Program dated October 2022 documents visitors are encouraged to report suspected concerns of abuse immediately to the administrator or to an immediate supervisor who immediately reports to the administrator. This policy documents employees accused of abuse will be removed from resident contact immediately and not permitted to return to work until the results of the investigation have been reviewed by the administrator and determined abuse is unsubstantiated. On 3/16/26 at 11:31 AM R6 stated about a week or so ago a Certified Nursing Assistant (identified as V41 CNA) assisted R6 onto the bedpan during the night. R6 stated R6 told V41 that R6 couldn't decide if R6 was too hot or too cold and V41 told R6 that R6 better make up R6's mind because V41 was not going to keep coming into R6's room every five minutes as V41 is only required to come in every two hours. R6 stated R6 felt like this was scolding in nature and belittling, R6 is an adult and not a child. R6 stated this was a dignity issue but also abuse and R6 did not like being treated like that at all. R6 stated R6 thought R6 reported this to V42 Corporate Marketer last Thursday.R6's Minimum Data Set, dated [DATE] documents R6 as cognitively intact. After reviewing the facility's abuse log provided on 3/17/26, there were no documented allegations involving R6. R6's abuse allegation was reported to V2 Director of Nursing on 3/17/26 at 12:10 PM. On 3/17/26 at 12:20 PM V2 was asked about any follow up regarding R6's abuse allegation. V2 stated V42 spoke with R6 yesterday and R6 reported that she did not recall the alleged incident and therefor abuse was not suspected. V2 stated V2 had not yet spoken to V41 and V41 was not on the schedule to work last night. At 12:30 PM V2 verified which resident rooms are considered Hall 1 on the 200 unit. On 3/17/26 at 1:36 PM V41 CNA stated V41 worked last evening from 6:00 PM until 6:00 AM on Hall 1 of the 200 unit but R41 helped answer call lights on other halls on that unit. V41 stated V41 answered R6's call light last night and assisted R6 onto the bed pan. V41's timecard documents V41 worked on 3/16/26 from 5:47 PM until 5:57 AM. The facility's Resident List Report dated 3/16/26 documents R13-R21 reside on Hall 1 on the 200 unit.

Based on interview and record review the facility failed to monitor and report changes in condition and follow physician's orders for four of six residents (R1, R2, R6, R11) reviewed for changes in condition in the sample list of 21. Findings include:The facility's Notification of Resident Change in Condition policy dated [DATE] documents the nurse shall inform and consult with the resident's physician and representative regarding significant changes in condition and the nurse should use professional judgement based on assessment and findings or signs and symptoms of changes which could lead to deterioration if not treated. This policy documents to monitor signs and symptoms and vital signs, and notify the family and physician of significant findings. The facility's undated Laboratory Services policy documents the facility must obtain laboratory services to meet the needs of the residents and the facility is responsible for the timeliness of services. 1.) On [DATE] at 11:31 AM R6 stated R6 had a cough, went to the hospital and was diagnosed with acute bronchitis. R6 stated the facility uses agency nurses but the Certified Nursing Assistants (CNAs) have been good about letting the nurses know changes in my health and when R6 should be sent to the hospital. R6 stated R6 feels like they have always sent her to the hospital timely and when needed but R6 didn't remember much about her treatment prior to going to the hospital. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact.R6's Care Plan documents a problem of Congestive Heart Failure (CHF) and altered respiratory status related to difficulty breathing and sleep apnea, with interventions dated [DATE] to monitor/document and report to physician as needed any signs of CHF, including edema, shortness of breath, cool skin, dry cough, distended neck veins, weakness, weight gain, crackles/wheezing upon lung assessment, weakness/fatigue, increased heart rate, lethargy, and disorientation. This care plan also includes interventions to monitor and report symptoms of respiratory distress and abnormal breathing patterns, including increased/decreased respirations, decreased oxygen saturation, restlessness, sweating, headaches, pleuritic pain, use of accessory muscles for breathing, skin color changes, periods of apnea, prolonged deep or shallow breathing, pursed lip breathing and nasal flaring.R6's Progress Note dated [DATE], recorded by V20 Nurse Practitioner, documents R6 presents with increased cough, congestion, inspiratory wheezing noted on lung assessment and increased fatigue. This note includes the following orders: chest x-ray, Complete Blood Count (CBC), Complete Metabolic Panel (CMP), use of spirometer, supplemental oxygen if needed, nebulizer treatments as needed (PRN) and continue to monitor respiratory status. R6's February 2026 Medication Administration Record documents PRN nebulizer treatments were given four times between [DATE] and [DATE] and R6 used oxygen on the evening of [DATE]. There is no documentation in R6's medical record that vital signs or respiratory assessments were completed [DATE]-[DATE]. There is no documentation that chest x-ray and laboratory orders were completed. R6's Nursing Note dated [DATE] [DATE] at 3:40 PM documents R6 was sent to the hospital for shortness of breath and coughing. R6's vital signs were as follows: blood pressure 137/65, Pulse 91, oxygen saturation 95% on 3 liters, temperature 98.3 degrees Fahrenheit. V20 contacted hospital for update and R6 was transferred to transferred to higher level hospital due to R6's oxygen saturation dropping while on bilevel positive airway pressure and Troponin levels were elevated. R6's Hospital History and Physical dated [DATE] documents R6 was direct admit from another hospital emergency room due to concerns for possible Non-ST-segment Elevation Myocardial Infarction, R6 reported symptoms of generalized weakness, fatigue, body aches, wet nonproductive cough, shoulder pain from coughing, severe sore throat, and shortness of breath that progressively worsened over the last four days. While in the emergency room R6 had tachycardia with pulse in the 110s beats per minute, increased respirations of 20-30 per minute, decreased oxygen saturation of 85% which required oxygen via 2 liters per minute. R6 was admitted for sepsis secondary to Pneumonia with Acute Hypoxemic Respiratory Failure with source as seen on admission Chest Computed Tomography Angiography showing persistent regions of right lung dependent atelectasis/consolidations. On [DATE] at 4:00 PM V20 stated V20 evaluated R6 on [DATE] and a chest x-ray, CBC, and CMP were ordered for wheeze, shortness of breath and cough. V20 stated the facility's laboratory and x-ray services do not come on the weekends so the orders would have been completed on [DATE]. V20 stated R6 was stable at that time and the nurses should have been monitoring R6's vital signs and completing respiratory assessments every shift and reported any changes to V20. V20 stated depending on the x-ray results and if R6 had any reported changes V20 would have ordered to send R6 to the hospital sooner. V20 reviewed R6's vital signs and nursing notes and confirmed there were no documented assessments or vital signs after [DATE] until R6 was sent to the hospital on [DATE] with sepsis secondary to pneumonia. V20 stated R6 would have required hospital treatment regardless and did not feel R6's sepsis could have been prevented if treated sooner since R6's vitals did not indicate sepsis on [DATE]. If she was notified of any changes during that time prior to results she would have just ordered for her to go to the hospital sooner. On [DATE] at 9:30 AM V37 MDS Coordinator confirmed there were no vital signs or respiratory assessments for R6 from [DATE] until [DATE] when R6 was hospitalized . V37 stated R6 had a prior incentive spirometry order that would have monitored respiratory status that was not resumed after R6 had previously returned from the hospital. V37 stated the x-ray company contacted the facility on [DATE] to schedule R6's x-ray, but R6 had already been transferred to the hospital. 2.) R2's MDS dated [DATE] documents R2 has severe cognitive impairment and is dependent on staff for activities of daily living (ADLs.) R2's care plan documents R2's diagnoses include Hypertension, Peripheral Vascular Disease, Alzheimer's Disease, Heart Failure, and Old Myocardial Infarction. R2's pulse record dated [DATE]-[DATE] documents R2's pulse ranged 60s-80s beats per minute until [DATE] at 5:56 PM when R2's pulse was 106. There are no blood pressures or pulse recorded after this date in R6's medical record. There are no documented assessments, monitoring or notification to R2's Family (V22), V38 Physician or V20 Nurse Practitioner after R2's pulse increased. R2's Nursing Note dated [DATE] at 7:17 AM documents R2 was transferred to the local emergency room for evaluation and treatment per V22's request due to lack of response to stimuli, cold extremities and gurgling. V20 was notified. R2's Emergency Medical Technician report dated [DATE] at 7:21 AM documents upon arrival R2 was unresponsive, flaccid, and cold with mottled extremities, with signs of respiratory distress with rales noted upon lung assessment. Initially unable to obtain blood pressure reading to touch. At 7:36 AM R2's blood pressure was 57/35, pulse was 114 per minute, respirations 10 per minute and oxygen saturation was 51% on room air. R2's Hospital Records dated [DATE] documents R2 died at 9:30 AM. On [DATE] at 1:43 PM V21 Registered Nurse (RN) stated V21 was R2's nurse on dayshift on [DATE] and didn't recall any changes in R2's condition that V21 observed or was reported to V21. V21 did not recall any information regarding R2's 106 pulse on [DATE]. V21 stated V21 would have documented any changes in R2's condition and R2 tapped while the electronic machine obtained R2's pulse and blood pressure, which could have affected the pulse results. V21 stated if she had rechecked R2's pulse manually or did any follow up it would be documented in a nursing note. V21 did not recall reporting any changes in R2 and would have documented this. On [DATE] at 2:39 PM V19 Licensed Practical Nurse stated a CNA came to get V19 after end of shift report, R2 was gurgling and was unresponsive, and nothing had been passed on in the prior shift's report. On [DATE] at 3:18 PM V19 stated a CNA came to get V19 to assess R2 that morning and V19 tried to get oxygen saturation but did not bother with any other vital signs. V19 notified R2's family who wanted R2 sent to the hospital and emergency services was contacted right away. On [DATE] at 12:30 PM V2 Director of Nursing stated physician and family notification is documented in a nursing note. V2 stated for abnormal blood pressure or pulse, the nurse should recheck these vitals manually and look for any symptoms and report to the provider and family. V2 stated if it is a major change for that resident then the nurse should use nursing judgement and send that resident to the hospital right away. On [DATE] at 9:35 AM V34 CNA stated around 5:00 PM-6:00 PM on [DATE], R2 was not acting herself, not verbally responsive, R2's legs were purple up to her knees and cold to touch, and R2 had not swallowed R2's medications that were given earlier. V34 stated V34 reported these things to V21 RN who checked R2's vital signs. V34 stated V34 told the night shift staff to watch R2 closely that night and the next day R2 died at the hospital. On [DATE] at 12:53 PM V20 Nurse Practitioner stated staff should have reassessed and reported R2's pulse of 106. V20 stated the CNAs should report changes to the nurse and then the nurse should have assessed R2 and rechecked vital signs. V20 stated if V20 was notified of these changes, V20 would have deferred to notifying R2's family to determine if they wanted R2 hospitalized , due to R2's age with advanced dementia and Do Not Resuscitate order. V20 stated if V20 was notified V20 would have assessed R2 and checked R2's lungs. 3.) R1's MDS dated [DATE] documents R1 admitted to the facility on [DATE] and had moderate cognitive impairment. R1's Care Plan documents R1's diagnoses included Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Hypertension, and Type 2 Diabetes Mellitus. This care plan documents R1 receives a diuretic and includes interventions to monitor for side effects and effectiveness, and report pertinent laboratory findings, especially sodium and potassium levels, to the physician. R1's Physician's Order dated [DATE], entered by V20, documents CBC and CMP, send the order to the laboratory and place copy in V20's folder. There is no documentation that this order was implemented. R1's Progress Note dated [DATE], recorded by V38 Physician, documents new orders for Spironolactone (diuretic) 25 milligrams (mg) daily and to repeat Basic Metabolic Panel (BMP) in one week. There is no documentation that the order for BMP was entered into R1's medical record and completed. R1's Progress Note dated [DATE], recorded by V20, documents R1 had recent elevated [NAME] Blood Cell count 15.46 on [DATE], and R1 has cellulitis, continue with antibiotics until [DATE] and monitor for improvement.R1's February 2026 Medication Administration Record documents R1 refused 6:00 AM medications on [DATE], recorded by V21 RN. This is the first documented time that R1 refused medications and there is no documentation why R1 refused these medications or any follow up regarding this. R1's Nursing Note dated [DATE] at 11:42 AM documents R1 died at 9:00 AM in the facility. There is no documentation in R1's medical record that R1's family or provider were notified of refusing medications or R1's statements of wanting to die. On [DATE] at 1:43 PM V21 RN stated V21 did not recall much about R1 or when V21 last saw R1 on [DATE] and thought R1's 6:00 AM medications were given by the night nurse and did not recall why R1's medications were refused or any follow up regarding this. V21 stated communication with the providers are documented in a nursing note. V21 confirmed V21 was the nurse who confirmed R1's death on [DATE] at 9:00 AM. On [DATE] at 3:03 PM V31 CNA stated V31 cared for R1 on the evening of [DATE] and R1 had made comments R1 wanted to die, the nurses were aware of this but said it was just R1's anxiety. On [DATE] at 9:35 AM V34 CNA stated V34 started morning rounds on [DATE] and R1 is one of the last ones since R1 liked to sleep in. V34 stated V34 found R1 in bed at approximately 8:00-9:00 AM and got the nurse. On [DATE] at 9:30 AM V37 MDS Coordinator stated V38 gives all his orders to V2 Director of Nursing to enter when V38 rounds at the facility. At 10:34 AM V37 confirmed R1's BMP order from [DATE] was not entered into R1's medical record and there was no documentation that R1's laboratory orders were completed but V37 has contacted the laboratory. At 11:35 AM V37 confirmed R1 did not have laboratory results as scheduled/ordered for [DATE] and 2/10-[DATE]. On [DATE] at 12:53 PM V20 stated the nurses should report refusals of medications and document the reason for refusal, and staff should have reported R1's statements of wanting to die. V20 stated if V20 was notified, V20 would have met with R1 and R1's family to discuss this further. V20 stated V38 Physician saw R1 on [DATE] and ordered Spironolactone and to repeat BMP in one week, which would have been acceptable to draw on the morning of [DATE]. 4.) R11's Hospital discharge date d [DATE] documents R11 was treated for Acute Kidney Injury. R11's CMP dated [DATE] at 7:15 AM documents R11's Blood Urea Nitrogen (BUN) was 32 milligrams per deciliter (mg/dl normal range 5-25), Creatinine was 2 mg/dl (normal 0.5-1.4), Sodium was 135 millimoles per liter (mmol/l normal 135-148) Potassium was 4.5 mmol/l (normal 3.3-5.3) and Estimated Glomerular Filtration Rate (eGFR) was 24 milliliters per minute per 1.73 meters of body surface area (normal greater than 60). R11's [DATE] Medication Administration Record documents R11 received Spironolactone 25 mg daily, Bumex 1 mg twice daily, and Eliquis 5 mg twice daily starting on [DATE]. R11's Progress Note dated [DATE], recorded by V20, documents hyperkalemia (elevated potassium) likely due to Chronic Kidney Disease Stage 4 and dehydration, intravenous fluids given, and CMP ordered.R11's CBC and CMP dated [DATE] documents R11's WBC was 11.44, BUN was 35, Creatinine was 2.4, eGFR was 19 and Potassium was 4.9. R11's physician's order dated [DATE] documents start date [DATE] and stop date [DATE] for CBC and CMP, send order to the laboratory and place copy in V20's folder. There is no documentation that these orders were implemented. R11's Nursing Notes document R11 was evaluated and treated with antibiotics and pain medications beginning on [DATE] for broken teeth, bleeding gums, and infection. There is no documentation that this was reported to V29, R11's Guardian.On [DATE] at 11:13 AM V29 stated V29 saw R11 the day of the hospice referral but didn't realize R11 had declined that bad until that day. V29 stated V29 was not aware that R11 had dental problems or needed to see a dentist prior to that day since no one had reported this to V29. On [DATE] at 12:53 PM V20 stated R11 had been treated for cellulitis and lymphedema and was hospitalized the end of December and treated for dehydration and Acute Kidney Injury. V20 stated Bumex, Spironolactone and Eliquis can decrease blood pressure and increase work on the kidneys causing elevated BUN and Creatinine and decreased eGFR. V20 stated these levels were improving after intravenous fluids on [DATE] and CBC/CMP were ordered to track WBC, potassium, and kidney function. V20 confirmed CBC and CMP order entered [DATE] but results were never obtained.

Based on interview and record review the facility failed to accurately transcribe and follow physician's orders which resulted in multiple significant medication errors for two of six residents (R11, R4) reviewed for change in condition in the sample list of 21.Findings include:The facility's Medication, Treatment, and Other Order policy dated January 2019 documents orders should be entered in the orders section of the resident's electronic health record (EHR) by the licensed personnel receiving the order and changes in dosage or frequency will require a new order to be entered into the resident's EHR. The facility's Medication Administration Policy dated March 2014 documents medications will be administered according to the practitioner's orders, medications will be recorded on the Medication Administration Record (MAR), and the MAR will be verified against physician's orders. 1.) R11's Hospital discharge date d 12/26/25 documents R11 was treated for Acute Kidney Injury and to stop taking Bumex (diuretic) 1 milligrams (mg), Spironolactone (diuretic) 25 mg, and Eliquis 5 mg. These orders document to start taking Eliquis 2.5 mg twice daily. These orders were not transcribed into R11's EHR upon readmission to the facility on [DATE]. R11's Complete Metabolic Panel dated 12/26/25 at 7:15 AM documents R11's Blood Urea Nitrogen (BUN) was 32 milligrams per deciliter (mg/dl normal range 5-25), Creatinine was 2 mg/dl (normal 0.5-1.4), Sodium was 135 millimoles per liter (mmol/l normal 135-148) Potassium was 4.5 mmol/l (normal 3.3-5.3) and Estimated Glomerular Filtration Rate (eGFR) was 24 milliliters per minute per 1.73 meters of body surface area (normal greater than 60). R11's December 2025 and January 2026 MARs document: R11 received Spironolactone 25 mg daily, Bumex 1 mg twice daily, and Eliquis 5 mg twice daily starting on 12/27/25. On 1/1/26 Spironolactone was reduced to 12.5 mg daily. Eliquis was reduced to 2.5 mg BID on 1/14/26. R11's CMP dated 12/29/26 documents BUN was 35, Creatinine was 1.9, eGFR was 22, and Potassium was 5.3. R11's CMP dated 1/3/26 documents R11's BUN was 35, Creatinine was 2.4, eGFR was 19 and Potassium was 4.9. R11's Progress Note dated 12/31/25, recorded by V20 Nurse Practitioner, documents hyperkalemia (elevated potassium) likely due to Chronic Kidney Disease Stage 4 and dehydration, intravenous fluids were given. R11's Progress Note dated 1/13/26, recorded by V38 Physician, documents R11 had recent hospitalization and was treated for acute kidney injury secondary to acute tubular necrosis with slow renal function improvement noted. This note documents R11 was taking Eliquis 5 mg twice daily and to decrease to 2.5 mg twice daily due to renal insufficiency and serum creatinine levels. On 3/18/26 at 12:53 PM V20 stated R11 was hospitalized in December and treated for dehydration and Acute Kidney Injury. V20 stated the facility should follow hospital discharge orders and V20 did not realize that R11's Bumex, Spironolactone and Eliquis orders had changed. V20 reviewed R11's hospital discharge orders and MAR and verified the orders were not transcribed correctly. V20 stated this is a nursing medication error. V20 stated these medications can cause decreased blood pressure and increased work on the kidneys, causing elevated BUN, Creatinine and decreased eGFR. V20 stated based on R11's laboratory results from 12/29/25, R11 was treated with intravenous fluids. V20 reviewed and compared R11's laboratory results from December 2025 and January 2026, and stated R11's BUN, Creatinine and Potassium increased slightly but overall had improved. 2.) R4's Hospital discharge date d 1/23/26 documents to take Keflex (antibiotic) 500 mg by mouth four times daily for four days. R4's January 2026 MAR documents this order was transcribed and administered as only twice daily for two days. R4's Hospital discharge date d 2/15/26 documents to continue taking Losartan 12.5 mg daily. This was never entered as an active order in R4's EHR after returning to the facility on 2/15/26. R4's February and March 2026 MARs document to administer Midodrine Hydrochloride Oral Tablet 5 mg by mouth three times daily related to hypotension and hold if systolic blood pressure is greater than 120. R4 received four doses in February and ten doses in March when R4's documented systolic blood pressure was greater than 120. On 3/18/26 at 12:53 PM V20 stated Midodrine should be held if systolic blood pressure is greater than 120, if not this could increase blood pressure.On 3/18/26 at 2:39 PM V2 Director of Nursing stated the nurses are responsible for reviewing, verifying and transcribing admission orders. V2 confirmed a check mark on the MAR indicates the medication was administered. On 3/19/26 at 1:05 PM V20 stated V20 confirmed there were no ordered changes for R4's Keflex and Losartan orders. V20 stated these were also medication errors.

Based on interview and record review the facility failed to report an allegation of verbal abuse to the state survey agency for one of 13 residents (R6) reviewed for staff behavior in the sample list of 21. Findings include:The facility's Abuse Prevention Program dated October 2022 documents visitors are encouraged to report suspected concerns of abuse immediately to the administrator or to an immediate supervisor who immediately reports to the administrator. This policy documents the facility will report allegations of abuse to the Illinois Department of Public Health (IDPH). On 3/16/26 at 11:31 AM R6 stated about a week or so ago a Certified Nursing Assistant (identified as V41 CNA) assisted R6 onto the bedpan during the night. R6 stated R6 told V41 that R6 couldn't decide if R6 was too hot or too cold and V41 told R6 that R6 better make up R6's mind because V41 was not going to keep coming into R6's room every five minutes as V41 is only required to come in every two hours. R6 stated R6 felt like this was scolding in nature and belittling, R6 is an adult and not a child. R6 stated this was a dignity issue but also abuse and R6 did not like being treated like that at all. R6 stated R6 thought R6 reported this to V42 Corporate Marketer last Thursday.R6's Minimum Data Set, dated [DATE] documents R6 as cognitively intact. After reviewing the facility's abuse log on 3/17/26, there were no documented allegations involving R6. R6's abuse allegation was reported to V2 Director of Nursing on 3/17/26 at 12:10 PM. On 3/17/26 at 12:20 PM V2 was asked about any follow up regarding R6's abuse allegation. V2 stated V42 spoke with R6 yesterday and R6 reported that she did not recall the alleged incident and V2 did not report R6's allegation to IDPH (state survey agency) since abuse wasn't suspected. V2 stated V2 reported R6's allegation to V9 Corporate Administrator yesterday.

Based on observation, interview, and record review the facility failed to appropriately label an insulin vial, insulin pens, and eye and ear drops with the date opened and failed to discard an insulin pen and ear drops for four (R11, R36, R69, R85) of seven residents reviewed for medication administration on a sample list of 41. Findings Include:On 1/13/2026 at 10:00 AM, the facility's Main Skilled Medication Cart located on the 200 Hall was inspected in the presence of V6 Licensed Practical Nurse (LPN). During the inspection, R11's Basaglar pen and Adelong pen were found without any documented date of opening. Additionally, R36's Novolog Flex Pen was labeled with an open date of November 26, 2025. Further review revealed that R69's Ofloxacin and R85's Latanoprost also lacked documented dates of opening.Review of R11's Medication Administration Record (MAR) dated January 2026 confirmed that R11 has an active physician's order and is currently receiving both Basaglar and Adelong.Review of R36's MAR dated January 2026 documents that R36 has an active physician's order and is currently receiving Novolog.Review of R69's MAR dated January 2026 documents that R69 had a physician's order for Ofloxacin with a completion date of 1/1/2026.Review of R85's MAR dated January 2026 documents that R85 had an active physician's order and is currently receiving Latanoprost. On January 13, 2026, at 10:26 AM, V6, Licensed Practical Nurse (LPN), stated R11's Basaglar and Adelong pens, as well as R85's Latanoprost, should have been properly labeled with open dates. V6 LPN further agreed that R36's Novolog Flex Pen, which had an open date of 11/26/2025, and R69's Ofloxacin, which lacked an open date, should have been discarded.On 1/13/26 at 12:15 PM, V2, Director of Nursing (DON), stated that eye drops, and ear drops should be labeled with the date opened and discarded 28 days after opening, and insulin vials and pens should also be labeled with the date opened and discarded within 28-30 days of opening.The facility's Medication Labels Policy dated 10/27/2014 documents that medications must be labeled in accordance with facility requirements and applicable state and federal laws. The policy specifies that only the dispensing pharmacy or a registered pharmacist may modify, change, or attach prescription labels. Additionally, the policy requires that every medication be labeled with a beyond use (expiration) date on the package.

Based on observation, interview, and record review the facility failed to implement proper hand hygiene during medication administration for three residents (R40, R43, R63) of seven reviewed for medication administration on a sample list of 41. Findings include: On 01/12/2026 at 8:57 AM, V5 Registered Nurse (RN) prepared R43's oral medications and inhaler, entered the R43's room, handed R43 the cup of medications and placed a cup of water on the bedside table. V5 RN then provided R43 with his inhaler, followed by a cup of water for swish and spit. After use, R43 returned the cup and inhaler to V5 RN. At no point before, during, or after medication administration did V5 RN perform hand hygiene.On 01/12/2026 at 9:10 AM, V5 RN prepared R40's oral medications, entered R43's room, handed R40 the cup of medications and placed a cup of water on the bedside table. Before leaving the room V5 RN disposed of R40's used cups. At no point before or after medication administration did V5 RN perform hand hygiene.On 01/12/2026 at 9:25 AM, V5 RN prepared R63's oral medications, entered the resident's room, handed R63 the cup of medications, and placed a cup of water on the bedside table. R63 requested more water; V5 RN took his Styrofoam cup, stated she would refill it after R63 took all of his medications. V5 RN then provided additional small cups of water as R63 continued taking medications. Afterward, V5 RN filled R63's cup with ice from the 100 Hall ice chest. At no point before, during, or after medication administration did V5 RN perform hand hygiene.On 01/13/2026 at 10:32 AM, V5, RN, stated she was unsure of the facility's expectations regarding hand hygiene during medication administration but agreed it should be performed between each resident.On 01/13/2026 at 2:20 PM, V2, Director of Nursing, stated her expectation for nursing staff is that hand hygiene must be performed prior to preparing medications, after administering medications, and whenever hands are visibly soiled.The facility's Handwashing/Hand Hygiene Policy dated November 2013 documents that it is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. The facility's Medication Administration policy dated November 3, 2014, documents that the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and medications given via enteral tubes. Hand sanitization is done with an approved sanitizer between handwashing's, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface). Sanitizations can be done at regular intervals during the medication pass such as after each room, again assuming handwashing is not indicated. Sanitization is not a substitute for proper handwashing and washing should be done if there is any question.

Based on observation, interview, and record review the facility failed to ensure one resident (R4) was free of a restraint which limited her ability to move about freely of one resident reviewed for restraints in a sample list of 41.Findings Include:R4's Care Plan dated 9/8/25 lists then following diagnoses: Osteomyelitis, Pressure Ulcer of the Sacrum, Neoplasm of the Spinal Cord, Type II Diabetes, Polyneuropathy, Unsteady on Feet, and Neurofibromatosis. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact.On 1/11/26 R4 was seated in a (Geriatric) Chair in her room. This chair does not allow R4 to self-propel herself. R4's personal wheelchair was sitting on the other side of her room. R4 stated I want to sit in my chair R4 gestured to the wheelchair across the room with her name on it. I can't even move around in my room in this chair. I HATE it. I can't get my hairbrush, or my soda from my fridge or anything. It also makes my back and sores hurt. (R4 currently has two Stage IV Pressure Ulcers) They tell me it's because I try to move from the bed to my chair and I have had falls. I feel restricted.On 1/13/26 at 2:00PM V2 Director of Nursing (DON) stated The (Geriatric) Chair is for (R4's) safety and positioning. We have not done a restraint assessment since we don't feel it is a restraint. Occupational Therapy is working with (R4) to acquire a custom-made wheelchair for (R4) which will allow (R4) to self-propel in her room. V2 verified the (Geriatric) Chair does not allow (R4) to self-propel. V2 also verified the use of the (Geriatric) Chair was not addressed in R4's Care Plan.The facility's Physical Restraint Policy dated February 2014 states Purpose: To achieve a restraint free environment to improve or maintain quality of life and process implemented to pursue this goal. Restraints shall not be used for the purpose of punishment or for staff convenience. Periodic assessment shall assess the resident's status in an effort to reduce or eliminate restraints whenever possible and assure the least restrictive method is used which allows the resident to function at their highest practicable level. Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove and that restricts freedom of movement or normal access to one's body.

Based on observation, interview and record review the facility failed to ensure a resident receive proper treatment and assistive devices to maintain vision for one resident of one resident (R53) reviewed for vision and hearing out of a sample list of 41.Findings include:R53's care plan, dated 12/16/2025, documents an admission date as 08/22/2024 with the following diagnoses: Essential Hypertension, Hyperlipidemia, Fibromyalgia, Lumbago with Sciatica, left side and Diaphragmatic Hernia without Obstruction.R53's Care Plan, dated 12/16/2025, documents R53 wears reading glasses to assist with vision related to macular degeneration with an intervention documenting: Ensure that adaptive equipment that R53 needs is provided and is present and functional, eyeglasses.On 1/11/2026 at 9:30 AM R53 stated she has needed glasses, and her glasses have been broken for a long time.On 1/12/2025 at 1:25 PM V6 LPN (Licensed Practical Nurse) stated R53 does not currently have eyeglasses for use.On 1/12/2025 at 1:32 PM V7 CNA (Certified Nursing Aide) stated R53 does not have corrective eyeglasses for use and has not had eyeglasses that she was aware of.On 1/12/2026 at 2:29 PM R53 stated she doesn't have a good pair of glasses to use because her old pair has had a broken frame. No eyeglasses were observed on or with R53 during resident interview.On 1/13/2026 at 12:15 PM V7 CNA stated R53 continues daily activities without eyeglasses.On 1/13/2026 at 12:33 PM V3, Social Services Director, stated she does not schedule eye appointments for R53. V3 stated R53's Daughter is to schedule appointments for R53 regarding eye appointments.

Based on observation, interview, and record review the facility failed to ensure resident rooms and equipment were clean and in good repair for two of three residents (R8 and R25) reviewed for homelike environment in the sample list of 41. Findings include:1) R25's minimum data set (MDS) dated [DATE] documents R25 is cognitively intact.On [DATE] at 8:45 AM, R25 stated she is embarrassed by how her room looks, stating, is this what I'm supposed to live with? The wall behind R25 was noted have cracked, fading paint and large nails placed in various spots. R25 stated she hangs pictures and a tee shirt to distract visitors from the condition of the walls. R25 stated she has expressed to staff about how bad her room looks. R25 stated she was ashamed when the doctor came in for a visit. R25 stated she spoke with her roommate stating, have we died, and this is where we ended up. R25 stated she is worried about her ceiling tiles being asbestos since they are so old.On [DATE] at 12:05 PM, R25's room and bathroom were observed with V2 Director of Nursing (DON). There were visible cracked areas on the walls with peeling of paint. There was visible dark debris in the light covers of the ceiling and the lighting in the room was very dim. Dark and rust color debris was present on the back of the toilet riser in the crease behind the toilet seat and in the ridge along the back of the seat. There was a string-like substance hanging from the ceiling corners in the bathroom of R25's room. On [DATE] at 12:05 PM, V16 Plant Operations Manager stated she is going to work on the painting of the walls in the building when they hire another driver for transportation. V16 stated V16 has had to fill in for transportation of the residents to appointments since there isn't a regular transportation driver. V16 reported she used to work maintenance, and she paints the rooms herself. V16 stated she has been too busy with transportation and hasn't had a chance to check if the other areas are being cleaned by housekeeping staff since she is also the supervisor of housekeeping. V16 confirmed there is no dated plan of action to do inside repairs at this time.On [DATE] at 9:00 AM, V2 DON stated repairs on the roof were started last spring and they are waiting to do inside repairs until after they get the roof completed. On [DATE] at 9:25 AM, V1 Administrator stated repairs are in process. V1 confirmed the roof is being done in sections and the inside will be done afterwards. The undated Maintenance Policy of the facility documents to ensure a safe, accessible, effective, and efficient environment of care that is consistent with its mission, services, law, and regulations. To ensure that the building (interior and exterior), grounds, and equipment are maintained in a safe operable manner.2) R8's minimum data set (MDS) dated [DATE] documents R8 is cognitively intact.On [DATE] at 10:41 AM V16 Plant Operations Manager stated that on [DATE] she received a call from the facility to go back to the dialysis unit, pick up R8's wheelchair, and take it to the carwash to clean it. V16 stated after arriving, she witnessed an approximately six inch around area of a hard, dark substance on the backrest of R8's wheelchair that she believed to be feces. V16 stated she took the chair to the carwash, as directed by V2, and cleaned the wheelchair before returning it to the dialysis center. On [DATE] at 1:00 PM R8 stated she remembered the incident, R8 stated she had been sick with vomiting and diarrhea the prior weekend and the dialysis staff brought the hardened substance on the backrest of her wheelchair to her attention.On [DATE] at 11:00 AM V14 Dialysis Staff, stated that when R8 stood up to be weighed, she noticed a dried substance that appeared to be feces on the back rest of the wheelchair, but the substance was not on R8's person. V14 reported an odor that smelled like feces. V14 stated she then called the facility to report it.On [DATE] at 1:30 PM V2 DON stated V2 was called by the dialysis unit staff member telling her there was feces on the backrest of R8's wheelchair. V2 stated she called V16 and instructed her to go get the wheelchair, take it to the car wash, and clean it before returning it back to the dialysis center. The Equipment policy dated [DATE], documents wheelchairs are maintained by the facility for general use of all residents.

Based on observation, interview and record review the facility failed to prevent cross contamination during wound care of one (R2) residents Right Ankle Arterial wounds out of three residents reviewed for wound care in a sample list of eight residents. Findings include:R2's MDS dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires moderate assistance with transfers and supervision with walking up to 50 feet. R2's Care Plan intervention dated 8/21/25 instructs staff to provide treatment to areas as ordered. R2's Physician Order Sheet (POS) dated December 2025 documents a physician order starting 11/26/25 to Clean R2's Right Ankle Arterial wound with wound cleanser, apply barrier ointment to the surrounding wound, apply Vaseline soaked gauze to the open wounds and cover with absorbent pad and gauze wrap daily and as needed. The facility daily staffing sheets show contract nurses were scheduled as R2's nurses from 10/16/25-10/20/25. R2's Hospital Record dated 10/20/25 documents R2 does have localized Right Lower Extremity wrap and when unwrapped the hospital staff noted Erythema and Cellulitic appearance to lower leg. This same record documents there was localized maggots on wound when unwrapped with the appearance that it had not been changed in some time as the gauze was adhered to the skin and difficult to remove with sterile water. Adult Protective [NAME] (APS) was contacted due to maggots found on lower extremity cellulitic wound. On 12/9/25 at 12:25 PM V5 Registered Nurse (RN) stated R2 was seen in the emergency room initially for a resident to resident altercation that occurred at the facility. V5 stated upon completing a skin check on R2 V5 and V6 Nurse Practitioner (NP) found that R2 had an open wound on his ankle. V5 stated there was a dressing on R2's ankle that was very dry and hard to remove due it stuck to R2's skin. V5 stated R2's dressing was not labeled/dated. V5 stated when V5 removed R1's dressing there were multiple maggots crawling on R2's wound and inside of the dressing. V5 RN stated R2's open ankle wound had a large amount of slough and was very red with minimal drainage. V5 RN stated R2 was started on an antibiotic for his ankle wound prior to R2 being sent to a psychiatric facility to address his behaviors. On 12/11/25 at 11:30 AM V10 Licensed Practical Nurse (LPN) completed wound care for R2's Right Lower Extremity Arterial wounds. R2 has three seperate open areas each the size of a baseball. R2's open Arterial wounds were all red with moderate drainage and red periwounds. V10 LPN used the same piece of gauze to cleanse all three of R2's Arterial wounds. V10 LPN wiped R2's Arterial wounds dry by rubbing the same piece of dry gauze over each wound, periwounds and around the dry skin around R2's entire Right Ankle/Foot. R2's prior dressing was not dated/initialed. On 12/11/25 at 12:20 PM V11 Registered Nurse (RN) and V10 Licensed Practical Nurse (LPN) both stated the nurses who work directly for the facility do the dressing changes for R2 as ordered but the contracted nurses do not do the treatments. V11 RN stated she works part time she will change R2's dressing as ordered, then be off work for three to four days and return to see her same dressing on R2's Ankle. V10 LPN stated R2 will allow her to complete his dressing change and also sees her own dressing on R2's ankle two to three days after she has been off and then returns to work. Both V10 LPN and V11 RN stated the facility is aware of this and they are told that V21 Wound LPN will return soon and be able to monitor dressing changes. V21 RN stated she does not want to get the facility 'in trouble' but believes the residents 'deserve better care' than what the contracted nurses are providing. V21 RN stated the contracted nurses should be held accountable for signing off treatments as being done when they are not doing them. On 12/17/25 at 11:00 AM V2 Director of Nurses (DON) stated R2 has an Arterial wound on his Right Ankle. V2 DON stated V21 Wound Nurse/LPN is on leave so V2 DON has been overseeing the wound program in V21's absence. V2 DON stated she does not observe the resident wounds/dressings. V2 DON stated the last time V2 DON visualized R2's Right Ankle wounds was two weeks prior to R2 being sent to the emergency room. V2 DON stated My nurses are adults and know to do the dressings. I shouldn't have to follow them around. V2 DON stated she reviews the Treatment Administration Record (TAR) to see that the wound treatments are signed off but does not have a system in place to ensure the dressings are being completed and/or the dressings are being dated or monitored. V2 DON stated there is no audit system in place for wound dressings. V2 DON stated the facility utilizes 'a lot' of contract nurses. V2 DON confirmed R2 was seen by V17 Wound NP on 10/26/25 and from 10/16/25-10/20/25 was assigned all contract nurses. V2 DON confirmed R2's treatment was signed off as being completed on 10/20/25 prior to R2 being sent to the emergency room where he had to have his dressing soaked off due to adherence to his skin. On 12/17/25 at 1:00 PM V1 Administrator stated the facility currently has a Performance Improvement Plan (PIP) for wound care due to problems were identified with treatments not being completed. V1 Administrator stated the contracted nurses are responsible for providing wound care to any resident they are assigned to. V1 Administrator stated any nurse who works in the facility should follow the Physician orders for every resident. V1 Administrator stated the facility will revisit the monitoring of the wound program to ensure all residents are being provided wound care ordered by the physician. On 12/17/25 at 6:00 PM V17 Wound Nurse Practitioner (NP) stated she provides weekly assessments of R2's Right Ankle Arterial wounds at the facility. V17 NP stated the facility staff removes the dressings and has the resident sitting in his recliner with his Right Foot elevated prior to V17 assessing R2's wounds. V17 stated she does not see the previous dressing, but only sees the wound itself. V17 stated after completing R2's wound assessment she then travels to the next resident without seeing what dressing is applied. V17 stated she does not know if the correct dressing is being utilized, does not know if the dressing is dated or if the facility is applying the treatment as ordered and/or monitoring R2's wounds. V17 NP stated she has not seen any maggots in R2's wound and would document any such observation in her progress notes. V17 NP stated she had no concerns of any type of pests contaminating R2's wounds. V17 NP stated she does not believe the facility caused harm to R2. V17 NP stated she has not seen anything directly that would make her the facility was not following the physician orders.

Based on observation, interview and record review the facility failed to ensure the right to be free from verbal abuse of one (R1) resident from another resident (R2) out of four residents reviewed for abuse in a sample list of eight residents. Findings include:R1's Electronic Medical Record (EMR) documents medical diagnoses as Legal Blindness, Lack of Coordination, Disorders of Muscles, Dementia and Anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 requires maximum assistance with bed mobility and is dependent on staff for bathing, toileting, dressing, personal hygiene and transfers. R2's MDS dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires moderate assistance with transfers and supervision with walking up to 50 feet. R2's Psychiatric Evaluation dated 10/21/25 documents R2 was admitted to a psychiatric hospital after threatening to kill his roommate (R1). This same report documents R2 stated he would act on his verbal threats to kill someone if they made him made enough because he had been trained in the military on how to kill someone. R1 and R2's Final Report to the State Agency dated 10/24/25 documents R2 was making verbally aggressive and threatening comments to his roommate R1 on 10/20/25. This same report documents R2 told staff if staff did not 'shut him up' (R1), then R2 would 'kill the son of a b****'. This same report documents R2 continued to threaten and scream at staff as they were separating R2 from R1. This same report documents V26 CNA witnessed R2 threatening R1 directly as V26 was separating R2 from R1. On 12/9/25 at 2:40 PM R2 was walking independently in his room, came to the hallway and returned into his room. On 12/17/25 at 2:00 PM R1 was laying in a reclined wheelchair yelling out 'help me' repeatedly. V25 CNA walked over to R1 to assist R1. R1 stated he did not need anything and continued to yell out 'help me'. V25 CNA stated R1 continually yells out with no purpose or need. V25 CNA stated R1 does not yell at any one person but just 'yells out all the time'. On 12/10/25 at 10:30 AM V2 Director of Nursing (DON) stated R2 is known to have verbal outbursts towards other residents and can be verbally and physically aggressive towards staff. V2 DON stated V2 and V9 SSD both witnessed an incident last week where R2 lifted his cane in an attempt to hit V2 and V9 with it. V2 DON stated R2 was went to the emergency room for Homicidal Ideations where he was then sent to a psychiatric facility. V2 DON stated R2 has not had any further behaviors since his medication changes and return to the facility on [DATE]. The facility policy titled Abuse Prevention Program dated October 2022 documents Abuse means 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 with resulting physical harm, pain or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again.

Based on observation, interview, and record review the facility failed to prevent resident elopement by failing to ensure an exit door was alarmed/monitored to prevent residents from exiting unnoticed and failed to develop and implement a care plan for a resident at risk for elopement for one of three residents (R1) reviewed for elopement on a sample list of five. These failures resulted in R1, a cognitively impaired resident at risk for falls, leaving the facility unsupervised in a wheelchair in the dark. R1 was found three tenths of a mile from the facility in the middle of a country road near railroad tracks by a local citizen who alerted facility staff of R1's location. Findings include:The immediate jeopardy began on 9/05/25 at approximately 9:00 p.m. when R1 left the facility in a wheelchair unnoticed, after staff disable the door alarm, and traveled unsupervised down a country road approximately three tenths of a mile away from the facility. V1, Administrator was notified of the Immediate Jeopardy on 9/25/25 at 3:20PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 9/25/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's admission Record dated 9/23/25 documents R1 admitted to facility 8/28/2019. The admission Record documents R1's medical diagnoses include Congestive Heart Failure with presence of Cardiac Pacemaker, Age-Related Cognitive Decline, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Abnormalities of Gait and Mobility, Lack of Coordination, Parkinson's Disease Without Dyskinesia, Need for Assistance with Personal Care, Unsteadiness on Feet, and Insomnia.R1's Minimum Data Set (MDS) Section C dated 8/15/25 documents R1 has moderate cognitive impairment.R1's Elopement Risk assessment dated [DATE] identifies R1 at risk for elopement.R1's undated Care Plan documents R1 has confusion and a cognitive communication deficit, R1 is high risk for falls, has a history of falls with major injury, and staff have observed R1 turning off safety alarms. The Care Plan documents R1 has psychosocial well-being issues with reported feelings of isolation, has diagnoses of Major Depressive disorder and Insomnia, is at moderate risk for abuse related to dependence on others, displays inappropriate behaviors, has impaired cognitive function, and has suicidal ideations. R1's undated Care Plan documents Elopement risk was added on 9/6/25 by V4 Social Services Director (SSD) with a goal of R1 will not leave the facility without being escorted by family or staff. The Nurse Practitioner Visit Note dated 8/20/25 documents R1 is a high fall risk, impulsive, needs safety reminders and lists diagnoses of confusional arousals and Altered Mental Status (AMS).R1's Nursing Progress Notes dated 8/26/25 document R1 was found unresponsive with decreased respirations.R1's Physician Visit Note dated 8/27/25 documents R1 had a transient unresponsive episode with bradypnea (abnormally slow breathing) and pallor, which resolved spontaneously. The Note documents to continue to monitor neurological and cardiopulmonary status closely, including level of consciousness, respiratory rate, and skin color, and maintain fall and safety precautions, especially during toileting and transfers.The Psychiatric Nurse Practitioner Visit Notes dated 8/29/25, document R1 reports feeling more depressed for one week. The Notes document staff suspect it could be due to family and staff talking to him about his behaviors. His appetite and sleep are so-so. Reports ongoing suicidal ideations. When asked if he had a plan, he stated That's my business, not yours. When educated on notifying staff of any worsening thoughts or development of plan, he stated I told you it's my business. If l want to do it, I'll figure it out somehow. The Notes document R1 denies homicidal ideations or audio-visual hallucinations and staff are aware of his statements and will continue to monitor closely.R1's Psychiatry Visit Notes dated 9/15/25 document staff reported R1 has new behavior of exit seeking with multiple attempts over previous week and R1 confirmed to practitioner that he would continue to exit seek as he does not want to be at facility.On 9/23/25 at 11:41 AM, V6, R1's friend, stated that on Friday night of 9/5/25, he received a phone call from the facility stating they believed R1 had gotten out of the facility and someone in the community had called reporting they had seen him. V6 could not recall the exact time of the call but stated it was dark outside and he was already in bed. V6 stated that approximately an hour after he received the first call, R1 called from facility stating he was back. V6 stated that R1 stated to V6, R1 had to go home to feed the dog, and he didn't want to be in the facility anymore. V6 stated R1's residence prior to living at the facility was an apartment approximately 45 miles north that was right behind the railroad tracks. V6 stated R1 has stated to V6 previously that he would just follow the tracks home. V6 stated R1 knew the exit code because it had been posted on the door for years. V6 stated staff (Unknown) told him where R1 had been found indicating R1 had to travel over uneven, bumpy, railroad tracks to get to the location R1 was found. V6 stated if R1 fell out of the wheelchair he would not have the strength to pull himself back in. On 9/23/25 at 1:15 PM near the area R1 was found there was an audible sound of a railroad train traveling down railroad tracks and a train was observed traveling through the crossing at moderate speed. No warning lights or barriers were present at the crossing. On 9/24/25 at 11:20 AM, R1 was at the front entrance of the facility demanding to be let out to go home. At 3:00 PM on 9/24/25, R1 stated he does not remember much about the night of 9/5/25. R1 stated he knew he wanted to go home to feed his dog [NAME] and stated it was very dark, and it was getting cold.On 9/25/25 at 12:10 PM, V12, Certified Nurse Aide (CNA), stated on Friday September 5th at 10:05 PM she received a call from V14, Registered Nurse (RN), to initiate a head count with suspicion of a missing resident. V12, CNA, stated V12 completed the head count on the skilled side and ran up to the front entryway where V15 CNA stated someone called to report that there was a person rolling around in the street in a wheelchair that may live here and that R1 was missing. V12 CNA stated at that time the two nurses on duty, V14 RN, and V16 RN, pulled up in parking lot. One was in a car, and the other was pushing R1 in his wheelchair. V12 CNA stated that one nurse pushed him back in the wheelchair, while the other used the car headlights to see due to no lights on the road, and it was very dark that night. When R1 was inside facility he stated to V12 CNA that he was going home to feed his dog, but it got cold outside. V12 stated R1 was wearing grey sweatpants, and a thin long sleeve zip up jacket. V12 stated R1 stated no one let him out, he just held the handle down for a few seconds and door opened but R1 was unable to recall when he left or how long he had been outside. V12 CNA stated R1 was found near railroad tracks approximately 0.3 miles from the facility and one tenth of a mile away from the highway. V12 CNA stated she began her shift at 6:00 PM that night and doesn't remember hearing any alarms that evening. V12 CNA stated staff should be able to hear the front door alarm. V12 CNA stated R1 has often made statements to her that he doesn't want to be here, and he wants to go home.On 9/24/25 at 11:05 AM V5, Maintenance Director stated all doors have alarms if opened and the alarm sounds in the area of open door as well as sends a notification to the alarm panel. V5 demonstrated doors/hallways that wander guards would trigger an alarm which included the front entrance (door #9). V5 stated the facility added a mag lock about 2 weeks ago which is essentially a video doorbell that can be opened remotely. V5 stated that he recoded the front door about a week ago.On 9/24/25 at 11:29 AM, V11 CNA stated that on 9/5/25 she was the only aide working on R1's hallway. R1 was very restless that evening so she got him up from bed and watched him roll toward the front hallway around 9:00 PM. V11 denied hearing any alarm but stated that another staff member (unknown) had turned the front door alarm off due to multiple visitors coming in that evening and not enough staff to monitor front area. V11 stated at approximately 9:40 PM, the nurse received a phone call from a local resident stating R1 was in her area. V11 stated no one had known R1 left the facility and without the call from the town resident, she is unclear when they would have noticed.The Timecard Report dated 9/5/25 documents between the hours of 9:00 PM and 10:00 PM there was one CNA and one nurse for 37 residents on R1's unit.On 9/24/25 at 11:53 AM V9 RN stated that on 9/5/25 she worked 2:00 PM to 6:00 PM until V14 RN arrived and took over. V9 stated R1 received medication from her at 5:30 PM in his room. V9 stated she noticed over the last week R1's behavior had changed notably. V9 stated R1 usually stayed to his room, but lately she noticed R1 sitting in the chapel near the front entrance staring outside. V9 stated when she returned on 9/7/25, the codes to the front door had been changed and the sign on the door with code had been removed.The Facility Investigation File dated 9/6/25 includes one written statement from V14 RN. V14's undated written statement documents that at 9:55PM she received a call from a local town resident stating she had observed someone in a wheelchair in the road near her home that she believed was a resident of the facility. A head count was initiated and R1 was found to be missing. R1 was last been seen heading toward the front hallway in a wheelchair around 9:00 pm. Upon R1's return, no injury was found, and a wander guard was placed on R1's right ankle. The statement documents notifications were made to V1 Administrator, V16 Supervisor, and V6 R1's Representative.At 3:15 PM on 9/24/25, V1 Administrator, stated that she did investigate the incident and that R1 previously had been assessed to go outside on R1's own and the night of 9/5/25, R1 was just checking things out so he did not elope.No assessment or physician order documented in R1's Medical Record documents R1 is able to leave the facility unattended.On 9/25/25 at 10:22AM V8, Nurse Practitioner, stated R1's Parkinson's Disease affects his cognition and safety awareness. V8 stated R1 has intermittent moments of clear speech and memory recall, however his baseline is confused and R1 has no safety awareness. V8, stated R1 is impulsive and has stated on many occasions that he wants to go home. V8 stated R1 has advanced cardiac disease and recently had an internal defibrillator replaced. V8 stated R1 had an unresponsive episode on 8/27/25 due to cardiac issues and has high potential for another. V8, stated R1 would sit outside facility at times but always had staff supervision and should not have ever been outside alone. V8, stated the potential for R1 to have been harmed or have succumbed to the elements during his elopement was highly likely. V8 stated V8 was not notified of the elopement.The facility document entitled Elopement and Search Policy dated 02/2014 documents all nursing personnel are responsible for knowing whereabouts of assigned residents, residents are not permitted to leave the building alone unless a physician order is present, and all personnel are responsible for promptly responding to the location of an alarm to determine the cause. The policy states if elopement occurs, the physician and resident representative are to be notified, and a report is to be sent to the Illinois Department of Public Health (IDPH).The Immediate Jeopardy that began on 9/5/25 was removed on 9/25/25 when the facility took the following actions to remove the immediacy:On 9/5/25, an alert band was placed on R1 to ensure his safety. On 9/6/25, a new elopement evaluation was completed for R1, and R1 was placed on 15-minute monitoring checks for 3 days to monitor exit-seeking behavior. On 9/7/25, V4 Social Service Director completed an audit of all wandering residents, and no issues were identified.Training for all staff was initiated on 9/25/2025 by V2 Director of Nursing and V5 Maintenance Director. Training included identifying exit-seeking behaviors, placing wander alert band immediately when identified at risk, physician orders, and where to locate the wander guard bands. The training also included the location of wander guard exit doors, and alarm panels, immediate response to a door alarm or wander guard alarm and completing safety checks indoors and outdoors to ensure that all residents are safe. The training included The Door Alarm and Missing Person and Elopement Policy and Procedures. The Missing Person and Elopement Policy and Procedures were reviewed 9/25/2025 by the Corporate Clinical Director. Care Plans were reviewed and revised as necessary by V4 Social Services Director to update interventions as appropriate on 9/25/2025.On 9/25/25, V5 Maintenance Director began audits of all exit doors with plans to conduct audits five days a week for six weeks, and then weekly to ensure proper function of all door alarms. On 9/25/25, V2 started audits of all residents at risk for wandering and will continue the audits on a weekly basis for six weeks to be sure Elopement Assessments and Care Plans are up to date with accurate information and interventions are in place. On 9/30/25 at 2:00 PM V2 stated V5 and V2 will bring the audits to the Quality Assurance meetings to be reviewed by the interdisciplinary team weekly, monthly, and quarterly. This was also confirmed with V1 and V5.The facility presented an abatement plan to remove the immediacy on 9/26/25 at 2:29 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned 9/26/25 at 3:51 PM. The facility presented a revised abatement plan to remove the immediacy on 9/26/25 at 4:51 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned 9/29/25 at 9:27 AM. The facility presented a revised abatement plan to remove the immediacy on 9/29/25 at 10:40AM. The survey team reviewed the abatement plan and was able to accept the plan to remove the immediacy. The abatement plan was approved on 9/29/25 at 11:01 AM.

Based on observation, interview, and record review the facility failed to provide adequate assistance and supervision during dining and failed to serve a hot beverage at a safe temperature. This failure resulted in R1 suffering a preventable, second degree burn to her bilateral upper legs. R1 is one of three residents reviewed for incident/accidents on the sample list of 17. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 05 (five), out of a possible 15, indicating R1 has severe cognitive impairment. R1's Same MDS documents: Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. R1 is Coded as follows: A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Eating is documented as 02. Substantial/maximal assistance - 'Helper does MORE THAN HALF' the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R1's incident investigation witness statements, submitted to the Illinois Department of Public Health reportable injury form documents: (V23) LPN (Licensed Practical Nurse), (dated) 11/5/2024 at 1050 am: Reporting staff member. Reported to DON (V2, Director of Nursing) that resident (R1) had taken another resident's (unidentified) hot chocolate and had spilled it onto her (R1) lap. Resident (R1) was taken to her room, disrobed, and a head-to-toe assessment was performed by the nurse. Noted some light pink areas to bilateral thighs. Nurse reports resident denied pain and showed no s/s (signs /symptoms) of distress. The same incident investigation documents the following: (V21, Certified Nursing Assistant) CNA, (dated) 11/5/2024 at 1200 pm: I was the one that made the hot chocolate. I put the three ice cubes in it- because of the burn last summer (unidentified resident) - and set it down. I had my back (R1 unassisted, unsupervised) to her (R1) but I heard it spill and (R1) made a surprised noise. I turned around and she (R1) had spilled it (hot chocolate) onto her lap. I pulled her dress away from her '[lap]' to limit contact of the hot chocolate on her skin. We (V21, and unidentified assistant) got her (R1) to her room and got her undressed. The nurse (V23) then came in and checked her out. (R1) didn't seem to be in any pain but just seemed upset that she got hot chocolate on her dress. R1's N Adv - Skin Issues dated 11/6/2024 at 3:54 pm documents the following: Skin Issues: Skin Issue: #001: New skin Issue. Location: Front right thigh. Additional location information: anterior Issue type: Burn. Superficial burn (downgraded to 'Full Thickness' burn. 11/13/24 report below). Wound acquired in-house. Exact date: 11/05/2024 Signs and symptoms of infection: None. Painful: No. Staged by: N/A. Length (cm): 19 Width (cm): 11 Depth (cm): 0 Undermining: No. Tunneling: No. Epithelial: 100%. Exudate amount: None. Odor after cleansing: None. Surrounding tissue: Normal in color. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Cleansing solution: Water. Other primary dressing: skin prep (protective wound treatment) Secondary dressing: No secondary dressing applied. Modalities: None. Other additional care: cups with lids & staff monitor at meal times. Skin Issues Note: Wound doctor (V14, Wound Nurse Practitioner) saw today. Treatment changed to skin prep daily. Skin issue education: Signs and symptoms of infection. Skin issue education: Treatment of skin issue. Skin issue education: Care of skin issue(s). Skin issue notification: Wound nurse. Skin issue notification: Provider. Skin issue notification: Family. Completed Clinical Suggestions. R1's Nurse Progress Note dated 11/07/24 at 1:10 pm documents the following: Note Text: NP (V14, Nurse Practitioner) in the building to see resident (R1) and assess areas to bilat (bilateral) inner thighs. New order received for Medihoney (medicated topical treatment) BID (twice a day) to bilat (bilateral) inner thighs for 10 days and monitor for s/s (signs/symptoms) of infection and pain and to report to NP (V14)/MD (unidentified physician) if noted. R1's Skin/Issue note completed 11/13/2024 at 6:02 pm documented by V12, Facility Wound Licensed Practical Nurse documents R1's Front right thigh. Issue type: Burn. Full thickness burn. Wound acquired in-house. Exact date:11/05/2024. The same Skin /Issue note documents R1's burn measure Length (cm):4 Width (cm): 4 Depth (cm): 0.1. R1's right thigh burn is documented as having Exudate amount: Light. Exudate type: Serous: clear watery fluid, which is separated from solid elements (blisters that opened). R1's same Skin/Issue report documents: Front left thigh. Issue type: Burn. Full thickness burn. Wound acquired in-house. Exact date:11/05/2024. R1's same Skin issue report note documents R1's left thigh burns has the following measurement: Length (cm): 5.5 Width (cm): 6 Depth (cm): Exudate type: Serous: clear watery fluid, which is separated from solid elements. R1's skin issue report note documents: Skin Issues Note: Saw wound doctor (was seen by V14, Wound Nurse Practitioner) today. Treatment for silver sulfadiazine 1% cream. On 11/27/24 at 1:37 pm V14, Wound Nurse Practitioner (consulting, wound care private company) stated V14 has seen R1 for her burns three times on 11/6, 11/13, and 11/20 and will be assessing R1's burns again today. V14 stated, The hot chocolate (R1) spilled on her thighs was obviously too hot to be served. Therefore, R1's burns could have been prevented. (R1) is cognitively impaired, requires assistance at meals. Staff are responsible to serve liquids at a safe temperature. V14 also stated On my first observation (11/6/24) of (R1's) burns were large, intact blisters (second degree). The blister area on her right thigh measured 9 centimeters (cm) long (L), by 9.5 cm wide (W). The blisters on her (R1's) left leg measures 19 cm L by 11 cm W. There was no depth measured because the blisters were intact. We were trying to keep the blisters intact as long as possible. I ordered skin prep. The blistered areas were difficult to maintain intact since she would be wearing clothes. When I came in on the thirteenth (11/13/24) the blisters had opened. I changed the treatment order to Silvadene to promote healing and decrease the discomfort. On the 20th (11/20/24) The Silvadene treatment was successful as evidenced by the decrease in measurement. On her (R1) left thigh 1.0 cm L by 3 cm W and Superficial depth.1 cm. (R1's) right thigh burn measured 2.5 cm L by 1.5 cm W, .1 cm D. I continued the Silvadene treatment. On 12/3/24 at 10:15 am V7, Dietary Manager stated, I was not here when (R1) spilled hot chocolate in her lap. I was on vacation. The first I heard of it was when that other surveyor was here last week. I tested the temperature of the water and coffee that day. The other surveyor was with me. The coffee and water temps (temperatures) were high, 166 degrees and 168 degrees (Fahrenheit) if I remember correctly. V7 then stated (R1) had grabbed (R6's) hot chocolate, as I understand it was the situation that day. V7 then went out to the resident main dining room. The main dining room was full of residents eating. V7 opened the spigot on the right side coffee dispenser and poured coffee into a cup. The coffee was steaming. V7 measured the coffee dispensed at 160 degrees Fahrenheit. Both surveyor and V7 took a drink of the coffee. This surveyor's mouth experienced an uncomfortable, hot tingling sensation. This surveyor had to pause before swallowing the coffee. V7 also sampled a cup of coffee from the right side coffee dispenser. V7 stated I like my coffee very hot, but this is very, very, hot. V7 also stated Hot beverages should be served, at most 120 - 130 degrees, though brewing temperature is 165. V7 then opened the spigot on the left side coffee dispenser and poured into a cup. V7 measured the coffee as 159 degrees Fahrenheit. V8, Certified Nursing Assistant (CNA) came over to the coffee/water dispenser and poured a cup water and placed a tea bag in a cup. V8 CNA stated she was preparing the tea for R11. V7 then measured the temperature of R11's tea . R11's tea measured which measure 160 degrees Fahrenheit. V8, CNA walked away with the R11's tea and served it steaming to R11 at a table adjacent to the coffee/water dispensers. V7 then stated Staff are supposed to add a couple of ice cubes when serving residents hot drinks. They should all know that. Surveyor asked R11 if her tea was too hot. R11 stated Yes, but I don't drink it until after I eat. It is always served real hot, but the tea steeps well when it is hot. On 12/3/24 at 11:12 am V43, Maintenance Director stated, We do not have a policy (for water temperatures). We do not have a mixing valve to turn the water supply temperature down on the coffee maker. I can tell you; we have to keep the resident bathroom and showers temperatures adjusted to 110 degrees (Fahrenheit) or less. That is straight from the state regulations, so a resident skin does not get burned. On 12/3/24 at 10:40 am V21, CNA stated that served the hot chocolate at R1's table the day R1 got burned. V21 also stated I am usually careful to put ice in the residents' hot drinks (beverages) because we had a resident (unidentified) last summer that got burnt on coffee. I am almost positive I put ice in that hot chocolate. I was surprised it was still hot enough to cause (R1's) legs to burn like that. It was though. I should have put more ice in it because it was still too hot, apparently. The facility's policy title Precautions for Handling Hot Beverages Guideline: Staff will monitor, serve and hold hot beverages in a safe manner to prevent potential burns. Procedure: It is recommended that the temperature of the equipment be set at the lowest possible temperature for adequate brewing; anticipated to be in the range of 160-170 degrees Fahrenheit. The serving temperature should be approximately 10 - 15 degrees less than the brewing temperature. 4. Additional precautions: a- Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. b- Ensuring staff monitor the identified high-risk resident during meal times and/or when hot beverages are served.

Based on observation, interview, and record review the facility failed to monitor weights and implement nutritional interventions for significant weight loss for four (R8, R52, R25, R44) of five residents reviewed for nutrition in the sample list of 46. These failures resulted in ongoing weight loss following a significant weight loss for R8, R52, R25, and R44. Findings include: The facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol dated August 2008 documents to assess for recent weight loss and the physician will review for possible causes of weight loss with the nursing staff and/or dietitian before ordering interventions. This policy documents the physician and/or designee will authorize appropriate interventions as indicated, reconsider dietary restrictions and altered diet consistency, and consider diagnostic testing. The facility's Routine Nutritional Documentation and assessment dated 2020 documents residents are assessed and monitored for nutrition in accordance with the Minimum Data Set (MDS) schedule, and residents who are considered with nutritional risk or concerns are referred to the Registered Dietitian for a comprehensive nutritional assessment. This policy documents the Dining Services Manager and Registered Dietitian will document quarterly progress notes for observations, progress of nutritional goals, and nutritional care information. 1.) R8's MDS dated [DATE] documents R8 is cognitively intact, R8's weight was 156 pounds (lb), and R8 had no significant weight loss within the last six months. The last documented nutritional assessment in R8's medical record is dated as 3/2/24 and there is no documentation that R8's significant weight loss in September was evaluated by a dietitian. R8's ongoing weight log documents R8's weight as follows: 4/4/24 150.4 lbs, 7/1/24 156.4 lbs, 8/2/24 156 lbs, 9/2/24 146 lbs (6.41% loss in one month), and 10/30/24 143 lbs (8.3% loss in three months). There were no documented weights in R8's medical record after 9/2/24 until 10/30/24. R8's Care Plan dated 5/26/23 documents R8 has a nutritional problem related to abnormal weight loss and interventions include to provide supplements as ordered, dietitian to evaluate and make dietary changes as needed. This care plan does not document any nutritional interventions were developed/implemented after 5/26/23 to address R8's significant weight loss. R8's active October 2024 physician's orders documents R8's diet as Regular/Mechanical Soft. There are no documented orders for nutritional supplements. R8's Wound Care Telemedicine Follow Up Evaluation dated 10/25/24 documents R8 has stage three pressure ulcers to the right buttock and left hip. On 10/27/24 at 10:23 AM R8 was in the dining room eating. R8's meal consisted of waffles, banana, and sausage, and did not include any nutritional supplements. On 10/29/24 at 12:34 PM V19 Registered Dietitian stated R8 was due for an annual nutritional evaluation in June 2024, but one was not done because the electronic software program did not trigger for one to be done with R8's annual MDS. V19 stated R8's last nutritional assessment was completed in March 2024. V19 stated no one had requested to evaluate R8's nutritional status and V19 was unaware that R8 had developed pressure ulcers. V19 stated residents with wounds should be evaluated by the dietitian monthly. If V19 had evaluated R8, V19 would have recommended Zinc, Vitamin C, a multivitamin, liquid protein. V19 stated V19 possibly would have recommended a nutritional supplement if R8 had lost weight, but R8 does not have a documented weight for October. On 10/29/24 at 2:00 PM V2 Director of Nursing stated weights are recorded under the weight section of the resident's electronic medical record. R8's weight was requested to be obtained at this time. On 10/30/24 at 11:02 AM V10 Restorative Nurse/Registered Nurse stated R8's weight today was 143 lbs. 37813 2.) R44's weight flow sheet documents on 05/12/2024, (R44) weighed 125.8 lbs. On 10/04/2024, R44 weighed 101.2 pounds which is a 19.55 % Loss. R44's Wound Care Telemedicine initial evaluation dated 10/18/24 by V7, Wound Physician documents R44 developed a facility acquired Stage III Pressure Ulcer of greater than 10 days duration on the coccyx. 10/29/24 12:39 PM V19 Registered Dietitian stated The facility does not reach out to me when a resident has a wound or a significant weight loss. Yes I should be notified of a significant weight loss and/or a wound and I should evaluate these residents. V19 verified V19 has not evaluated R44. 3.) R52's weight flow sheet documents on 09/03/2024, R52 weighed 131.2 lbs. on 10/15/2024, R52 weighed 123.6 pounds which is a 5.79 % loss. R52's Treatment Administration Record (TAR) for October 2024 documents a new treatment dated 10/26/24 for Clean area to left buttock with normal saline. Apply calcium alginate to wound bed & cover with gauze foam daily every day shift for wound care. On 10/29/24 at 10:00 AM V12 Licensed Practical Nurse (wound Nurse) stated (R52) developed a new facility acquired Stage II pressure ulcer on 10/25/24. We are treating it. 10/29/24 12:39 PM V19 Registered Dietitian stated The facility does not reach out to me when a resident has a wound or a significant weight loss. Yes I should be notified of a significant weight loss and/or a wound and I should evaluate these residents. V19 verified V19 has not evaluated R52. 50993 4.) R25's ongoing weight logs document R25's weight as 229.6 pounds on 08/01/24 and 216 pounds on 09/02/24, demonstrating a 5.92% weight loss in one month. This log documents R25's October 2024 weight as 215.4 pounds. R25's Nursing Progress Notes dated 9/1/24 - 9/30/24 does not document that V35 R25's Nurse Practitioner or V19 RD (Registered Dietician) were notified of R25's significant weight loss. R25's September and October 2024 Physician Order Sheets do not document any new orders for nutritional supplements following R25's significant weight loss. On 10/29/24 at 11:10 AM, V2 DON (Director of Nursing) stated V2 was unaware of R25's weight loss. V2 stated the expectation is that V19 RD (Registered Dietitian) would report the weight loss to nursing services with their recommendations. On 10/29/24 at 12:31 PM, V19 RD stated that the weight loss from 08/01/24 through 09/02/24 would be considered a significant weight loss. V19 explained the facility should have reached out to V19 so that V19 could have evaluated R25's weight loss and ordered nutritional supplements due to R25's weight loss but the facility does not do that.

Based on observation, interview, and record review the facility failed to complete weekly pressure ulcer assessments, implement treatment orders timely, administer treatments as ordered, maintain wound dressings, accurately complete skin and wound assessments, and implement interventions to prevent the development and worsening of pressure ulcers for four (R8, R32, R52, R44) of four residents reviewed for pressure ulcers in the sample list of 46. These failures resulted in R8 developing stage three pressure ulcer and R32 developing an unstageable pressure ulcer. Findings include: The facility's Measurement of Alterations in Skin Integrity policy dated January 2017 documents wound type, stage, measurements and characteristics should be assessed and documented upon identification and weekly thereafter, record refusal of treatment or pressure relieving interventions and the resident's care plan should also reflect this. The facility's Braden- Pressure Risk Assessment Tool policy dated January 2017 documents the Braden scale determines pressure ulcer risk and this assessment should be completed upon admission, then weekly for the first month, and then at least quarterly and with changes in condition. This policy documents appropriate individualized interventions should be implemented and documented on the resident's care plan. The facility's Pressure/Skin Breakdown- Clinical Protocol dated January 2017 documents to determine a resident's significant risk factors for developing pressure ulcers, such as immobility, recent weight loss, and a history of pressure ulcers; assess skin condition, pain, mobility, treatments, support surfaces, and diagnoses; and the physician will give orders for wound care including pressure redistribution surfaces. The facility's Prevention of Pressure Wounds policy dated January 2017 documents pressure injuries are usually due to sitting in the same position for an extended period of time causing increased pressure, decreased circulation, and subsequent tissue destruction; and can also be related to irritating substances on the skin such as urine and feces. This policy documents there should be a system or procedure in place to assure assessments are completed timely, changes in condition are identified, evaluated, reported to the physician, and addressed. This policy documents preventative measures include repositioning at least every two hours, determining if a special mattress is needed, use of pressure relieving cushions for chairs, avoiding donut shaped or waffle cushions, routinely assessing skin condition, using moisture barrier creams, using pillows to float heels when in bed, immediately reporting any signs of pressure injuries, administering vitamins and supplements per physician's orders, and having the dietitian assess nutrition and make recommendations. 1.) R8's Minimum Data Set (MDS) dated [DATE] documents R8 is cognitively intact, requires partial/moderate staff assistance for rolling in bed, requires substantial/maximal staff assistance for transfers, and is occasionally incontinent of urine. R8's Braden assessment dated [DATE] (after R8's pressure ulcers developed) document R8 is low risk. The last Braden Assessment recorded for R8 was on 10/13/23. R8's Care Plan dated 5/26/23 documents R8 is at risk for impaired skin integrity, and includes interventions to apply barrier cream three times daily as needed, Braden Assessments weekly for four weeks then quarterly, and to encourage good nutrition and hydration to promote healthier skin. There is no documentation that R8 refuses turning/repositioning. This care plan has not been updated to include R8's pressure ulcers or any new pressure relieving interventions after 5/26/23. R8's Physician Order dated 6/19/23 May use Pressure relieving mattress and/or cushion on w/c (wheelchair) if Needed. There is no documentation that R8 requires a pressure relieving cushion in R8's wheelchair. R8's ongoing weight log documents R8 had a significant weight loss between August 2024 and September 2024, and continued weight loss as of 10/30/24. R8's October 2024 Treatment Administration Record (TAR) documents an order dated 10/6/24 to cleanse right buttock wound with wound cleanser, apply collagen and bordered foam every shift for Stage Two pressure ulcer, and an order dated 10/10/24-10/28/24 to clean right buttock wound, apply Santyl, apply Calcium Alginate, and cover with a bordered foam dressing daily. This TAR documents to complete skin assessments on Mondays and Thursdays, and inaccurately documents R8's skin as intact and without wounds 10/7-10/14/24. This TAR documents to apply barrier cream to the left buttock three times daily as of 10/7/24, and there is no documentation that barrier cream was applied prior to 10/7/24. R8's Nursing Note dated 10/6/24 at 12:12 AM documents R8 had a new Stage Two Pressure Ulcer to the right buttock, the Wound Nurse (V12) was notified, the area was cleansed, Collagen was applied, and the wound was covered with a bordered foam dressing. There is no documentation of wound characteristics and measurements prior to evaluation by V7 Wound Physician on 10/7/24. R8's Wound Care Telemedicine Follow Up Evaluation dated 10/7/24, recorded by V7, documents R8 has a Group 1 mattress and a foam cushion in R8's chair. This note documents R8 has a right buttock Stage Three Pressure Wound of greater than three days duration that measured 1.5 centimeters (cm) long by 1.7 cm wide by 0.2 cm deep and had 90% slough (dead cells). This note includes recommendations to off-load wound, reposition per facility protocol, Group 2 Mattress (air mattress), Multivitamin once daily, Vitamin C 500 milligrams (mg) twice daily, Zinc Sulphate 220 mg once daily for 14 days. There is no documentation in R8's medical record that the recommended vitamins were implemented. R8's Wound Care Telemedicine Follow Up Evaluation dated 10/18/24 documents R8's right buttock wound resolved and R8 had a left hip Stage Three Pressure Wound of greater than two days duration that measured 1.3 cm by 1 cm by 0.2 cm and had 50% slough. This note documents R8 now has a Group 2 mattress as of today (11 days after V7's order) and recommends to off-load wound and repositioning. R8's Wound Care Telemedicine Follow Up Evaluation dated 10/25/24 documents R8's left hip Stage Three Pressure Wound measured 1.2 x 1 x 0.2 cm, and R8's right buttock Stage Three Pressure Wound reopened over three days ago and measured 2.0 x 2.0 x 0.3 cm. There is no documentation in R8's medical record that R8 has been evaluated by a dietitian since March 2024, prior to R8's weight loss and wounds. On 10/27/24 at 8:30 AM and 11:58 AM R8 was sitting in a wheelchair near the nurses' station with a soft lap cushion looped through the armrests of R8's chair. at 10:18 AM R8 was sitting in a wheelchair in the dining room. At 11:58 AM R8 was sitting in her wheelchair. R8 stated R8 has wounds on R8's bottom, but was unsure how long the wounds had been there or how often treatments are administered. On 10/28/24 at 9:21 AM R8 was sitting in a wheelchair by the nurses' station. At 10:38 AM R8 was sitting in a wheelchair in the dining room. At 11:13 AM staff transported R8 in a wheelchair from the dining room to the 100 hall nurses' station. Continuous observations were made from 11:13 AM until 11:39 AM of R8 sitting in a wheelchair near the nurses' station. The lap cushion remained in place during all of these observations. On 10/28/24 12:02 PM V4 and V6 Certified Nursing Assistants (CNAs) transferred R8 from her wheelchair into bed. There was a foam horseshoe shaped cushion, that was approximately one inch thick, in R8's wheelchair. R8 was incontinent of urine and V6 provided incontinence cares. R8 had open pink wounds to the right buttock and left hip that were not covered with dressings. V6 stated V6 had not provided any cares for R8 yet today and was unsure how long the wounds were without dressings. V6 stated V6 will notify the nurse so the wounds can be covered. On 10/28/24 at 12:16 PM V3 Licensed Practical Nurse stated R8's wounds started with the right buttock that was a thin layer of skin that had sheered off, and then a few days later the left hip wound developed. V3 entered R8's room, administered R8's pressure ulcer treatment, and used pillows to position R8 on her right side before leaving the room. V3 stated no staff had reported that R8's dressings came off, prior to V6. On 10/28/24 at 2:34 PM V11 CNA stated V11 R8 was transferred out of bed around 7:30 AM and V11 provided no other transfer or toileting cares for R8 prior to leaving at 10:00 AM. V11 stated V4 was the only other CNA working on R8's hall at that time. On 10/28/24 at 3:04 PM V4 CNA stated V4 did not provide any cares for R8 besides the transfer observed at 12:02 PM. On 10/28/24 at 3:23 PM V12 Wound Nurse stated V12 has been the facility's wound nurse for approximately three weeks. V12 stated V12 has not yet updated resident care plans to include wounds, but they should be updated to reflect wounds and new interventions. V12 stated V12 and V7 Wound Physician complete weekly wound assessments which are documented in the assessment section of the resident's electronic medical record (EMR) or in V7's notes. V12 stated there can't be a delay in starting treatment, and the nurses should notify the physician and document an assessment of the wound when found. V12 confirmed Braden assessments are documented in the assessments section of the EMR, and should be done on admission, then weekly for four weeks, and then quarterly. V12 stated residents at high risk for pressure ulcers should have weight monitored weekly, placed on a turning and repositioning schedule, and skin checks more than weekly. V12 stated turning/repositioning should be documented on the care plan and in tasks in the EMR. V12 stated residents with wounds should be referred to the dietitian. At 4:00 PM V12 Wound Nurse stated V12 rounds with V7 Wound Physician, and V12 is responsible for entering V7's orders/recommendations. V12 stated R8 used to walk and then recently declined requiring total assistance for cares. V12 stated staff should reposition R8 at least every two hours and offload pressure from R8's wounds. V12 stated That is way too long for (R8) to be in her wheelchair, when told R8 had not been repositioned from 7:30 AM until 12:00 PM. V12 stated R8's air mattress was installed on 10/18/24. V12 stated V12 was unsure when R8's wheelchair cushion was implemented. V12 was unaware of V7's recommendations for Vitamin C, Zinc and Multivitamin, and confirmed these recommendations were never implemented. On 10/29/24 at 12:18 V12 confirmed V12 had not notified the dietitian of residents with wounds, and confirmed all of V7's wound notes were uploaded into R32's electronic medical record. On 10/30/24 at 11:05 AM V12 stated V12 was unable to determine the type and brand of R8's cushion, so the cushion was replaced today. On 10/29/24 at 11:57 AM V2 Director of Nursing stated V2 used to oversee wounds until June 2024. V2 stated the wound nurse is responsible for sending a wound list to the dietitian. On 10/29/24 at 12:34 PM V19 Registered Dietitian stated R8's last nutritional assessment was completed in March 2024. V19 stated the facility does not notify or request for V19 to evaluate residents with wounds. V19 stated V19 runs reports to determine which residents need to be evaluated, but there is no report that identifies wounds. V19 stated V19 has to ask staff to determine if residents have wounds. V19 stated no one had requested to evaluate R8's nutritional status and V19 was unaware that R8 had developed pressure ulcers. V19 stated if V19 had evaluated R8, V19 would have recommended Zinc, Vitamin C, a multivitamin, and liquid protein; and possibly would have recommended a nutritional supplement if R8 had lost weight, but R8 does not have a documented weight for October. On 10/29/24 from 1:00 PM-1:15 PM V7 stated V7 has been the facility's wound physician for the last few months and V7 conducts her visits virtually, not in person. V7 stated Prealbumin is ordered to evaluate nutrition and protein levels and should be implemented by the next month's laboratory draw. V7 stated vitamins aid with wound healing and should be implemented by the next day. V7 stated Group 1 mattresses are foam mattresses that are good for up to Stage Two Pressure Ulcers and a Group 2 mattress is a low air loss mattress used for Stage Three Pressure Ulcers and higher, or if the resident has a low Body Mass Index. V7 stated residents at high risk for pressure ulcers should have preventative interventions implemented based on the facility's protocol, which generally includes frequent repositioning and offloading and use of pressure relieving surfaces. V7 stated V7 avoids using horseshoe or donut cushions since they cause skin to spread and can cause wounds to worsen. V7 stated generally foam cushions with approximately three inch thickness are used. V7 stated there was a period of time where the facility didn't have a wound nurse due to staffing issues; V7 worked closely with V2 when V2 was the Assistant Director of Nursing, but then V2 changed positions and there were several weeks where no one was assessing wounds. V7 confirmed not implementing pressure relieving interventions, physician recommendations, nutritional evaluations, wound and skin assessments/monitoring, and treatments timely and as ordered, can contribute to the development and worsening of pressure ulcers. 2.) R32's MDS dated [DATE] is inaccurate and documents R32 did not have pressure ulcers. R32's MDS dated [DATE] documents the following: R32 has sever cognitive impairment, R32 requires supervision/touch assistance from staff for bed mobility, and partial/moderate staff assistance with transfers. R32 is occasionally incontinent of urine and requires dependence on staff for toileting hygiene. R32 had an unplanned significant weight loss within the last six months. R32 has two facility acquired pressure ulcers, one stage three and one unstageable. R32's Braden assessment dated [DATE] documents R32 scored low risk for developing pressure ulcers. There are no other documented Braden Assessments in R32's medical record until 10/8/24, after R32 developed unstageable and stage three pressure ulcers. R32's Care Plan dated 7/9/24 documents R32 has potential for impaired skin integrity and includes interventions to apply barrier cream three times daily as needed, Braden scale weekly for four weeks then quarterly, encourage good nutrition and hydration, follow physician's orders for treatment. This care plan has not been updated to include R32's pressure ulcers or any new pressure relieving interventions after 7/9/24. There is no documentation that R32 refuses pressure relieving interventions. R32's Physician's Order dated 7/11/24 documents to give Pro Stat (protein supplement) 30 milliliters once daily. R32's Physician Order dated 7/9/24 documents to apply pressure relieving boots or offload heels when in bed. R32's Physician Order dated 7/31/24 documents air mattress to bed. R32's Physician Order dated 7/12/24 documents May use pressure relieving mattress and/or cushion on w/c if Needed. There is no documentation that barrier cream, air mattress, or wheelchair cushion was applied prior to these orders. R32's Admission Evaluation dated 7/3/24 documents R32 admitted with a Stage Two Pressure Ulcer of sacrum/coccyx. There is no documentation that a treatment order was initiated for this wound until 7/9/24 and there are no documented assessments of this wound until 7/31/24 when the wound had deteriorated to a Stage Three. There is no documentation that R32 admitted with any foot wounds. R32's Shower Sheet dated 7/7/24 documents R32 had a blister to the left heel and left big toe. There are no documented measurements or wound descriptions, and no documentation that the physician was notified and a treatment was initiated prior to 7/9/24. R32's Nursing Note dated 7/9/2024 at 12:34 PM documents R32 had a blister to the left heel that measured 3.5 cm by 7 cm, a skin protectant and dry dressing was applied, R32's buttocks was red/excoriated with no open areas. An antifungal cream and zinc oxide cream was applied. R32's Nursing Note dated 8/4/2024 at 5:29 PM documents R32's coccyx had a 6 cm by 3 cm maroon spot with a small open area. Triple antibiotic ointment and a bordered foam dressing was applied and education was provided on timely depend changes and cream application. R32's Registered Dietitian Note dated 8/29/24 at 8:07 AM documents R32's weight has decreased over the past month and there were no new interventions. This note does not document that the dietitian was aware of R32's stage three pressure ulcers and there is no documentation that R32 was evaluated by a dietitian in September. There are no weekly wound assessments in R32's EMR prior to October 2024, besides V7's assessments on 7/31/24, 8/9/24, 8/15/24, 9/5/24, and 9/12/24. R32's Wound Care Telemedicine Initial Evaluation dated 7/31/24, recorded by V7, documents R32's unstageable Deep Tissue Injury of the Left Heel measured 6.9 cm by 4.4 cm and no measurable depth. and R32's Stage Three Pressure Ulcer of the coccyx measured 1.9 cm by 1 cm by 1.2 cm. V7 recommended to off-load wound, reposition per facility protocol, float heels in bed, pressure relieving boot, dietitian consult, and Prealbumin level. There is no documentation that R32's Prealbumin level was obtained as recommended and V7 documents Prealbumin results pending on V7's Evaluations from July-October 2024. R32's Wound Care Telemedicine Evaluation dated 10/25/24 documents R32's unstageable heel ulcer measured 1.0 x 0.7 x 0.2 cm, the wound was macerated (moisture related damage), and the treatment was changed to Calcium Alginate with bordered foam dressing applied three times weekly. R32's Stage Three Pressure Ulcer of the coccyx measured 1.0 x 0.5 x 0.5 cm. R32's August and September 2024 TAR documents R32's left heel treatment scheduled three times per week was not administered three times in August and five times in September. R32's daily coccyx treatment was not administered eight times in August and eight times in September. On 10/27/24 at 11:44 AM R32 stated R32 has sores on her feet/heel and her bottom that R32 did not admit with. R32 was lying in bed on her back and was not wearing heel protectors. R32's heels were in direct contact with R32's air mattress. R32's wheelchair pressure relieving cushion decompressed with applied hand pressure and the wheelchair seat could be felt through the cushion, indicating the cushion was not fully inflated with air. On 10/27/24 at V8 CNA stated V8 was unsure if R32 has any foot wounds, but R32 has a wound on R32's bottom. V8 stated R32 wears pressure relieving boots at night. V8 tested R32's wheelchair cushion with hand pressure and confirmed the cushion decompressed. V8 stated I believe that is how it (cushion) is suppose to be. On 10/28/24 at 9:03 AM R32 was sitting in her wheelchair in her room. At 11:20 AM staff brought R32 to her room and R32 was still in her wheelchair. R32 remained sitting in her wheelchair in her room until 11:45 AM when V4 CNA transferred R32 onto the toilet. At 11:54 AM V5 CNA responded to R32's bathroom call light. V5 confirmed R32's wheelchair cushion was not fully inflated by testing it with applied hand pressure. V5 stated that is how much it has been inflated since R32 started using it. V5 transferred R32 off of the toilet and into R32's wheelchair containing the cushion. On 10/28/24 at 11:59 AM V4 stated V4 transferred R32 out of bed and into her wheelchair between 8:00 AM and 9:00 AM. At 12:01 PM V4 and V5 transferred R32 into the stationary chair in R32's room and the chair did not contain a pressure relieving cushion. At 12:31 PM and 1:20 PM R32 was still sitting in the stationary chair. On 10/28/24 at 12:31 PM V3 Licensed Practical Nurse stated V3 already completed R32's heel treatment earlier this morning and V3 had applied a medicated honey treatment. V3 stated V3 wasn't aware that R3's heel treatment had changed to calcium alginate, so V3 will need to do R32's heel treatment again. At 1:36 PM V3 stated skin assessments are documented on the Medication Administration Records, the nurse documents if skin is intact, or if there is a wound or new wound. V3 stated there should be wound descriptions in the progress notes. V3 confirmed CNAs should use the care plan to determine pressure relieving interventions. V3 entered R32's room, transferred R32 from the stationary chair into bed, and administered R32's left heel and coccyx wound treatments. R32's stationary chair did not contain a pressure relieving cushion. R32's left outer heel had a small superficial wound and there was a deep marble sized wound to R32's coccyx. V3 raised the head of R32's bed, applied R32's covers, and left R32 lying on her back with the head of the bed elevated approximately 45 degrees (causing pressure to R32's coccyx). V3 did not offer or encourage R32 to off-load pressure from her coccyx and lay on her side prior to leaving R32's room. On 10/28/24 at 1:57 PM V3 confirmed V3 did not offer or encourage R32 to lay on her side prior to leaving the room. V3 stated V3 just didn't think of it (off-loading), and confirmed off-loading pressure from the coccyx would aide in wound healing. On 10/28/24 at 3:23 PM V12 Wound Nurse stated R32's wounds are pressure related and interventions include repositioning, off-loading, and pressure relieving boots. V12 confirmed R32 requires staff assistance to reposition or off-load, R32 should be repositioned at least every two hours and pillows should be used to off-load coccyx and heel pressure, unless pressure relieving boots are in place. V12 stated R32 should use a pressure relieving cushion in the wheelchair and stationary chair in her room. V12 confirmed R32's wheelchair cushion should be inflated and you should not be able to feel the seat of the wheelchair when pressure is applied V12 stated the CNAs should be checking that. V12 confirmed nurses should look at the TAR for treatment orders prior to administration and treatment administrations are documented on the TAR. V12 confirmed a blister is a stage two pressure ulcer and not implementing pressure ulcer interventions could contribute to a decline in wounds. V12 confirmed R32 admitted with a stage two pressure ulcer of the sacrum, there is no documentation of left heel wound on admission, and there are no assessments or measurements of this wound prior to being seen by V7. V12 confirmed there are no documented Braden Assessments in R32's EMR after 7/3/24 until 10/8/24. V12 stated a Braden score of 15 is considered high risk and that was R32's score on admission. V12 confirmed Prealbumin was never ordered for R32 and V12 stated she will follow up on this. On 10/29/24 at 9:38 AM V34 MDS Coordinator reviewed R32's admission and nursing notes and MDS, and confirmed R32's July MDS does not accurately reflect R32's skin status at that time. V34 stated V34 was told by staff at that time that R32 did not have any wounds, the wound nurse is suppose to enter wounds into the wound rounds tracking system, but there was no information entered for R32 at that time. V34 stated V34 consulted with corporate and will need to submit a modification for this MDS. V34 stated the wound nurse is responsible for adding wounds and new interventions on the care plan, and pressure relieving boots are documented in physician orders and on the care plan. On 10/29/24 at 12:34 PM V19 Registered Dietitian stated R32 was evaluated in July and August with no new recommendations, but V19 was not aware that R32's wounds had declined when R32 was evaluated in August. V19 stated if V32 was aware, V19 may have increased liquid protein to be given twice daily. V19 stated R32 should have been evaluated again in September, but V19 does not see where that was done. The manufacturer's instructions for R32's pressure relieving cushion dated 5/3/24 documents to inflate air until all of the air cells feel firm, remove the hand pump,allow air to escape from the valve until the air deflation is no longer felt or heard, and then close the inflation valve. Perform a hand check to evaluate sufficient air between the person and the base of the cushion, and adjust as needed. 37813 3.) R44's Minimum Data Set (MDS) dated [DATE] documents R44 is at risk for pressure ulcers and was admitted with no pressure ulcers. R44's Wound Care Telemedicine initial evaluation dated 10/18/24 by V7, Wound Physician documents R44 developed a facility acquired Stage III Pressure Ulcer of greater than 10 days duration on the coccyx measuring 1.6 cm (centimeters) by 1.0 cm by 0.3 cm deep. At that time V7 ordered the following wound dressing: Calcium Alginate with silver covered with gauze island dressing with border. R44's Treatment Administration Record documents this treatment was initiated. R44's Wound Care Telemedicine Follow-up evaluation dated 10/25/24 by V7, Wound Physician documents the wound has increased in size to 3.0 cm (centimeters) by 1.5 cm by 0.5 cm deep. At that time V7 ordered the following wound dressing: medicated honey Calcium Alginate with silver covered with gauze island dressing with border. R44's Treatment Administration Record documents this treatment was not initiated. The treatment ordered 10/18/24 was continued. On 10/29/24 at 1:00PM V12 Licensed Practical Nurse (wound Nurse) applied R44's treatment. V12 removed the old dressing, removed gloves, performed hand hygiene, cleansed R44's wound with normal saline, removed gloves, performed hand hygiene, applied calcium alginate with silver to clean wound bed and covered with a bordered foam dressing. V12 did not apply medicated honey to wound as ordered. When asked why she did not apply the medicated honey V12 stated I don't think that is ordered on the TAR. At this time it was observed R44 had a new Stage III pressure ulcer on her left ischium approximately the size of a quarter. There is no documentation R44 has been evaluated by a dietitian for the facility acquired pressure ulcers. On 10/29/24 at 12:34PM V19 Registered Dietitian stated, When a resident develops a facility acquired pressure ulcer, the facility should reach out to me and I should evaluate and make recommendations to enhance healing. This facility does not do so. I usually pick up on issues like this when I do the periodic visits. I have not evaluated (R44). 4.) R52's Minimum Data Set (MDS) dated [DATE] documents R52 is at risk for pressure ulcers and was admitted with no pressure ulcers. R52's Treatment Administration Record (TAR) for October 2024 documents a new treatment dated 10/26/24 for Clean area to left buttock with normal saline. Apply calcium alginate to wound bed & cover with gauze foam daily every day shift for wound care. On 10/29/24 at 10:00 AM V12 Licensed Practical Nurse (wound Nurse) stated (R52) developed a new facility acquired Stage II pressure ulcer 10/25/24. We are treating it. On 10/29/24 at 1:15PM V12 Licensed Practical Nurse (wound Nurse) applied R52's treatment. V12 removed the old dressing, removed gloves, performed hand hygiene, cleansed R52's wound with normal saline, removed gloves, performed hand hygiene, applied calcium alginate with silver to clean wound bed and covered with a bordered foam dressing. At this time V12 verified R52's wound is now a Stage III because it has visible slough of tissue. V12 also verified R52 has developed an additional dime sized stage III pressure ulcer to her right buttock. R52 was sitting in the bed with the head elevated to sitting position. R52's bed did not have a pressure relieving mattress in place. There is no documentation R52 has been evaluated by a dietitian for the facility acquired pressure ulcers. On 10/29/24 at 12:34PM V19 Registered Dietitian stated, When a resident develops a facility acquired pressure ulcer, the facility should reach out to me and I should evaluate and make recommendations to enhance healing. This facility does not do so. I usually pick up on issues like this when I do the periodic visits. I have not evaluated (R52). There is no documentation to support R52 has been evaluated by the wound care Physician. On 10/29/24 at 1:15PM V12 verified this.

Based on observation, interview and record review the facility failed to protect the resident's right to be free of misappropriation of money and personal property for four of five residents (R13, R130, R25 and R46) reviewed for misappropriation in a sample list of 40 residents. Failing to prevent the misappropriation of R13's commemorative coin set, which is not replaceable, resulted in R13 being tearful and experiencing feelings of sadness and loss due to the sentimental value of the coins. Findings Include: The facility Abuse Prevention Program dated October 2022 documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. 1. R13's Care Plan updated 10/27/24 documents: (R13) has an alteration in neurological status related to: Major Depressive Disorder Recurrent, Agoraphobia, Anxiety, and PTSD (Posttraumatic Shock Disorder). R13's Minimum Data Set (MDS) dated [DATE] documents R13 is cognitively intact. On 10/29/24 at 9:00AM R13 was seated in a wheelchair in R13's room with a family member visiting. R57 (R13's) roommate was in bed in the room. R13 stated I can talk to you in front of my roommate and my (family member) I trust them. I had $100.00 and eight double struck commemorative coins taken from my lock box. It had to be staff because they might have known I was keeping my key beside my bed in my pencil box. It is bad enough I lost the money, but I used to carve the casts and strike the coins. Those I had here were in silver and bronze. I am losing my sight and my fingers don't work well because I have neuropathy. Those coins meant a lot to me. I kept them here because I like to look at them and remember what I used to do. I can't remember the exact date, but my (family member) can tell you. I reported it to (V1) Administrator and (V29), Social Services. They did not offer to call the police, but I wish they had. R13 looked upset and bit his bottom lip as he talked. Tears started to well up in R13's eyes. V33, R13's family member stated (R13) had the coins and his $100.00 on the evening of 10/16/24. I saw them. I came back on 10/17/24 and he did not have them. R57 stated I did not see (R13's) coins that day before, but I have seen that (R13) had the coins he made. On 10/29/24 at 11:00AM V1, Administrator stated there is really no documented investigation. I do not believe the money has been returned to (R13). 2.) The facility's Grievance Log for the three months prior to the survey documents R130 withdrew money from the bank on 9/1/24 and stored it in her purse. On 9/2/24 (R130) noticed money was missing around noon. (R130) was interviewed and family confirms money was withdrawn from the bank. Facility will replace the money. R130's MDS dated [DATE] documents R130 is cognitively intact. R130's Progress Note documents R130 was discharged home with home care services 10/28/24. On 9/30/24 R130 stated I took $140.00 out of the bank and put it in my purse. I went to therapy and when I came back I was going to address cards to my family and put in the money but the money was gone. I never got the money back. I told (V34) Care Plan Nurse the money was missing. I never heard anything so I just thought I would still be getting it. I have been sick and that was quite a bit of money to me. Now that I am home, I will be a little short at the end of the month and it was for my family. I save that up. You know I think whoever took it must really need it, but I would have just given it to them if they asked. On 10/30/24 at 12:00PM V34 verified R130's account of the allegation. V34 stated I really thought (R130) had the money replaced. on 10/30/24 at 12:15PM V29, Social Service also verified R130's account of the allegation. V29 also stated she was under the impression R130 was reimbursed for this loss. 50993 3.) The facility's grievance log dated 10/25/2024 documents: R25 reported to manager (V10 Restorative Registered Nurse) that (R25) had money missing. V29 SSD (Social Service Director) followed up and R25 explained that last week (R25) had $100 missing and then on October 22nd (R25) had another $20 missing. He stated the money was in his wallet in his top drawer. V29 reported R25's missing money to V1 Administrator to follow up. R25's MDS (Minimum Data Set) dated 8/19/24 documents R25 is alert and oriented. On 10/27/24 at 9:58 AM, R25 stated I have had money missing twice. R25 explained, two weeks ago R25 had $170 in cash in R25's wallet, which was in the top drawer of R25's nightstand. R25 left his room to attend therapy, leaving the wallet in the nightstand drawer, and upon returning to R25's room, R25 found that the $100 bill was gone leaving $70 in the wallet. R25 stated he reported the theft to the unidentified Certified Nurses Assistant (CNA) and Registered Nurse (RN), but doesn't remember who it was. R25 stated again on 10/23/24, R25 had money stolen. R25 explained that R25 left the facility for a physicians appointment and while en route, realized he had forgotten his wallet. Upon returning to the facility, R25 noticed that the top drawer of the nightstand was open a couple inches and another $20 was missing, leaving $50 in the wallet. R25 reported this theft to the unidentified RN on duty. R25 stated that V29 SSD informed R25 that four to five people have been hit in the last couple of weeks and that the facility is looking into the thefts. On 10/28/24 at 10:39 AM, V29 SSD confirmed that R25 had reported having money stolen but that V29 was not made aware of the allegation until 10/25/24 On 10/28/24 at 10:45 AM, V1 Administrator confirmed V1 was aware of R25's missing/stolen money. On 10/28/24 at 11:29AM, V10 Restorative Registered Nurse stated R25's missing money was reported to her by V6 Certified Nurses Assistant (CNA) on 10/23/24. V10 explained that V10 reported the missing/stolen money to V1 Administrator and V2 Director of Nursing (DON) on 10/24/24. On 10/28/24 at 11:40 AM, V6 CNA stated R25 came to the nurses' station and stated loudly this is the second time someone stole from me! On 10/30/24 at 10:00 AM, V25 LPN (Licensed Practical Nurse) stated V25 is familiar with R25 and has seen cash in a money clip on R25's wallet. On 10/30/24 at 10:10 AM, R25 stated R25 had been given the money by his family explaining his son or daughter will bring him cash whenever he needs it. 4.) The facility's grievance log dated 10/25/24 documents R46 had money stolen on 10/1/24. On 10/27/24 at 9:50 AM, R46 stated R46 had cash stolen from R46 during a room move. R46 explained R46 had $100 in cash in R46's dresser drawer and after moving rooms, the $100 was missing. R46 stated an unidentified housekeeper saw the cash in R46's drawer while assisting R46 with the room move. R46's MDS (Minimum Data Set) dated 9/11/24 documents R46 is alert and oriented. R46's ongoing Census Sheet documents R46 changed rooms on 10/01/24. On 10/28/24 at 10:39 AM, V29 SSD confirmed R46 reported having money stolen and reported it to V29 on 10/25/24. V29 reported that V29 completed a Grievance Form and that V1 Administrator was handling the investigation. On 10/28/24 at 10:45 AM, V1 Administrator confirmed V1 was made aware of R46 having money stolen and that the facility was handling it internally. On 10/28/24 at 11:40 AM, V6 CNA (Certified Nursing Assistant) stated on 10/23/24, R46 reported to V6 that R46 had money stolen. On 10/29/24 at 11:40 AM, V16 LPN (Licensed Practical Nurse) stated R46 reported to V16 that R46 had money stolen from him. On 10/30/24 at 10:15 AM, R46 stated that R46 gets cash out of the ATM (Automated Teller Machine) using a debit card from his Social Security Card, therefore he does not have any bank statements.

Based on observation, interview, and record review, the facility failed to conduct pressure ulcer risk assessments (R1, R5, R6), failed to obtain treatment orders for identified pressure ulcers (R5, R6), failed to complete pressure ulcer monitoring (R5, R6), and failed to complete pressure ulcer treatments according to physician orders (R5, R6). These failures affect three residents (R1, R5, and R6) out of three reviewed for pressure ulcer services on the sample of six. These failures resulted in R5 developing a worsening stage 3 pressure ulcer. Findings include: The facility's policy Braden Pressure Risk Assessment Tool dated [DATE], documents each resident should be assessed for risk of developing pressure ulcers on admission, weekly for the first month, at least quarterly, and with any significant change in condition, utilizing the Braden scale assessment form. The facility policy Measurement of Alterations in Skin Integrity dated [DATE], documents all skin alterations, wounds, and ulcers will be measured weekly and the results documented in the clinical record. This policy describes the stages of pressure ulcers, instructs staff to assign a stage to the ulcer, document a description of the ulcer, measure the ulcer, measure or describe the depth of the ulcer, and to describe any drainage or odors. 1. R5's Assessments dated [DATE] document this was the most recent date located in R5's medical record for facility staff assessing R5's risk for developing pressure ulcers utilizing the Braden scale pressure ulcer risk assessment tool. On [DATE] at 1:15 PM, V1, Administrator, stated, I know we have a more recent Bradens than over a year ago, I completed a whole house sweep of every resident for a Braden back in April, but even that still puts us over a quarter behind. V1, Administrator, provided a more recent Braden assessment dated [DATE] which rated R5 as at risk. R5's Care Plan documents a focus area of R5's risk for impaired skin integrity with a nursing intervention listed as Braden scale weekly x 4 weeks then quarterly, initiated [DATE]. R5's Nurses Note dated [DATE] documents a notation of an open pressure ulcer located on R5's left buttock measuring 2 centimeters (cm) by 1.5 cm. R5's Nurses Note dated [DATE] documents R5's dressing change for the left buttock was unable to be completed because R5 was sitting in a chair. R5's Nurses Note dated [DATE] documents R5's dressing change for the left buttock was completed by the wound nurse. There was no documentation of measurements nor a description of this ulcer. R5's Nurses Note dated [DATE] documents R5's dressing change for R5's wounds was completed by the hospice nurse and also documented an open ulcer located on R5's coccyx measuring 2 cm by 1.5 cm. There was no mention of the left buttock ulcer, and no description of either ulcer. R5's Nurses Note dated [DATE] documents completion of wound rounds with the wound physician, the physician ordered to continue the current treatments, and that R5 had no open areas. R5's Nurses Note dated [DATE] documents R5 had open wounds with dressings in place. There was no documented location, measurements, nor descriptions of the open wounds. R5's Nurses Note dated [DATE] documents the presence R5's left buttock ulcer. There was no documented measurements nor description of this ulcer, nor any mention of R5's coccyx open ulcer. R5's Treatment Administration Record dated for [DATE] documents a treatment order for R5's coccyx ulcer was not obtained or implemented until [DATE]. This record documents R5's treatment for the coccyx ulcer was not completed according to the physician orders on [DATE] and [DATE] on day shift. This same record documents R5's coccyx treatment was discontinued and changed to the evening shift on [DATE]. This same record documents R5's left buttock treatment order had been continuously in R5's treatment record from [DATE] through the current date ([DATE]), disputing the documentation on [DATE] that R5 had no open areas during the wound rounds. This record documents R5's treatment for the left buttock was not completed according to physician orders on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. This same record documents the treatment for R5's left buttock was likewise discontinued [DATE] and changed to the evening shift. R5's Treatment Administration Record dated for [DATE] documents R5's treatment for the open ulcer on R5's coccyx was not completed on [DATE]. This record documents the treatment order for R5's coccyx was revised [DATE] and implemented to begin [DATE]. On [DATE] at 1:15 PM, V1. Administrator, stated, We know we have some things to work on and improve. We have not been consistent in doing our weekly measurements. Part of the issue is we had a wound company who stopped serving our facility back in February (2024), then the new practitioner is only providing us their service when they can squeeze us into their schedule, and they aren't actually coming onsite, they are doing their visits by telehealth (virtual visits over the computer). V1 continued, We did designate one of our nurses as the wound nurse, but her training has been delayed because we had needs for her to work the floor (in direct care). On [DATE] at 1:15 PM, V2, Director of Nursing, stated, We also have had to use agency nurses which do not necessarily know the residents well and are not diligent about signing treatments in the record. We also have cross over of shifts like some nurses might work 12 hours shifts and some work 8 hour shifts, so there is some confusion about which nurse is going to do the treatments when they are set up as day shift or evening shift. On [DATE] at 2:35 PM, facilitated by V10, Licensed Practical Nurse, and V2, Director of Nursing, R5's coccyx ulcer was observed to be approximately (visually estimated but confirmed by V10 and V2) 3.5 cm long by 0.5 cm wide and apparently stage 3 with full thickness skin loss and subcutaneous (fat) tissue exposed. This open ulcer was surrounded by an area of non-blanchable redness (stage 1 with tissue damage already occurred) approximately (again confirmed with V2 and V10) 7 cm long by 6 cm wide. On [DATE] at 2:35 PM, V10 stated, When this ulcer first started it was open stage 3 like this, it remained stable for a few weeks, then it worsened and has been like that for the past several weeks. On [DATE] at 3:25 PM, V1, Administrator, stated, The treatment orders have to be obtained faster than that (from [DATE] until [DATE]). I would expect a nurse to at least put a dry gauze dressing in place when they first notice an open area, then turn it over to inform the physician to obtain a more targeted treatment. 2. R6's Assessments dated [DATE] document this was the most recent date located in R6's medical record for facility staff assessing R6's risk for developing pressure ulcers utilizing the Braden scale pressure ulcer risk assessment tool. On [DATE] at 1:15 pm, V1, Administrator, provided a more recent Braden assessment dated [DATE] which rated R6 as very limited risk. R6's Care Plan documents a focus area that R6 is at risk for altered skin integrity and potential for pressure ulcers with nursing interventions including Braden scale quarterly, implemented [DATE]. R6's Nurses Notes dated [DATE] document R6 developed an open pressure ulcer on the left shoulder which measured 1 cm by 1 cm. There was no depth measurement, nor a description of this open area. This same Nurses Note documents R6 also developed a second open pressure ulcer on the left hip measuring 1 cm by 0.5 cm. There was likewise no depth measurement or description of this second open ulcer. R6's Nurses Notes dated [DATE] document a second notation of R6's two open areas. This note documented the open ulcer on R6's left shoulder measured 2 cm by 1.4 cm, indicating this area had grown in size since [DATE]. There was no depth measurement nor description for R6's open ulcer on the shoulder. This note documented the open ulcer on R6's left hip measured 0.5 cm by 0.5 cm with no documented depth measurement nor description. There were no additional measurements nor descriptions between [DATE] and [DATE]. R6's historical Physician Order Sheet and Treatment Administration Record for [DATE] document there was not a treatment order obtained from R6's physician to treat the two open ulcers until [DATE], at which time the orders for treatment indicated R6's open ulcers were on the right shoulder and right hip. On [DATE] at 2:35 PM, V2, Director of Nursing, stated, The ulcers are actually on (R6's) right hip and right shoulder. (Staff) must have been looking at (R6) and documented what side the ulcers were related to their own left not the residents left. R6's Nurses Notes dated [DATE] documented the presence of R6's two open ulcers but no measurements or description. There were no additional measurements or descriptions between the note on [DATE] and [DATE]. R6's Treatment Administration Record dated for [DATE] documents the treatment for the pressure ulcer on R6's right shoulder was not completed according to the physician orders on [DATE] for the day shift. This same treatment order was documented as discontinued on [DATE] and changed to the evening shift. This same treatment record documents R6's treatment for the right hip was not completed on [DATE] and [DATE] for the day shift. This right hip treatment was likewise discontinued [DATE] and changed to the evening shift. On [DATE] at 2:35 PM, facilitated by V10, Licensed Practical Nurse/ Wound Care Nurse, and V2, Director of Nursing, R6's pressure ulcer of the right shoulder was observed to be a stage 2 (partial skin thickness) with surrounding healing scar tissue, and likewise the right hip pressure ulcer on R6 was a stage 2 with surrounding healing scar tissue. On [DATE] at 1:35 PM, V10 stated, Those are definitely stage 2, partial skin layers. They used to be larger but they have been healing. They have always been stage 2. On [DATE] at 3:25 PM, V1, Administrator, stated, The treatment orders have to be obtained faster than that (from [DATE] until [DATE]). I would expect a nurse to at least put a dry gauze dressing in place when they first notice an open area, then turn it over to inform the physician to obtain a more targeted treatment. 3. R1's Minimum Data Set List and Census Details document R1 was discharged deceased from the facility [DATE]. R1's Assessments dated [DATE] documents this was the most recent pressure ulcer risk assessments utilizing the Braden scale pressure ulcer risk assessment tool conducted by facility staff located in R1's medical record. On [DATE] at 1:15 PM, V1, Administrator, provided a more recent Braden assessment dated [DATE], rating R1 as high risk for pressure ulcers. R1's Nurses Note dated [DATE] documents a notation of a sore located on R1's left ankle with a measurement of 7 cm long by 6 cm wide, along with an area of redness on R1's right heel. A subsequent nurses note on this same date documented the presence of redness on R1's gluteal area (buttock) and coccyx. On [DATE] at 9:55 AM, V1, Administrator (former direct care registered nurse at the facility), stated, I did see (R1's) ulcer on the ankle. I did see that the nurse (V5, Registered Nurse) documented the area on (R1's) ankle was 7 cm by 6 cm, but I think he was measuring the entire area, but the hole in the skin was only about this big. V1 held up his fingers to indicate approximately 0.75 cm diameter. V1 further stated, I would stage that ulcer at stage 2.

Based on record review and interview the facility failed to ensure a resident (R1) received appropriate treatment for an infection of the heart muscle. The facility also failed to ensure the physician and Nurse Practitioner were aware of R1's infection treatment plan. Theses failures affect one (R1) of three residents reviewed for IV Medication/Infection in a sample list of three residents. These failures resulted in (R1) being hospitalized with sepsis and subsequently expiring due to R1's worsening infection. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 6:42PM when R1's antibiotic intravenous treatment was changed for Enterococcus with Endocarditis without physician coordination of R1's Infectious Disease plan when discharged from the hospital ([DATE]). V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 11:09 AM. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on [DATE] at 2:30PM but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of continuing audits, education, and initiation of plan of correction. Findings include: R1's Progress Note dated [DATE] at 6:42PM documents R1 was admitted to the facility following hospitalization (as documented on R1's Post Acute Care Transition Document dated [DATE]) for Sepsis secondary to cellulitis, Bacteremia with Enterococcus with Endocarditis, Atrial Fibrillation with Rapid Ventricular Response (RVR), RVR likely triggered from Sepsis, Sepsis on admission with Tachycardia, Leukocytosis. Blood Cultures Positive for Enterococcus. Repeat Blood Cultures Positive for Gram Positive Cocci in Chains. Repeat Blood Cultures Negative. Percutaneous Intravenous Central Catheter (PICC) line placed on day of discharge. Infectious Disease consult recommended six weeks of Intravenous Vancomycin. Further Infectious Disease recommendations as mentioned in discharge instructions for lab orders and monitoring. Cardiology consulted Transesophageal Echocardiogram showed Mitral Vegetation. Discharge to (the facility) with six weeks of Intravenous Vancomycin. R1's Progress Note dated [DATE] documents V10, Licensed Practical Nurse (LPN) entered the correct hospital discharge order for Vancomycin 1000 Milligrams by IV Route every 48 hours for 40 days. in R1's electronic medical record. The facility order report for R1 dated [DATE] documents CBC with diff, CMP, Vanco trough (goal ,d+[DATE]) weekly **Fax results to (Fax#) Attn: (infectious disease specialist) one time a day every Mon for Vanco administration until [DATE], there was no documentation provided that reports were faxed as ordered Monday, [DATE]. R1's Post Acute Care Transition Document was uploaded to R1's electronic medical record on [DATE]. On [DATE] at 11:46AM V1 Administrator verified This document and other transfer information arrived with the resident via ambulance and were given to the admitting nurse. On [DATE] at 10:00AM V11, Registered nurse (RN) confirmed Pharmacy notified V11, Registered nurse (RN) R1's Vancomycin was changed to 1000 Milligrams every 24 hours on [DATE]. V11 confirmed V11 was instructed by pharmacy to change the Vancomycin order from every 48 hours to every 24 hours 1,000 Milligrams Per PICC line. V11 stated I don't change anything with a Vancomycin order unless Pharmacy or the Nurse Practitioner give me an order, V6, Nurse Practitioner signed the order. No lab was drawn and there is no rationale documented to justify the change. On [DATE] at 11:15AM V9 Registered Pharmacist (IV service) stated I believe the change in the Vancomycin order for (R1) was not done by pharmacy intentionally. The only trough (antibiotic dose testing) and kidney function test the pharmacy had at the time the order was changed was the hospital trough which was 16 ug/mL(micrograms per milliliter) and Creatinine was within normal limits so there was no rationale for the order to be changed. R1 Medication administration record for June and [DATE] documents R1 received the 1000 Milligram dose of Vancomycin daily [DATE], [DATE], [DATE] and [DATE]. A Vancomycin trough, Complete Blood Count, and Comprehensive Metabolic Panel was obtained prior to the administration of the [DATE] dose of Vancomycin. The lab reported a panic level of Vancomycin at 37.4 and a Creatinine of 3.9, and a Glomerular Filtration Rate of 12% which the lab report documents indicate Kidney Failure. Following these lab values one more dose of 1000 milligrams of Vancomycin was administered prior to discontinuing on [DATE] by V6, Nurse Practitioner. V6 then ordered Clindamycin 150 Milligrams three times daily for 10 days for cellulitis. On [DATE] at 2:00PM V6 (NP) stated (R1) was admitted after (R1) was hospitalized for Sepsis due to Cellulitis. I wasn't aware there was an admitting diagnosis of Bacterial Endocarditis. On [DATE] at 1:42PM V13, Medical Director stated I was not aware that (R1) had Endocarditis. I thought the Clindamycin was appropriate because I believed (R1) was being treated for cellulitis. Had I been aware of the Endocarditis and the abnormal trough and kidney function I would have had (R1) sent out to the hospital. R1's Progress Note dated [DATE] at 1:04PM documents R1 experienced nausea and vomiting and had felt unwell since the prior day and was sent out to the hospital. R1 was admitted with Sepsis. R1 was treated until R1 expired on [DATE]. R1's Hospital Admission record dated [DATE] by emergency room Physician documents (R1) presents to Emergency Department with recurrence of presentation that (R1) was hospitalized last month at (other hospital) for. Patient (has) Recurrent Cellulitis Leading to Sepsis, Infectious Endocarditis, with recurrent Atrial Fibrillation with RVR. Was supposed to be discharged with six weeks Intravenous Vancomycin. Patient (does) not have PICC line in currently. This same record documents R1 had a [NAME] Blood Count of 25.8 (normal reference range 4XXX,d+[DATE].00) and Lactic Acid 3.2 (normal reference range 0XXX,d+[DATE].0). On [DATE] at 2:53PM V7, Infectious Disease Physician (from the hospital) R1 was admitted to on [DATE] stated The lack of care for (R1) at (the facility) caused (R1) to be rehospitalized with Sepsis from Endocarditis. Ultimately (R1) had a stroke in my opinion from a bit of vegetation that broke off from (R1's) heart and traveled to (R1's) brain. I believe the lack of appropriate care at (the facility) hastened (R1's) death. (R1's) Endocarditis was caused by enterococcus. Enterococcus is not even susceptible to the clindamycin they put (R1) on at (the facility). R1's death certificate dated [DATE] lists R1's cause of death as Acute Onset Chronic Respiratory Failure Metabolic Toxic Encephalopathy secondary to Recent Endocarditis with Enterococcus Faecalis Valve Endocarditis. The Facility Assessment last reviewed [DATE] states Infection Prevention: 24-hour Communication Report is reviewed and if any concerns it is addressed. An Infection Control/Preventionist (ICP) all aspects of prevention and infection control including policy and plan development, recording, and staff training. All new orders are checked a daily and if an antibiotic is ordered an infection verification form is completed to see if the signs and symptoms met criteria. Then resident is placed on log with appropriate information and plotted on facility floor plan to track and watch for trending. If any trends are identified staff, visitors, families, and residents are given education as appropriate. The ICP reports weekly to the NHSN database all COVID related information, performs weekly resident and staff COVID testing, and keeps a log of call-ins with signs and symptoms from all employees and consults with local public health officials to ensure the highest level of infection control is received. The Immediate Jeopardy that began on [DATE] at 6:42PM was removed on [DATE] at 2:30PM when the facility took the following actions to remove the immediacy: 1. The corrective action(s) taken for the resident(s) found to have been affected by the deficient practice: R1 did not return to the facility. 2. The corrective action(s) for other resident(s) having the potential to be affected by the same deficient practice: All residents on IV antibiotics have the potential to be affected by this practice. R2 has the potential to be affected by the same deficient practice. All ancillary orders necessary for the care and maintenance of R2's access port were reviewed for accuracy. This was completed on [DATE]. DON confirmed R2's antibiotic orders were correct with the prescribing MD on [DATE]. 3. The measures put into place and a systemic change made to ensure the deficient practice does not reoccur: IT confirmed on [DATE] that the facility contracted Medical Director and Nurse Practitioner have remote access to Point Click Care and Point Click Care Connect. IV antibiotic orders for all current residents were reviewed for accuracy by Infection Preventions to include indication, dosage, access type and location, and all necessary ancillary orders. Any identified discrepancies were brought to the attention of the MD/NP. This was completed on [DATE]. All new admission discharge notes will be reviewed during the AM clinical meeting by Medical Records or designee, the DON or designee, and the MDS coordinator or designee the following business day. All discrepancies will be reported to the MD/NP. Any pharmacy recommended antibiotic dosage changes, discontinuation of antibiotic treatment prior to end date ordered by the facility's contracted MD or NP, or initiation of another antibiotic in lieu of the facility's contracted MD's or NP's prescribed antibiotic treatment will first be approved by the prescribing physician. The DON, Nurse Practitioner, and the Infection Preventionist were educated by the Administrator on how to view new or changed antibiotic orders on the clinical dashboard in Point Click Care. This was completed on [DATE]. Corporate Consultant educated DON on medication and treatment reconciliation for admissions/readmissions. This was completed on [DATE]. 4. To ensure the deficient practice does not reoccur, the corrective actions(s) will be monitored by: The DON or designee will audit all new admission/readmissions to ensure that all orders and diagnoses have been accurately transcribed. This audit will be completed the next business day after each admission/readmission and will be an ongoing review. Any identified issues will be immediately corrected. Infection Preventionist or designee will review the Point Click Care dashboard daily for any new antibiotic orders to ensure that the antibiotic therapy is appropriate. Any changes to existing antibiotic orders or discrepancies will be reported to the MD/NP immediately to ensure that they are aware of the change and notified of the discrepancy. This will be an ongoing review. The QAPI Committee will monitor results for compliance. 5. Completion date systemic changes will be completed: [DATE] The facility removal plan was submitted [DATE] reviewed, revised and accepted [DATE].

Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to implement fall interventions and provide a safe transfer for a severely cognitively impaired resident at risk for falls. The facility failed to follow therapy recommendations for R1's transfer and delayed treatment of R1's injuries. Failing to follow therapy recommendations for R1's transfer resulted in R1 falling backwards and R1 hitting R1's head on the floor and R1 sustaining an Occipital Fracture, Left Hip Fracture, Subarachnoid Hemorrhage (traumatic), Traumatic Intraparenchymal Hemorrhage, and Traumatic Subdural Hematoma. R1 subsequently died on [DATE] while on Hospice care. These failures affect one (R1) of four residents reviewed for falls on the sample list of four residents. The immediate jeopardy began on [DATE] when R1 was improperly transferred resulting in R1 falling and sustaining an Occipital Fracture, Left Hip Fracture, Subarachnoid Hemorrhage (traumatic), Traumatic Intraparenchymal Hemorrhage, and Traumatic Subdural Hematoma. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 2:07 PM. The surveyor confirmed by observation, interview and record review that the immediate jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training through ongoing Quality Assurance Performance Improvement (QAPI) review. Findings include: R1's Electronic Medical Record (EMR) reviewed on [DATE] documents R1's new diagnosis of Left Humerus Fracture from [DATE] fall, Occipital Fracture, Left Hip Fracture, Subarachnoid Hemorrhage (traumatic), Traumatic Intraparenchymal Hemorrhage, and Traumatic Subdural Hematoma from [DATE] fall and past medical history of Atrial Fibrillation, Weakness, Need for Assistance with Personal Care, Dementia, History of Falling, Repeated Falls, Convulsions, Inflammatory Spondylopathy Lumbar Region, Trans Ischemic Attack (TIA) and Cerebral Infarction. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as requiring supervision for transfers, bathing, mobility, eating, personal hygiene and walking. R1's Care Plan intervention dated [DATE] instructs staff to place walker in front of R1 for visual cue and [DATE] intervention instructs staff to inform (R1) what you are doing and what is expected of her, apply gait belt, and give verbal/visual cues as needed for safe transfer technique. This same careplan does not include R1's transfer status. R1's Physician Order Sheet (POS) dated [DATE] documents a physician order for Plavix (anti-platelet medication) 75 milligrams (mg) daily. R1's Nurse Progress Note dated [DATE] at 4:47 AM documents (R1) motion alarm sounding. (R1) had fallen in bathroom. (R1) Sitting on bilateral buttocks with both legs extended in front of body. (R1) stating that she had hit back of head on bathroom wall. When asked what (R1) was attempting to do stated I was going to the bathroom, I have to go. Assisted from floor with two assist and gait belt. Bathroom cares provided. Ice pack applied to head. Emergency Services (EMS) called due to (R1) hitting head and taking Plavix. Initially denied pain, approximately five minutes later began complaining of pain to Left Upper Extremity (LUE). R1's X Ray report dated [DATE] documents Reason for exam is Shoulder pain from a fall. Summary: Displaced Fracture Proximal Left Humerus. R1's Physical Therapy Treatment Encounter dated [DATE] (after R1 returned from emergency room after [DATE] fall) documents R1 is not to use a walker and staff are to use a gait belt with transfers while keeping R1's Left Upper Extremity (LUE) immobilized and non-weight bearing due to R1's Left Humerus Fracture sustained in [DATE] fall. R1's Nurse Progress Note dated [DATE] at 6:00 AM documents (R1) was ambulating to the bathroom with walker with (V8) CNA when (R1) stopped responding to (V8) CNA and fell backwards. (V8) CNA was unable to catch (R1). (R1) noted to be in a post-ictal like state. (V8) CNA reported that resident did hit head. (R1) began to become more alert and endorsed pain in her left arm which is currently in a sling due to a humerus fracture. (R1) assisted up via staff and placed in bed. R1's Nurse Progress Note dated [DATE] at 10:44 AM documents (R1) sent out to emergency room . (V22) (Registered Nurse) RN told this nurse that (R1) had a fall last night and hit her head. (R1) unable to put weight on Left Leg and cries out in pain. (V8) CNA told this writer when (R1) fell (V8) CNA noticed (R1's) eyes rolling to the back of head and gagging. (R1) has altered mental status, decreased level of consciousness (LOC) and unable to keep eyes open and respond. R1's Hospital Record dated [DATE]-[DATE] documents R1 transferred to this hospital's trauma unit via air transfer from community hospital due to a mechanism of fall. The record documents (R1) is a [AGE] year old female with multiple prior falls who fell at facility again today (,d+[DATE]) and subsequently developed progressive altered mental status (AMS) and is incomprehensible moaning at this time. This same report documents R1 showed tenderness to her Posterior Scalp and her pupils were pinpoint bilaterally. This same report documents R1's Computerized Tomography (CT) results as Acute Sub Arachnoid Hematoma along the bilateral frontal lobes, five millimeter (mm) Left Convexity Acute Subdural Hematoma, three (millimeter) mm Rightward midline shift, Right Parietal Lobe chronic infarction and Nondepressed Left Occipital Bone Fracture. This same report documents This is a significant brain injury and is not survivable in her condition. [AGE] year old woman status post fall now with multifocal Subarachnoid and Holohemispheric Left Subdural Hematoma. In the setting of age, significant prior stroke, and Dementia-this is a non-survivable injury. R1's Final Incident Report to State Agency dated [DATE] documents R1 fell on [DATE] at 5:10 AM while being transferred by staff to the bathroom. (V8) CNA was ambulating with (R1) to the bathroom when (R1) stopped responding to V8 CNA, stared forward and did not blink. R1 fell backwards before (V8) could catch her. (R1) appeared to be in a post-ictal state, mentation slowly improved and staff assisted (R1) up and into bed. (R1) given pain medication. R1 obtained a 'Hemorrhage, Fractured Occipital Bone and Left Hip Fracture. R1's Physician Progress Note dated [DATE] documents. (R1) readmitted on [DATE] post fall at facility, hit her head and has skull fracture with Subdural bleed. Is pending Hospice admission for comfort cares. On [DATE] at 3:00 PM R1 was laying in bed with eyes closed. R1's brows were furrowed and hands were laying on top of covers in a clenched position. The Nurse Progress note dated [DATE] at 10:45 am documents R1 died at the facility. On [DATE] at 10:48 AM V12 Certified Nurse Aide (CNA) stated V12 came on duty the early morning of [DATE] and heard 'commotion' from R1's room. V12 stated I went to (R1's) room and saw (R1) laying on the floor with her feet towards the bathroom door and her head was towards the room door. (R1) was laying on her back. (R1's) eyes were going back and forth real fast. (V8) CNA told me that (V8) was taking (R1) to the bathroom and (R1) fell straight back and hit her head hard two or three times. (R1) did not have a gait belt on and I didn't see one in the room. (V2) Director of Nurses (DON) told us (V8, V12) to get R1 up and lay her on (R1's) bed so we did. (R1) wasn't walking very well. (R1) was still pretty out of it. (R1) was vomiting and I was afraid she was going to choke on her own vomit so I got her laid on her side on the bed. (R1) was coughing and choking. It was so scary. We (V8, V12) told (V2) about (R1) vomiting and gagging. (V2) had stepped out of the room to get the IPAD to call the telehealth doctor. On [DATE] at 1:05 PM V2 Director of Nurses (DON) stated V8 Certified Nurse Aide (CNA) was walking R1 to the bathroom. V2 stated R1 quit responding when V8 opened the bathroom door. V2 stated V2 was told R1 had a blank stare and then fell backwards. V2 DON stated V2 was at the nurses station when R1 fell . V2 stated When I saw (R1), she was laying on her back on the floor with her head towards the door and her feet towards the bathroom. (R1) was somewhat responsive but not as much as usual. (R1) was complaining of pain in her Left Arm. They (V8, V12) got (R1) back to bed. I gave (R1) a pain pill which she took orally. (R1) seemed very drowsy but was able to answer some basic questions. I had left the room to get the IPAD to call telehealth. When I returned with the IPAD, (R1) was laying in bed and looked like she was resting ok. I didn't see a gait belt laying around anywhere or on (R1). The telehealth doctor was able to see (R1) laying in bed with her eyes closed and gave orders to keep monitoring her and return the call if (R1's) mentation changes. V2 DON stated R1 had a post-ictal stare, only moved her hands and made a 'm-m-m' noise. V2 DON stated V2 did not see R1 vomit but did observe R1 'swallow hard' several times as if she was trying to swallow something. V2 stated V2 re-assessed R1 and found no changes in her mentation until the time V2 left that morning at 6:20 AM. V2 stated (V22 Registered Nurse (RN)) dayshift nurse was informed of R1's fall and change in condition. V2 DON stated at the time of her [DATE] fall R1 required supervision and a walker to ambulate. On [DATE] at 11:35 AM V20 Licensed Practical Nurse (LPN) stated I came into work on [DATE] at 10:00 AM. As soon as I got report from (V22) RN about (R1), I briefly assessed (R1) and knew that she needed to be sent to the emergency room . I didn't even do the full neuros (Neurological Assessment) because it was obvious something was really wrong. On [DATE] at 1:05 PM V8 Certified Nurse Aide (CNA) stated she went into R1's room ([DATE]) to find R1 sitting up in bed. V8 stated R1 sat up on the side of the bed and was 'a little woozy.' V8 stated V8 gave R1 a non-wheeled walker to use to walk to the bathroom. V8 did not use a gait belt during transfer or walking R1 to the bathroom. V8 CNA stated she was not aware that R1 had previously broken her arm but R1 was wearing a sling on her left arm. V8 CNA stated she instructed R1 to use the walker with her Right hand. V8 CNA stated just before reaching bathroom, R1 became unresponsive and had a blank stare. V8 CNA stated There was something definitely wrong. (R1) had a thousand-mile stare. (R1) wouldn't respond to me. I was standing behind her and when she stopped, I walked in front of her to open the bathroom door. (R1) wasn't wearing a gait belt. That is when (R1) fell backward. (R1) didn't bend her knees or anything. (R1) fell like a tree. (R1) hit her head hard and it bounced off of the floor two to three times. The nurse (V2) Director of Nurses (DON) came into (R1's) room. (V2) told me to get her to bed so we (V8, V12) got her up and moved her to her bed. Then (V2) came back in with the IPAD for the doctor to see her. (IPAD described as an off-site video doctor exam). On [DATE] at 11:25 AM V11 Director of Rehab Services stated V11 worked with R1 prior to her [DATE] fall and then again between her [DATE] fall and [DATE] fall. V11 stated R1 had a major decline in her cognition and physical abilities since her [DATE] fall, but 'especially after her [DATE] fall.' V11 stated prior to R1's fall on [DATE] she was able to walk with supervision about the facility. V11 stated after R1's fall on [DATE] where she obtained a Left Humerus Fracture R1 was wearing a sling on her Left Arm for immobilization. V11 stated when working with R1 after her [DATE] fall, V11 only provided physical therapy while R1 was laying in bed. V11 stated It was just too painful for her to get up and move very much so we focused on strengthening and positioning while (R1) was in bed. If the staff were getting her up, they should have been using a gait belt and wheelchair. V11 stated R1 had very poor safety awareness but was 'very compliant and re-directable.' On [DATE] at 3:40 PM V14 Medical Director stated R1 fell on ,d+[DATE] at the facility during a witnessed fall. V14 confirmed R1 was not transferred safely which contributed to R1's fall. V14 Medical Director stated anytime a resident has a witnessed fall and they 'hit hard' such as R1 did on ,d+[DATE], that resident should be automatically sent to the emergency room . V14 stated You don't need a Physician order to send one of the residents to the emergency room for evaluation. That is left to the nurse's critical thinking skills. V14 stated the facility should have sent R1 to the emergency room immediately after the fall. V14 stated moving R1 could have worsened her injuries. V14 stated R1 sustained several major injuries which could affect her neurological status. V14 stated due to R1's previous fall on [DATE] where she had a Left Humerus Fracture, the staff should have known to use a gait belt on her and monitor her more closely. The facility policy titled 'Neurological Assessment' revised [DATE] documents a change in the level of consciousness constitutes the most significant or earliest sign of neurological deterioration. It must be accessible in in all situations. If there is a decline in the level of alertness, orientation, then the complete neurological assessment should be performed. When performing a neurological assessment, be sure to record the best response obtained. Documentation should be made in the nurse's notes or on a flow sheet, describing the required aspects, including bowel and bladder functioning. Always be complete, specific and compare the Right side of the body with the Left. Dangerous trends that need to be reported to the physician are: any pupillary reaction changes, especially with a decrease in level of consciousness, any decrease in level of consciousness from baseline assessment or from resident normalcy, any sensory or motor loss or decline, any marked changed in vital signs; other significant symptoms include nausea and vomiting, seizure activity, visually disturbances and headache. Neurological Assessments should be performed as follows for a 72 hour period, unless otherwise ordered by the attending physician: Every 15 minutes times four times, every one hour times four time, every two hours times eight times and every four hours until 72 hours is complete. The undated facility policy titled 'Gait Belt Policy and Procedure' documents facility staff will utilize a gait belt around a resident's waist to help transfer the resident to the destination safely unless contraindicated by medical condition or use of mechanical lift. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. V2 Director of Nurses (DON), V16 Registered Nurse (RN)/Restorative Nurse and V34 Minimum Data Set (MDS)/Licensed Practical Nurse (LPN) provided inservicing to nursing staff on where to find individual transfer instructions, types of transfer instructions and the provision of safety during those transfers which began on [DATE] and was completed with inservicing V33 Agency Registered Nurse (RN) on [DATE] after V33 provided care for residents on [DATE] and [DATE]. Inservicing was completed by V2 Director of Nurses, V16 Registered Nurse (RN)/Restorative Nurse and V34 RN/Minimum Data Set (MDS) Coordinator. 2. V2 Director of Nurses (DON) inserviced nursing staff on Neurological Assessments on [DATE]. 3. V16 Registered Nurse (RN)/Restorative Nurse (RN) started re-evaluating all residents for risk fall risk on [DATE]. V16 reviewed resident care plans for up to date fall care plans and fall interventions. The facility has not had any new admissions since [DATE] per V1 Administrator. V16 RN/Restorative nurse will continue to review all new residents for risk of falls and ensure fall care plan with fall interventions are in place. V2 DON and V16 RN/Restorative Nurse provided inservicing to nursing staff on fall interventions on [DATE]. V33 Agency RN worked with residents providing direct cares on [DATE] and [DATE]. V33 Agency RN received her fall training on [DATE] midshift. 4. V1 Administrator stated on [DATE] that the facility fall policy was reviewed and revised on [DATE]. V1 Administrator stated the 'Falls-Clinical Protocol' Policy was revised to add section that reads If a resident is on anticoagulation or anti-platelet medications then initiate neurological checks. If a resident is on anticoagulation then send resident to the emergency room for an evaluation. V34 RN/MDS stated all residents on anticoagulation or antiplatelet therapies were also added an 'alert' line on the face sheet of their Electronic Medical Record (EMR). 5. V1 Administrator stated on [DATE] the facility Quality Assurance Performance Improvement (QAPI) team met on [DATE] and resident falls were discussed. V1 stated the next QAPI meeting is [DATE]. 6. V1 Administrator, V2 DON, V16 RN/Restorative Nurse and V34 MDS/LPN all stated the facility has a new plan to monitor any new residents for fall risk, implement a baseline fall careplan with interventions and also ensure that any current resident who has a fall will have their careplan reviewed and fall interventions updated by V16 Restorative Nurse/RN. V1 Administrator stated the facility will also implement fall training in all new hire orientation. V2 DON stated audits will be completed for chart review items as well as random on the spot gait belt observations. The facility presented an abatement plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on [DATE], and the survey team accepted the abatement plan on [DATE]. B. Based on interview and record review the facility failed to implement fall interventions for one (R2) of four residents reviewed for falls in a sample list of four residents. Findings include: R2's undated Medical Diagnosis List documents R2's medical diagnoses as Orthostatic Hypotension, Atrial Fibrillation, Heart Failure, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Abnormalities of Gait and Mobility, Dementia with Agitation, Need for Assistance with Personal Care, Unsteady on Feet and Repeated Falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired and requires maximum assistance for toileting and moderate assistance (helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for toilet transferring. R2's Care Plan documents a fall intervention dated [DATE] for staff to supervise transfers providing (R2) with verbal/visual cues as needed for safe transfer technique (i.e. push up from bed/chair to stand and reach back before sitting). Staff to provide physical assistance as needed while encouraging (R2's) highest level of functioning. R2's Nurse Progress Note dated [DATE] at 12:30 PM documents (R2) had fallen in bathroom and hit her head. (R2) complained of (c/o) pain in her head, neck, and lower back. (R2) sent to emergency room for evaluation. R2's Post Fall Evaluation dated [DATE] documents R2 slipped while washing her hands in the bathroom R2's Hospital Record dated [DATE] documents R2 was seen in the emergency room after having a nonsyncopal fall (slipped off the toilet) at facility and hit head. R2's hospital diagnosis documents Likely closed head injury. On [DATE] at 11:05 AM V35 stated I wheeled (R2) back to her room from the dining room in her wheelchair. (R2) said she needed to use the bathroom so I assisted her to the toilet. I left (R2) alone in the bathroom to go get some towels. Then I heard (R2) hit the floor in her bathroom. (R2's) feet were tangled up in her wheelchair. (R2) was sitting against the wall of her bathroom on the floor with her arm leaning on the garbage can. (R2) hit the back of her head. On [DATE] at 1:50 PM V16 Registered Nurse (RN)/Fall Nurse stated V35 CNA should not have left R2 in the bathroom unattended. V16 stated R2 had recent falls and required closer supervision. The facility assessment updated [DATE] documents the facility will respond to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity.

Based on interview and record review the facility failed to transfer residents to the hospital timely for evaluation, notify the physician of a resident's change in condition, and provide medical care timely after falls for two of four residents (R1 and R4) reviewed for falls on the sample list of four residents. Failing to transfer R1 to the hospital timely and notify the physician of neurological changes after R1 fell resulted in a delay in treatment and R1 experiencing pain and vomiting. Findings include: 1.) R1's undated Medical Diagnosis List documents R1's medical diagnoses as Atrial Fibrillation, Weakness, Need for Assistance with Personal Care, Dementia, History of Falling, Repeated Falls, Convulsions, Inflammatory Spondylopathy Lumbar Region, Transischemic Attack (TIA) and Cerebral Infarction. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as requiring supervision for transfers, bathing, mobility, eating, personal hygiene and walking. R1's Nurse Progress Note dated 5/5/24 at 6:00 AM documents (R1) was ambulating to the bathroom with walker with (V8) CNA when (R1) stopped responding to (V8) CNA and fell backwards. (V8) CNA was unable to catch (R1). (R1) noted to be in a post-ictal like state. (V8) CNA reported that resident did hit head. (R1) began to become more alert and endorsed pain in her left arm which is currently in a sling due to a Humerus fracture. (R1) assisted up via staff (V8, V12) and placed in bed. R1's Nurse Progress Note dated 5/5/24 at 10:44 AM documents (R1) sent out to emergency room . (V22) RN told this nurse that (R1) had a fall last night and hit her head. (R1) unable to put weight on Left Leg and cries out in pain. (V8) CNA told this writer when (R1) fell (V8) CNA noticed (R1's) eyes rolling to the back of head and gagging. (R1) has altered mental status, decreased level of consciousness (LOC) and unable to keep eyes open and respond. R1's Hospital Record dated 5/5/24-5/8/24 documents R1 transferred to this hospital's trauma unit via air transfer from community hospital due to a mechanism of fall. The record documents (R1) is a [AGE] year old female with multiple prior falls who fell at facility again today (5/5) and subsequently developed progressive altered mental status (AMS) and is incomprehensible moaning at this time. This same report documents R1 showed tenderness to her Posterior Scalp and her pupils were pinpoint bilaterally. This same report documents R1's Computerized Tomography (CT) results documents R1's Acute Sub Arachnoid Hematoma along the bilateral frontal lobes, five millimeter (mm) Left Convexity Acute Subdural Hematoma, three mm Rightward midline shift, Right Parietal Lobe chronic infarction and Nondepressed Left Occipital Bone Fracture. This same report documents This is a significant brain injury and is not survivable in her condition. [AGE] year old woman status post fall now with multifocal Subarachnoid and Holohemispheric Left Subdural Hematoma. In the setting of age, significant prior stroke, and Dementia-this is a non-survivable injury. R1's Final Incident Report to State Agency dated 5/5/24 documents R1 fell on [DATE] at 5:10 AM while being transferred by staff to bathroom. (V8) CNA was ambulating with (R1) to the bathroom when (R1) stopped responding to V8 CNA, stared forward and did not blink. R1 fell backwards before (V8) could catch her. (R1) appeared to be in a post-ictal state, mentation slowly improved and staff assisted (R1) up and into bed. (R1) given pain medication. R1 obtained a 'Hemorrhage, Fractured Occipital Bone and Left Hip Fracture'. R1's Physician Progress Note dated 5/9/24 documents (R1) readmitted on [DATE] post fall at facility, hit her head and has skull fracture with Subdural bleed. Is pending Hospice admission for comfort cares. On 5/14/24 at 10:48 AM V12 Certified Nurse Aide (CNA) stated V12 came on duty the early morning of 5/5/24 and heard 'commotion' from R1's room. V12 stated I went to (R1's) room and saw (R1) laying on the floor with her feet towards the bathroom door and her head was towards the room door. (R1) was laying on her back. (R1's) eyes were going back and forth real fast. (V8) CNA told me that (V8) was taking (R1) to the bathroom and (R1) fell straight back and hit her head hard two or three times. (R1) did not have a gait belt on and I didn't see one in the room. (V2) Director of Nurses (DON) told us (V8, V12) to get R1 up and lay her on (R1's) bed so we did. (R1) wasn't walking very well. (R1) was still pretty out of it. (R1) was vomiting and I was afraid she was going to choke on her own vomit so I got her laid on her side on the bed. (R1) was coughing and choking. It was so scary. We (V8, V12) told (V2) about (R1) vomiting and gagging. (V2) had stepped out of the room to get the IPAD to call the telehealth doctor. On 5/14/24 at 1:05 PM V2 Director of Nurses (DON) stated V8 Certified Nurse Aide (CNA) was walking R1 to the bathroom. V2 stated R1 quit responding when V8 opened the bathroom door. V2 stated V2 was told R1 had a blank stare and then fell backwards. V2 DON stated V2 was at the nurses station when R1 fell . V2 stated When I saw (R1), she was laying on her back on the floor with her head towards the door and her feet towards the bathroom. (R1) was somewhat responsive but not as much as usual. (R1) was complaining of pain in her Left Arm. They (V8, V12) got (R1) back to bed. I gave (R1) a pain pill which she took orally. (R1) seemed very drowsy but was able to answer some basic questions. The telehealth doctor was able to see (R1) laying in bed with her eyes closed and gave orders to keep monitoring her and return the call if (R1's) mentation changes. On 5/14/24 at 2:40 PM V36 (R1) Power of Attorney (POA) for Healthcare stated As soon as (R1) fell , they (facility) should have just called for the ambulance. We (family) had not planned on (R1) going on hospice. Before these last two falls, (R1) was up walking all over, eating well, talking with staff. Even with (R1's) Dementia she was living a good life. After the fall on 5/5/24 the hospital told us that she would not survive because of that fall. It is really sad. On 5/15/24 at 10:35 AM V23 Certified Nurse Aide (CNA) stated V23 worked 6:00 AM-2:00 PM on 5/5/24. V23 stated V23 was told in verbal report that R1 had fallen earlier that morning. V23 stated I was told (R1) fell , hit her head hard and her eyes were rolling back in her head and she was gagging a bit. I was told that (V8) CNA was the only person with (R1) and didn't have a gait belt on her. I was told to keep an eye on her. I helped (V17) take her to the toilet at 9:00 AM. (V22) Registered Nurse (RN) told us (V17, V23) to get (R1) out of bed, take her to the bathroom, get her dressed and bring her out to the nurses medication cart so (V22) RN could see her better. (R1) was not right. (R1) was moaning and crying out in pain. That was the first time I saw (R1) was at 9:00 AM. We (V17, V23) did what (V22) asked in getting (R1) up. (R1) was not right. I have taken care of (R1) plenty of times and she was not right. On 5/15/24 at 10:50 AM V22 Registered Nurse (RN) stated V22 was R1's day shift nurse on 5/5/24. V22 RN stated I came in and got in report from (V2) Director of Nurses (DON) that (R1) had fallen, hit her head and was not sent in to the emergency room but resting in her room. V22 RN stated V22 was aware R1 was in the beginning of her Neurological Assessments and should have assessed R1 more frequently. V22 RN stated V22 assessed R1's Neurological status at 6:55 AM and again at 7:55 AM. V22 stated When I assessed (R1) at 6:55 AM she was complaining of pain in her hip, leg and arm so I gave her a pain pill. (R1) was moaning and crying out. (R1) was not responding as per her normal. I should have sent (R1) to the emergency room as soon as I saw her but didn't because I was too busy. (R1) should have had better care. I feel awful. V22 RN stated V20 Licensed Practical Nurse (LPN) came on duty at 10:00 AM. V22 RN stated she waited until V20 LPN came on duty to have V20 send R1 to the emergency room . V22 RN stated (V22) told them (V17, V23) Certified Nurse Aides (CNA) to get (R1) up out of bed, assist her to the toilet and then get her dressed and bring her to me. I can't assess a resident in these rooms. There is not enough light. When they (V17, V23) brought her to me (R1) couldn't stand. I asked (V17, V23) to stand (R1) up out of her wheelchair. (R1) was not responding very well. (R1) was screaming in pain as I assessed her. This was about 9:00 AM. (V20) LPN came in at 10:00 AM and got (R1) sent out for me. On 5/15/24 at 11:32 AM V17 Certified Nurse Aide (CNA) stated V17 was assigned as R1's CNA on 5/5/24. V17 stated I checked on (R1) and she looked like she was sleeping in her bed. (R1) was moaning in pain. This was about 7:00 AM. I let the nurse (V22) know. I didn't see any real injuries for (R1). (V22) Registered Nurse (RN) told us (V17, V23) to get (R1) up, dressed, toileted and bring (R1) to (V22) out in the hallway by her medication cart. (V23) and I used a gait belt and walked (R1) to the bathroom. (R1) was not walking right and she was crying out in pain. Even when we (V17, V23) got her up, she was leaning to the side while we were trying to get her to sit on the side of the bed. This was 9:00 AM. We (V17, V23) both told (V22) RN about (R1's) pain and change in her overall condition. On 5/16/24 at 11:35 AM V20 Licensed Practical Nurse (LPN) stated I came into work on 5/5/24 at 10:00 AM. As soon as I got report from (V22) RN about (R1), I briefly assessed (R1) and knew that she needed to be sent to the emergency room . I didn't even do the full neuros (Neurological Assessment) because it was obvious something was really wrong. I am not sure why (R1) was not sent out to begin with right after she fell but I wasn't going to let (R1) suffer any longer. On 5/15/24 at 3:40 PM V14 Medical Director stated R1 fell on ,d+[DATE] at the facility during a witnessed fall. V14 confirmed R1 was not transferred safely which contributed to R1's fall. V14 Medical Director stated anytime a resident has a witnessed fall and they 'hit hard' such as R1 did on 5/5, that resident should be automatically sent to the emergency room . V14 stated You don't need a Physician order to send one of the residents to the emergency room for evaluation. That is left to the nurse's critical thinking skills. V14 stated the facility should have sent R1 to the emergency room immediately after the fall. V14 stated moving R1 could have worsened her injuries. V14 stated R1 sustained several major injuries which could affect her neurological status. On 5/15/24 at 3:00 PM V1 Administrator stated the facility should have called 911 emergency services for R1 at the time of her fall on 5/5/24. V1 Administrator stated I am not a nurse but would definitely consider (R1's) fall on 5/5/24 an emergent situation. Telehealth is a service that is available to our nursing staff for after hours Physician notification but it is not meant for emergency situations as what happened with (R1). 2.) R4's undated Medical Diagnosis List documents R4's medical diagnoses as Diabetes Mellitus Type II, Chronic Congestive Heart Failure, Kidney Failure, Persistent Atrial Fibrillation, Muscle Weakness, Abnormalities of Gait and Mobility, Dementia, Unsteady on Feet and History of Falling. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires maximum assistance for toileting, bathing, dressing, personal hygiene and transfers. R4's Physician Order Sheet (POS) dated May 2024 documents a physician order starting 4/5/24 for Apixaban (anticoagulant) 2.5 milligrams (mg) daily. R4's Fall Evaluation dated 5/5/24 documents R4 obtained a Laceration below R4's Left Eyebrow measuring 1.2 centimeters (cm) long by 0.5 cm wide by no measurable depth and a laceration to R4's Left Eyebrow measuring 1.5 cm by 0.8 cm by no measurable depth. R4's undated Fall Investigation documents R4 had an unwitnessed fall on 5/5/24 at 1:45 AM. This same report documents R4 observed in R4's bed approximately one hour prior to fall and was last toileted at 10:00 PM on 5/4/24. This same report documents R4 requires the assistance of one person and a walker, is severely cognitively impaired, and was found lying on the floor in the doorway of R4's room face down. The report documents R4 had one shoe on and the other half on/half off and R4 obtained two lacerations to his Left Eye and the wound was cleansed and steri strip applied. R4's Medication Administration Record (MAR) dated May 2024 documents R4 rated his pain at a three out of ten and was administered Acetaminophen 650 milligrams (mg) at 6:00 AM on 5/5/24. R4's Physician Progress Note dated 5/5/24 (no time documented) documents physician orders for Left Hip, Unilateral with Pelvis when performed, 2-3 views/Facial Bones, less than 3 views/Left Radiologic examination, femur; minimum 2 views, completed 5/6/24. R4's Nurse Progress Note dated 5/5/24 at 9:00 PM documents R4 was sent to the emergency room due to (R1) screaming 'somebody help me' due to Inguinal pain. R4's Nurse Progress Note dated 5/6/24 at 10:47 AM documents (R4's) order for Hip/Pelvis and Femur of Left side made via portable X-Ray. On 5/15/24 at 11:45 AM R4 was laying in his bed. R4 stated I don't remember exactly what happened but I know I fell . My eye (rubbing his Left eye) still hurts. I have problems holding my urine. If I have to go to the bathroom then I need to go as soon as I can get there. On 5/15/24 at 2:30 PM V2 Director of Nurses (DON) stated the night (5/5/24) R4 had an unwitnessed fall R4 was trying to find someone to help him get to the bathroom. V2 DON stated (R4) got up from bed and walked to the doorway of his room where he was found. (R4) had a goose egg and laceration on his Left eyebrow/forehead area. I provided first aid, the staff got him back up and helped him to the bathroom. On 5/17/24 at 1:00 PM V1 Administrator stated any resident on an anticoagulant who has fallen and obtained a head injury should be sent to the emergency room . V1 stated I am not sure why we (facility) waited to get the X-Rays done but we should have called for them that morning (R4) fell . (R4) could have had an internal injury that we couldn't see from the outside and we would never have known. The facility policy titled 'Falls and Fall Risk, Managing' revised August 2008 documents the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. Staff will identify and implement relevant interventions (e.g. hip padding or treatment of Osteoporosis, as applicable) to try to minimize serious consequences of falling. The staff, with the Physicians guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or Subdural Hematoma have been ruled out or resolved.

Based on observation, interview and record review the facility failed to implement fall prevention interventions to prevent falls for three of three residents (R2, R3, R4) reviewed for falls in the sample list of five. These failures resulted in R2 and R3 falling and suffering head lacerations that required staples at the emergency room . Findings include: The facility's Falls - Clinical Protocol policy with a revised date of August 2008 documents, As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The facility's Falls and Fall Risk, Managing policy with a revised date of August 2008 documents, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility's undated Gait Belt Policy & Procedure documents, It is the policy of this facility that gait belts are utilized on all residents requiring physical assistance with transfer unless contraindicated. The gait belt will be utilized for any resident that has been assessed to need a mechanical lift or stand by assist for safe transfer ability. 1.) R2's Order Summary Report documents diagnoses including Radiculopathy Lumbar Region, Other Malaise, Low Back Pain, Weakness, Morbid Obesity, Other Intervertebral Disc Degeneration Lumbar Region, Discitis Lumbar Region, Muscle Weakness, Unsteadiness on Feet and Difficulty in Walking. This Order Summary Report documents an order for Apixaban (anticoagulant) 5 mg (milligrams) twice a day with a start date of 10/4/23. R2's Care Plan dated 10/5/23 documents R2 is at risk for falls related to gait/balance problems, unaware of safety needs, Pain, Incontinence, Obesity, Depression, limited/decreased mobility, Osteoarthritis and Restless Leg Syndrome with an intervention to maintain a clear pathway in the room and free of obstacles. This Care Plan does not document how R2's transfers or ambulates. R2's Minimum Data Set (MDS) dated [DATE] documents R2 requires partial/moderate assistance for moving from a sitting position to a standing position, transferring from a chair to the bed or wheelchair and to walk 10 feet. Partial/moderate assistance is documented as the helper lifts, holds or supports the trunk or limbs. This MDS documents R2 has moderately impaired cognition with a BIMS (Brief Interview for Mental Status) of 11/15. The facility's Detailed Incident Summary dated 1/16/24 completed by V2 Director of Nursing documents on 1/10/24 at 1:00 AM, R2 turned on the call light for assistance to ambulate to the bathroom. V3 Certified Nursing Assistant assisted R2 with the walker and began ambulating to the bathroom. R2 requested V3 move a trash can. V3 bent down, picked up the trash can and turned to set it down when V3 heard R2's walker rattle. V3 was unable to catch R2 before R2 fell . The nurse on duty assessed R2 and R2 had a laceration on the back of the head. R2 was sent to the emergency room . R2's emergency room note dated 1/10/24 documents Patient Discharge Instruction which documents 6 staples, discharge diagnoses of a Fall - Primary and Laceration of Head - Primary. R2's Computed Tomography (CT) scans dated 1/10/24 document no acute fractures. R2's CT of the head dated 1/10/24 at 1:53 AM documents Clinical History/Indication for exam as pain - [AGE] year old female in emergency room (ER) after a fall hitting the back of (R2's) head, laceration to the back of the head. This ER report documents R2 received Fentanyl (narcotic pain reliever) IV (Intravenous) push of 50 mcg (micrograms) at 2:30 AM, Fentanyl 25 mcg IV push at 2:45 AM and Fentanyl 25 mcg IV push at 4:10 AM. This ER report documents wound care type - laceration to posterior head measuring 6 cm (centimeters) long by 0.5 cm wide by 0.25 cm deep. This report documents observed behaviors of R2 as grimacing, guarding, moaning and restraint to movement. On 1/29/24 at 1:04 PM, V3 Certified Nursing Assistant (CNA) stated that on 1/10/24 V3 answered R2's call light. V3 stated R2 needed to go to the bathroom so V3 moved the bedside table and assisted R2 to stand with the walker in front of R2. V3 stated R2 requested V3 move a trash can out of the way and V3 stated V3 bent over to move it and as V3 turned around R2 was falling to the floor. V3 stated that V3 got assistance from the nurse and sat R2 up and saw blood and the nurse called EMS (Emergency Medical Services) and they transferred R2 to the hospital. V3 confirmed V3 did not use a gait belt on R2 during the transfer and did not keep hands on R2 the entire time. On 1/29/24 at 1:29 PM, V2 Director of Nursing stated that V3 did not use a gait belt when transferring R2 but should have used a gait belt. On 1/30/24 at 8:55 AM, R2 stated that R2 was getting out of bed and the next thing R2 knew was R2 fell and hit the bottom part of the bed frame with the back of R2's head. R2 stated that R2 has right sided neck pain now after the fall. On 1/30/24 at 9:29 AM, V6 Physical Therapy Assistant/Director of Rehab stated that at the time of the fall on 1/10/24 that R2 would have required the assistance of one staff member. V6 confirmed that assistance should have been with a gait belt and hands on R2 for transfers. On 1/30/24 at 10:33 AM, V7 CNA/RNA (Restorative Nursing Assistant) and V5 CNA applied a gait belt to R2 while R2 was in the wheelchair and they both assisted R2 with hands on the gait belt to shuffle R2's feet over to the recliner and R2 sat down. V7 and V5 removed the gait belt and gave R2 the call light cord. On 1/30/24 at 11:08 AM, V4 Advanced Practice Registered Nurse confirmed that R2's fall on 1/10/24 caused the laceration to the back of R2's head and required an emergency room visit for 6 staples to close the wound. 2.) R3's Care Plan dated 1/15/24 documents R3 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Sleep Disorder, Orthostatic Hypotension, Weakness, Difficulty in Walking, History of Falling, Unspecified Dementia, Other Spondylosis with Radiculopathy Thoracic Region and Low Back Pain. This Care Plan documents R3 is at risk for falls related to gait/balance problems, Pain, Restless Leg Syndrome, Type 2 Diabetes, History of Falls, Unsteady Gait, Low Back Pain and Parkinson's disease dated 1/15/2024 with an intervention of a bed alarm and a chair alarm dated 1/18/24 and ensure that R3 is wearing appropriate footwear when transferring, ambulating or mobilizing in the wheelchair dated 1/15/2024. R3's MDS dated [DATE] documents R3 requires partial/moderate assistance for moving from a sitting position to a standing position, transferring from a chair to the bed or wheelchair and to walk 10 feet. Partial/moderate assistance is documented as the helper lifts, holds or supports the trunk or limbs. This MDS documents R3 has severe cognitive impairment. R3's Incident Investigation for 1/19/24 at 6:00 PM documents R3 had a prior fall on 1/18/24. This report documents a Summary of events/situation as the CNA entered R3's room and positioned R3 on the edge of the bed to eat R3's dinner with the tray in front of R3 and feet on the floor. This CNA exited the room. Approximately 15 to 20 minutes later another CNA heard a crash and responded to R3's room. R3 was bleeding from the left side of R3's head. Pressure was applied and EMS was called. This report documents that in the emergency room R3 had a laceration to the left side of the head closed with 5 staples. A CT scan was completed at that time and was clear. R3 returned to the facility. This Investigation includes a statement from V12 CNA which documents when V12 last saw R3 sitting on the edge of the bed that R3 had regular socks on. R3 Nurse's Note dated 1/19/24 at 6:00 PM by V13 Licensed Practical Nurse documents when V13 first saw R3 on the floor R3 was in a T-shirt and an incontinence brief with no pants on and no socks on R3's feet (barefoot). On 1/30/24 at 11:24 AM, V2 Director of Nursing stated that there was a conflict in stories that R3 did have socks on when R3 fell but they immediately implemented that R3 was to have gripper socks on at all times after this fall. V2 confirmed that R3 is not currently in the facility as R3 had to return to the hospital on 1/22/24. 3.) R4's Care Plan with an updated date of 1/3/24 documents diagnoses including Unspecified Dementia, Weakness, Adjustment Disorder, Unspecified Convulsions, History of falls, history of falls with fractures, Unsteadiness on Feet, Age Related Osteoporosis and Repeated Falls. This Care Plan documents R4 is at risk for falls related to a history of a fall with fracture of the right femur with right hemiarthroplasty, Dementia, A-Fib (Atrial Fibrillation) and Seizure Disorder. This Care Plan documents interventions of a bed and chair alarm due to decreased safety awareness and impulsivity with an initiated date of 4/20/2023 and a non slip mat to the recliner dated 9/22/22. On 1/30/24 at 8:47 AM, R4 was in the recliner in R4's room sleeping with the walker sitting in front of R4. There was no alarm on the recliner. There was a pressure alarm pad with the alarm box on the wheelchair sitting by the door but not on the recliner. On 1/30/24 at 9:18 AM, R4 was still in the recliner in R4's room with no alarm on the recliner. R4 is awake sitting in the recliner. On 1/30/24 at 9:19 AM, V5 CNA stated that R4 is supposed to have the alarm in the recliner but she hasn't gotten it moved to the recliner yet. At this time V5 had R4 stand up with the walker and V5 moved the alarm from the wheelchair to the recliner. The non slip pad remained in the wheelchair and it did not get moved to the recliner.

Based on interview and record review the facility failed to obtain ordered kidney function laboratory work and failed to complete neurological exams following a fall with a head injury for one of three residents (R3) reviewed for falls. These failures resulted in R3 being admitted to the hospital for Acute Kidney Injury, Dehydration and Altered Mental Status. Findings include: The facility's Falls-Clinical Protocol policy with a revised date of August 2008 documents, Assessment and Recognition 2. In addition, the nurse shall assess and document/report the following: a. vital signs b. Recent injury, especially fracture or head injury c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. (etcetera) d. Change in cognition or level of consciousness e. Neurological status. This policy also documents, Monitoring and Follow-Up. 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. The facility's undated Neurological Assessments Procedures provided by V2 Director of Nursing on 1/30/24 at 11:30 AM documents, Neurological assessments should be performed as follows for a 72 hour period, unless otherwise ordered by the attending physician. Every 15 minutes x (times) 4, Every 1 hour x 4, Every 2 hours x 8, Every 4 hours until the 72 hour time period is complete. Notify the physician of any significant change in neurological status immediately. 1.) R3's hospital History and Physical dated 1/3/24 documents R3 was admitted to the hospital for a fall with renal and splenic hematomas. This History and Physical documents laboratory levels for the BUN (Blood Urea Nitrogen) (test for kidney function) of 23 mg/dl (milligrams/deciliter) (5-25 normal range) and Creatinine (test for kidney function) of 1.45 mg/dl (0.5-1.4 normal range). R3's hospital after visit summary dated 1/12/24 documents to repeat the BMP (Basic Metabolic Panel) (includes BUN and Creatinine) within 5-7 days of discharge (discharge of 1/12/24). R3's Physician's Order documents an order for a BMP 5-7 days post hospital discharge with a start date of 1/17/24 and a stop date of 1/18/24. R3's medical record does not contain a BMP after admission on 1/12/24. R3's Nurse's Note dated 1/22/24 at 12:05 PM by V4 Advance Practice Registered Nurse documents that V4 called R3's Power of Attorney (POA) and reported R3's increased altered mental status, poor oral intake and headache. This note documents POA stated that R3 was not R3's self yesterday and agreed to send R3 to the emergency room . EMS (Emergency Medical Services) called and R3 sent to the hospital. R3 Nurse's Note dated 1/22/24 at 9:07 PM by V10 Registered Nurse documents V10 spoke to the hospital and R3 was admitted with diagnoses including Acute Kidney Injury, Dehydration and Altered Mental Status. On 1/30/24 at 1:34 PM, V1 Administrator confirmed R3's BMP did not get completed and V1 does not know why. On 1/30/24 at 2:30 PM, V4 Advance Practice Registered Nurse stated if the facility would have completed R3's BMP on 1/17/24 and the values were elevated V4 would have started IV (Intravenous) fluids and that may have kept R3 from having to go to the hospital. R3's hospital laboratory results dated [DATE] document a BUN of 46 (abnormal value) and a Creatinine of 1.5 (abnormal value). 2.) R3's Nurse's Notes dated 1/18/24 at 7:34 PM by V10 Registered Nurse documents at 7:15 PM a CNA (Certified Nursing Assistant) reported to V10 that R3 was found on the floor in front of the wheelchair laying on R3's left side. This note documents that neurological checks were initiated. The Neurological Assessment Flow Sheet documents that neurological checks were initiated at 7:15 PM every 15 minutes x 4, then every hour x 4, then every two hours x 8 with the last one being documented at 2:00 PM on 1/19/24. The next neurological check would have been at 6:00 PM but R3 had another fall. R3's Nurse's Note dated 1/19/24 at 6:00 PM by V13 Licensed Practical Nurse documents they heard a loud noise and the CNA ran to R3's room and R3 had fallen and hit R3's head. R3 had a laceration to the left side of R3's head and was bleeding. EMS (Emergency Medical Service) was called and they took R3 to the emergency room . R3's Nurse's Note dated 1/19/24 at 8:45 PM by V13 documents V13 spoke to the hospital nurse and they stated that R3 had 5 staples placed to the left side of R3's head. R3's Nurse's Note dated 1/19/24 at 11:00 PM by V14 Registered Nurse documents R3 returned from the hospital at 10:15 PM and neurological checks were within normal limits. R3's Neurological Assessment Flow Sheet documents the neurological checks (neuros) were restarted at 10:30 PM and then another at 1:00 AM on 1/20/24 then one more at 5:00 AM. R3's Nurses Notes document that R3 returned to the facility on [DATE] at 10:15 PM which was 4 1/4 hours after the second fall. R3 should have resumed the neuros with one remaining one hour check left and then eight remaining two hours checks and then the four hour checks to get to the 72 hours. R3's Neurological Assessment Flow Sheet only documents three checks being completed after R3 returned from the hospital and only one of those checks were completed at the appropriate time. On 1/30/24 at 11:08 AM, V4 Advance Practice Registered Nurse stated that V4 was under the understanding that the nurses were completing the neurological exams on R3 when R3 came back from the fall on 1/19/24. V4 stated that V4 expects them to pick up the neurological exams when R3 returned at the time frame R3 returned at. V4 stated that V4 examined R3 on 1/22/24 because nursing staff requested due to a change in condition and V4 sent R3 to the hospital for altered mental status. On 1/30/24 at 11:41 AM, V8 Licensed Practical Nurse stated that on 1/21/24 R3 wasn't chewing food well but R3 did not have any bottom teeth so V8 downgraded R3's diet to mechanical soft. V8 stated that R3 would get tired after receiving the Parkinson's Disease medication and that was normal for R3. On 1/30/24 at 11:53 AM, V10 Registered Nurse stated that on 1/22/24 V10 gave R3 the morning medications and R3 took them fine but after breakfast V10 noticed a decline in R3's condition and notified the Nurse Practitioner and V4 Advance Practice Registered Nurse examined R3 and sent R3 to the hospital.

Based on observation, interview and record review the facility failed to provide supervision and ensure fall interventions were in place, failed to supervise/transfer a resident for safety, and failed to provide a safe transfer to prevent falls for three of three residents (R1, R2, R3) reviewed for falls on the sample list of five. Facility staff left R1 sitting on the side of the bed unsupervised and without fall interventions in place resulting in R1 falling and fracturing R1's hip. Facility staff failed to supervise and transfer R2 out of the wheelchair when R2 was falling asleep resulting in R2 falling out of the wheelchair and sustaining lacerations to R2's forehead which required nine sutures. Findings include: 1.) R1's undated Face Sheet documents R1 admitted to facility on 8/15/23. This same Face Sheet documents R1 has medical diagnoses of Right Intertrochanteric Hip Fracture, Encephalopathy, Myelodysplastic Syndrome, Altered Mental Status, Overactive Bladder, Age Related Bilateral Nuclear Cataracts, Malignant Neoplasm of Prostrate, Muscle Weakness, Unsteady on Feet, Need for Assistance for Personal Care and Cognitive Communication Deficit. R1's Brief Interview for Mental Status (BIMS) dated 10/19/23 documents R1 as moderately cognitively impaired. R1's Care Plan documents R1 is at risk for falls due to weakness, unsteady gait, history of falls, Encephalopathy, altered mental status, Diabetes Mellitus Type II, bilateral cataracts, need for assistance with personal care, overactive bladder and sepsis. This same care plan documents fall interventions dated 8/16/23 which instruct staff to ensure R1's call light is within reach and encourage R1 to use it as necessary, keep needed items within reach and 8/18/23 to apply personal alarms. This same Care Plan documents a focus area dated 8/21/23 of R1 being non-compliant with using a call light and waiting for assistance with Activities of Daily Living (ADL). R1's Physician Order Sheet (POS) dated November 2023 documents a physician order starting 8/8/23 for Aspirin 81 milligrams (mg) daily and Eliquis 2.5 mg twice daily starting 10/23/23. R1's Hospital Record dated 10/20/23 documents Computerized Tomography (CT) without contrast summary as: Intertrochanteric Fracture Right Hip. This same record documents R1's admission diagnoses of fall and Right Intertrochanteric Hip Fracture. This same record documents (R1) was evaluated in the emergency room and found to have a non-displaced Right Intertrochanteric Hip Fracture. (R1) underwent surgical procedure of Intramedullary (IM) Nail on 10/20/23. (R1) will need extensive Physical Therapy (PT) and Occupational Therapy (OT) moving forward, skilled nursing facility. V3 Orthopedic Physician Progress Note dated 10/20/23 documents [AGE] year old white male being seen today for his Right Hip. (R1) had fallen at facility was getting into a different room when he tripped while grabbing the door. (R1) came down on his Right Hip producing a fracture. R1's Nurse Progress note dated 10/20/23 at 9:46 AM documents Staff heard a loud noise from (R1's) room followed immediately by (R1) calling out. (R1) laying on floor in common area that adjoins the two sides of the room. (R1) laying on Left side. Prior to fall event, therapy (V5) had been in room assisting with dressing and morning Activities of Daily Living (ADL). (R1) last seen sitting on edge of bed. (R1) reports (R1) got up to use the bathroom and did so unassisted and without the use of (R1's) walker. (R1's) wheelchair was noted near (R1) but facing away from (R1) and was unlocked. Call light was not activated at the time of the fall. (R1) reports hitting back of head and Right Hip pain. (R1) stated 'I hit both sides. (R1) reports pain and limited movement to Right Lower Extremity and increased pain upon palpation. (R1) reports increased pain to Right Inner Thigh. Hospital reported at 9:40 AM that ( R1) would be admitted for Right Hip Fracture. R1's Final Incident Report to Illinois Department of Public Health (IDPH) dated 10/25/23 documents (R1) stated 'I was coming around the corner in my room and reaching for the bathroom door handle. I think I wanted to go to the bathroom but not sure. I am too independent to use the call light. I was leaning to grab the door handle and my hand slipped off and lost my balance'. On 11/7/23 at 11:30 AM R1 was sitting up in highback wheelchair at community dining room table. No pressure alarm in place. On 11/7/23 at 2:40 PM R1 was laying in bed. R1's call light was laying on floor under R1's bed out of reach of R1. On 11/8/23 at 10:40 AM R1 was sitting in a highback wheelchair at the community dining table. R1's chair alarm was in place with alarm cord hanging from the back of the seat of the wheelchair not plugged in to anything. On 11/7/23 at 11:35 AM V4 RN stated the morning R1 fell , V4 was called into R1's room to assess R1. V4 stated R1 was laying on his Left side facing away from the door. V4 RN stated the staff all heard the crash and went running into R1's room. R5 (R1's wife) was present but not in R1's room. V4 RN stated R1's injury was obvious upon assessment. V4 RN stated R1 did not have personal alarms in place at time of fall. On 11/7/23 at 11:36 AM V9 Certified Nurse Aide (CNA) stated I am (R1's) CNA everyday. (R1) has days where he is alert and oriented and other days that he is really confused. (R1) does need some help getting up and walking. (R1) was walking a long way with therapy but now he just uses his wheelchair since his hip got broken. (R1) was supposed to be wearing bed and chair alarms. They (facility) started that after (R1's) first fall a long time ago. (R1) has a habit of trying to get up by himself. There are some days (R1) is stronger and can do that and others that he is much weaker and not oriented that he needs a lot more help. (R1) was supposed to use one assist, gait belt and a walker before this last fall (10/20). The space between (R1's) bed and the wall was not big enough for (R1) to use his walker or wheelchair. (R1's) bed was (adjacent) directly up against his wife's bed. (R1's) wife needed room for her wheelchair to fit on her side of the bed so (R1's) side was way too narrow for any of his equipment to fit in there. On 11/7/23 at 11:45 AM V5 Occupational Therapy Assistant (OTA) stated I work with (R1) several days a week. It was our (V5, R1) normal routine from me to help (R1) out of bed, get dressed and complete his morning Activities of Daily Living (ADL's). The morning (R1) fell I was working with him as normal. (R1) had urinated all over the bed so I was trying to get that cleaned up. I helped (R1) get dressed. (R1) was fully dressed and wearing no skid socks. I remember unclipping (R1's) call light from (R1's) bed linens and placing it over the footboard of (R1's) bed. This would have been out of reach. (R1) did not have any alarms on his bed. I grabbed up all of the soiled linen and left (R1) sitting on the side of his bare mattress. I left (R1) alone like that to take his dirty linens over across the unit to the soiled utility room. I was gone for one to two minutes at the most. I did not make sure (R1's) call light was in reach and did not put the bed alarm on the bed. I didn't even know (R1) used a bed alarm. I never saw one in (R1's) room. The space between (R1's) bed and wall was not nearly big enough to leave (R1's) walker. (R1's) wife was also a resident here (facility). (R1's) wife is not able to stand or walk so she needed extra space on her side of the bed to fit all of her equipment. There just wasn't enough room in there. We (staff) would leave (R1's) walker and wheelchair at the end of (R1's) bed because of the space issue. (R1) has times he is more confused and more weak due to his blood transfusions. (R1) gets blood transfusions regularly for his Cancer. (R1) was progressing quite well in therapy before this last fall and now I am not sure he will be going back home. On 11/7/23 at 2:20 PM R5 (R1's) spouse stated We (R1, R5) have never had any kind of alarms on our beds. I have never heard any kind of alarm going off. As much as (R1) tries to get up on his own, I would have heard something like that. On 11/8/23 at 10:30 AM V14 Director of Rehabilitation Services stated (R1's) cognition fluctuated. (R1) would have good days and other days he would struggle more. (R1) did not have much safety awareness. (R1) was non-compliant with recommendations. (V5) OTA should not have left (R1) alone without a call light or any way to reach out for help. The linens could have waited. (V5) should have completed (R1's) therapy, gotten (R1) positioned safely and then removed the linens. On 11/8/23 at 10:50 AM V15 Licensed Practical Nurse (LPN) stated (R1) is not always alert and oriented and he was a high fall risk even before his fall. The alarms were put in place after (R1's) first fall back in August, 2023. If I were to guess, I would go by whatever (R1's) careplan says and it says (R1) is supposed to have personal alarms. So that means to me as a nurse that the bed and chair alarms should be in place. We (staff) are supposed to follow those fall interventions. I will make sure (R1's) chair alarm gets plugged in. It doesn't do any good otherwise. On 11/8/23 at 3:00 PM V17 Nurse Practitioner stated R1 is not always alert and oriented. V17 stated R1's cognition fluctuates based on his medical condition and need for blood transfusions. V17 stated the facility caused R1's Right Intertrochanteric Fracture by not having the fall interventions in place to prevent R1's fall. 2.) R2's undated Face Sheet documents an admitted [DATE]. This same Face Sheet documents R2's medical diagnoses of Cerebral Infarction, Chronic Systolic Heart Failure, Dementia, Anemia, Weakness, Osteoarthritis of Left Shoulder, Muscle Weakness, Unsteady on Feet, Need for Assistance with Personal Care, Insomnia and History of Falling. R2's Minimum Data Set (MDS) documents R2 as cognitively intact. Requires extensive two assist for transfers, extensive one assist for bed mobility, dressing, toileting and personal hygiene. R2's Nurse Progress Note dated 11/1/23 at 9:06 AM documents (R2) was sitting at the desk and fell forward out of the wheelchair. (R2) was leaning over in wheelchair and rocking. (R2) had been reminded to sit up prior to this. (R2) fell hitting head on floor. (R2) has two lacerations to forehead; three centimeters (cm) on the Left Forehead and 2 cm x 2 cm mid forehead near hair line. R2's Hospital Record dated 11/1/23 documents R2 was seen in emergency room for a fall at facility. This same record documents (R2) to emergency room from facility with chief complaint of fall out of her wheelchair this morning resulting in a head injury. (R2) is noted to have two lacerations to her forehead with bleeding controlled. R2's Final Report to the State Agency dated 11/7/23 documents R2's fall at the facility on 11/1/23 and R2 receiving two lacerations that required nine sutures total to the left forehead. On 11/7/23 at 11:18 AM R2's left forehead had two separate areas with multiple sutures. R2's left forehead laceration's were dry with a small amount of redness. On 11/8/23 at 10:30 AM R2 was sitting in the wheelchair in front of the nurses desk. V4 Registered Nurse (RN) was standing with V4's back to R2 behind the opposite side of nurses desk. R2 was sitting in a slumped over position with R2's eyes closed. R2 Appeared to be sleeping with R2's head resting on the right side of R2's wheelchair. On 11/7/23 at 11:10 AM V7 Certified Nurse Aide (CNA) stated (R2) will start to lean forward and rock in her wheelchair when she starts to get tired. (R2) likes to sit at the nurses station but she will lay down sometimes when she gets tired also. That day (R2) fell , (R2) was sitting in front of the nurses desk. (R2) had been rocking back and forth for a while that morning. The only staff present was (V16) Licensed Practical Nurse (LPN) who was sitting behind the nurses desk. You can't see the residents from that point because the nurses desk is too tall and solid. No one had asked (R2) if she wanted to lay down. (R2) might have wanted to but no one asked. (V16) did tell (R2) to sit up a couple of times but didn't ask (R2) if she wanted to lay down. (R2) rocked herself to sleep that day and fell out of the wheelchair. I think (R2) got a bunch of stitches from her fall. On 11/7/23 at 11:20 AM R2 stated I don't remember falling but I do remember being taken to the hospital and had to get these things (pointing to forehead sutures). Let me tell you, that hurt! I was out here (next to nurses station) by myself and must have fallen or something because the next thing I know I was being sent to the emergency room . On 11/8/23 at 2:15 PM V16 Licensed Practical Nurse (LPN) stated R2 was known to rock herself to sleep in her wheelchair prior to R2 falling on 11/1/23. V16 LPN stated R2 was rocking in her wheelchair prior to her falling out of wheelchair. V16 LPN stated I gently nudged (R2) to wake her up. (R2) does that all the time. I have had to wake (R2) up in her wheelchair hundreds of times. I didn't ask (R2) if she wanted to lay down or sit in her recliner in her room. I just nudged her and then sat down at the nurses desk. I couldn't see (R2) from the desk. I just heard a big thud sound when (R2) hit the floor. I should have had the staff lay (R2) down. 3.) R3's undated Face Sheet documents R3 admitted to facility on 8/16/21. This same Face Sheet documents medical diagnoses of Dementia, Unsteady on Feet, Need for Assistance with Personal Care, Reduced Mobility, Muscle Weakness, Anterograde Amnesia and Heart Failure. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact. This same MDS documents R3 requires extensive assistance of one person for transfers. R3's Care Plan documents a fall intervention dated 4/23/21 for staff to provide proprioception (correction) of posterior lean. R3's Nurse Progress Note dated 10/28/23 at 10:34 AM documents (V7) Certified Nurse Aide (CNA) was walking (R3) to wheelchair when another resident (R4) came into room. (R3) turned to set in chair and fell backwards to the floor. (V7) CNA attempted to catch (R3). (R3) fell on to Right Hip and hit head on chair. (R3) complained of pain in Right Hip/Pelvis area. R3's Hospital Record dated 10/28/23 documents R3 was seen in the emergency room due to a fall at facility. This same record documents R3's discharge diagnoses of Closed Head Injury, Pain in Right Lower Limb, Strain of Neck Muscle and Fall. R3's undated Fall Investigation documents R3's fall on 10/28/23 as being witnessed by (V7) Certified Nurse Aide (CNA). This same report documents (R3) turned to sit down in her wheelchair and (R4) entered the room and began touching her blanket. (R3) became upset by (R4) touching her blanket and this caused her anxiety. It is probable that (R3) became fixated on (R4) touching her blanket and became off balance resulting in her fall. (V7) attempted to catch (R3) as she fell and was unable to do so. On 11/7/23 at 10:45 AM R3 stated I was sitting in my recliner and (V7) Certified Nurse Aide (CNA) was standing in front of me. I was trying to stand up when I saw (R4) walking right into my room. (V7) was looking at (R4), telling (R4) to leave when (R4) came over to my wheelchair and tried to grab my sweater from the back of my wheelchair. My wheelchair was sitting on my Left side in front of my roommate's chair by her bed. When I saw (R4) try to grab my sweater, I reached over to get a hold of it before (R4) took off with it. That is when I fell . I fell straight back. (V7) CNA could not have done anything to stop me because she was standing in front of me. I hit my head and hurt my hip. I had to go to the hospital emergency room and be checked out by the doctor. They (hospital) did a bunch of tests and sent me back. As soon as I got back I made sure my sweater was still there. On 11/7/23 at 11:00 AM V7 Certified Nurse Aide (CNA) stated I was the CNA helping (R3) the day she fell . I went into (R3's) room to get her up to go to an activity. (R3) was sitting in her recliner by her bed. (R3's) ex-roommate's highback chair that stayed in the room was sitting so close to R3's recliner on (R3's) Left side that there was no room for the wheelchair. I had to angle the wheelchair in front of (R3's) ex-roommates chair. I was standing in front of (R3) kind of on her Right side. There just wasn't enough room in there to set things up right. We (staff) just have to make do sometimes. (R3) stood and at the same time (R4) came into (R3's) room and tried to touch (R3's) sweater that was laying over the back of (R3's) wheelchair. (R3) started to grab at her sweater and that is when she lost her balance and fell . If I had been on (R3's) Left side, I would have been able to try to catch her. It is hard to catch someone when they fall back and you are in front of them. I felt so bad. I am glad (R3) did not get hurt anymore than she did. Next time, I will definitely just move the other chair so I can be positioned better. On 11/8/23 at 2:40 PM V18 Medical Director stated the facility should follow the resident's care plan in order to try to reduce accidents and/or falls from happening. V18 confirmed R1's fall interventions were not in place on 10/20/23 which resulted in his fall that caused his Right Intertrochanteric Fracture. V18 Medical Director stated staff should address the needs of the residents such as R2 falling out of the wheelchair before it happens. V18 Medical Director agreed staff should have positioned themselves/furniture better to avoid R3's fall. V18 Medical Director stated I can't say much in support of the facility with these kinds of preventable incidents. I will say they (facility) are working towards providing adequate care for the residents but it looks like they are not there yet.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility staff failed to complete wound dressing changes as ordered by the wound care physician. This failure affects one resident (R17) out of five reviewed for wound care on a sample of 18. This failure resulted in R17's foot wounds becoming infested and infected with parasitic fly larvae (maggots) requiring the use of intravenous antibiotics. B. Based on record review and interview, the facility staff failed to obtain and document resident weights as ordered by the physician for relevant medical diagnoses. This failure affects three residents (R1, R16, R17) out of 12 reviewed for physician orders on a sample of 18. Findings include: a. R17's Census Detail and Minimum Data Set List (undated) documents R17 was originally admitted to the facility 6/20/21, with a subsequent re-admission 1/5/22. R17's Nurses Notes dated 9/24/23 document R17 was discharged to the hospital on 9/24/23 due to shortness of breath, low blood pressure, elevated temperature, elevated heart rate, and low oxygen level. R17's current Diagnosis List (undated) documents R17 experiences medical diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Lymphedema, Diabetes, Anemia, Chronic Kidney Disease, Pressure Ulcer of the Buttock, and Need for Assistance with Personal Care. R17's Wound Care Physician Progress Notes from V16, Wound Care Physician, dated 9/20/23 documents R17 was experiencing multiple open draining lymphedema ulcers on both the right and left legs, in durations of between 1 day and 6 months, requiring combinations of calcium alginate, absorbent pads, and compression wraps. This same Progress Note documents R17 was experiencing open draining stage 3 pressure ulcers on both buttocks, in duration greater than 6 months, requiring treatment with absorbent pads and silicone barrier cream. This same Progress Note documents R17 was experiencing and open draining wounds on the right first toe and left first and second toes requiring a treatment procedure to place calcium alginate between R17's toes, absorbent pads, gauze wraps, and compression wraps to be changed twice daily. The treatment orders and dressing changes for R17's right first toe, initially noted on this progress note as a new wound, was not transcribed onto R17's Physician Order Sheet nor onto R17's Treatment Administration Record. This Progress Note documents R17's left first and second toe wounds were not at goal. R17's Nurses Note dated 8/5/23 at 2:29 PM documents R17 had complained that the dressings on his legs had not been changed in a few days. The responding nurse (V11, Registered Nurse) then found maggots in R17's left foot and documented soaking R17's feet in a (sodium chloride solution) and placing secured wraps on R17's feet. There was no documentation that the primary physician nor the wound care physician had been notified of the maggots and new open wounds on R17's left toes. R17's Nurses Note dated 8/7/23 at 5:03 PM documents an (unidentified nurse) notified the wound care physician (V16) about the maggots and new wounds discovered on R17's left toes. At this time V16 ordered for both of R17's feet to be soaked in a (sodium chloride solution) daily for 20 minutes, then twice daily to apply gauze soaked in betadine to R17's left toes and wrap with gauze roll. This dressing order was in effect through 8/18/23 when V16 revised the order to apply calcium alginate and absorbent pads twice daily. R17's historical Physician Order Sheet, undated but only including orders current at the time of R17's discharge to the hospital on 9/24/23 which had discontinue dates of 9/25/23, documents R17 was ordered to receive treatment and dressing changes to the left toes with betadine soaked gauze and gauze wrap every 7 days, initiated 12/21/22 and discontinued 8/18/23. This order was revised to include the daily sodium chloride soaks, and dressings twice daily 8/7/23, after nursing staff notified V16 about the maggots found on R17's left foot on 8/5/23, creating an overlap of conflicting orders from 8/7/23 through 8/18/23. R17's historical Physician Order Sheet, undated but only including orders current at the time of R17's discharge to the hospital on 9/24/23 which had discontinue dates of 9/25/23, documents 2 physician orders, one for R17 to receive skin assessments on shower days every Wednesday and Saturday, and the second for R17 to receive skin assessments on shower days every Tuesday and Friday. This same Physician Order Sheet documents a third physician order for R17 to receive daily skin checks due to being a high risk resident. R17's Treatment Administration Record for September 2023 documents two skin assessment orders, one for shower days on Wednesdays and Saturdays, and the other for daily skin checks. This same Treatment Administration Record documents the nursing staff did not complete the daily skin checks on 9/11/23 and 9/22/23. R17's Medication Administration Record for September documents the third skin assessment order to be completed on shower days every Tuesdays and Fridays. This same Medication Administration Record documents the daily skin check was not completed on 9/22/23. On 9/26/23 at 3:03 PM, V11, Registered Nurse, confirmed, I did see the maggots on (R17's) left foot a while back (8/5/23) and I was assisting R17's primary nurse to soak R17's foot. V11 further stated, I was R17's primary nurse Sunday night (9/24/23) when I had to send him to the hospital. I did get a report from the emergency room that he had maggots in his foot again but I didn't see them this time. On 9/26/23 at 3:25 PM, V16, Wound Care Physician, stated, I am not doing maggot therapy for (R17) but I have heard of that. (R17) had the maggots a couple of months before (8/5/23) and that was why I ordered the treatments for his toes to be twice daily (8/7/23). If the nurses were cleaning and changing the dressings twice per day then there would be no way for maggots to grow in there. V16 continued, After a fly lays eggs it takes a couple of days for the eggs to hatch and the maggots to get big enough to see. This is an indication that the treatments and dressing were not being completed, it's very unfortunate and it looks like some of the nurses are checking off the treatment when they don't do it. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, There was one other time in August (8/5/23) that (R17) had maggots in his foot wounds on his left foot, but at that time he wasn't getting any dressing changes on his feet, just his legs. V2 confirmed, (R17's) shower days are Tuesdays and Fridays. R17's historical Physician Order Sheets document R17 had a physician order for a weekly dressing treatment for the left foot to receive a roll gauze with betadine to be weaved between the toes, initiated 12/21/22 and discontinued 8/18/23. On 9/27/23 at 10:14 AM, V2, Director of Nursing, continued, I do know that (R17) refused his dressing changes on Friday evening (9/22/23) and Saturday for day shift (9/23/23) and if a resident refuses cares or treatment, the staff need to be documenting that. R17's Treatment Administration Record for September 2023 documents 3 incomplete treatments for R17's left toes, one on 9/3/23 on the day shift, 9/21/23 on the evening shift, and one on 9/22/23 on the day shift. These incomplete treatments were left blank as no nurse had completed the treatment or signed the record in any manner. This Treatment Administration Record documents 2 refusals of the left toes treatment by R17, one on 9/4/23 evening shift, and on on 9/22/23 evening shift. There was one treatment record for a referral to the nurses notes on 9/4/23 day shift, however there was not a nurses note at all in R17's record between 9/1/23 and 9/5/23. All other occasions for the twice daily left toes treatment were checked and initialed by nursing staff as though completed, including the day shift on Saturday 9/23/23 which V2 stated R17 had refused. The treatment for R17's right first toe was absent from the Treatment Administration Record which was ordered by V16 on 9/20/23 and was not transcribed to the Physician Orders nor Treatment Record. On 9/28/23 at 8:40 AM, R17 was laying supine in bed at (hospital), visibly pink in the face and obviously short of breath. R17 was utilizing supplemental oxygen running at 1.5 liters per minute through a nasal cannula and the head of the bed was elevated approximately 45 degrees. R17 was receiving intravenous antibiotics Vancomycin and Cefepime. R17 stated, It seemed that the care at (the facility) was better back when I first got there, but since it has changed hands, the care has gone down. V17 continued, I do have some sores on my butt, my legs, and my feet. At (the facility) my legs got wraps that stay on for 7 days, so they take them off on Tuesdays for my showers and that was when the wound doctor (V16) would come in, then on Fridays for my showers they would wrap my legs with bags to keep them from getting wet. I get some creams and salves and pads on my bottom. The nurses were not doing the dressings on my feet twice a day like they were supposed to. R17 further stated, I did not refuse or decline the dressings on my feet, I generally let them do whatever they need to do. There might have been a few times a nurse came to do my dressings and I said I needed to go to the bathroom first, but they never came back to do the dressings, or sometimes they come in after 10:00 PM and I say it's too late at that time. R17 then stated, I did have these maggots one other time about a couple of months ago, the nurse found them, but at that time they weren't putting dressings on my feet at all. Now this time I got them again but they weren't doing the dressings like they were supposed to. These maggots are a bad enough thing but they told me in the emergency room they found some bed bugs on me too. On 9/28/23 at 12:10 PM, V20, emergency room Nurse, stated, I was working when (R17) came to the emergency room this past Sunday night (9/24/23). (R17) did have maggots in his left foot. The maggots were falling out of his foot in clumps. We had to use a suction canister to suck them up as they were falling out. I would say there was maybe 100 of them in all different sizes, some were tiny and some were much larger. It was obvious that the maggots had been there for some period of time because it takes a few days for them to grow to the size that some of them were. These were not like the maggots for actual therapy, those are grown in a lab under extremely sanitary conditions, not from regular house flies around the environment. V20 further stated, The smell around (R17) was atrociously disgusting. I am the first person to know about resident rights but when the smell starts affecting other people, you just have to say 'no' we are going to get you cleaned up because you are affecting other people. My emergency room doctor (V21) was appalled when she saw the maggots and said we have to report this. R17's (hospital) Admission History and Physical dated 9/24/23 documents R17 was admitted to the hospital on this date after presenting to the emergency room with several days history of shortness of breath, leg ulcers, maggots, and bed bugs. b. 1. R17's current Diagnosis List (undated) documents R17 experiences medical diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Lymphedema, Diabetes, Chronic Kidney Disease, and Pressure Ulcer of the Buttock. R17's historical Physician Order Sheet, undated but only including orders current at the time of R17's discharge to the hospital on 9/24/23 which had discontinue dates of 9/25/23, documents R17 was to be weighed daily and reported to the physician if there was any weight gains of more than 3 pounds in one day or 5 pounds in one week. This order was documented as initiated 8/26/22 and discontinued 9/25/23 after R17 was sent to the hospital. R17 Treatment Administration Record documents these daily weights were not obtained by facility staff on 9/2/23, 9/3/23, 9/7/23, 9/10/23, 9/11/23, 9/18/23, 9/21/23, and 9/22/23, missing 8 out of 23 opportunities. This same Treatment Administration Record documents R17 had a 4 pound gain from 9/16/23 to 9/17/23, going from 284.6 pounds to 288.6 pounds. There was not a nurses note at all in R17's record between 9/15/23 and 9/19/23 to indicate facility staff had notified R17's physician of the weight gain. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, If a resident has an order for daily weights, like for our residents with CHF (congestive heart failure) then it should be done daily. 2. R16's current Diagnosis List (undated) includes Acute Pancreatitis with Necrosis, Hypertension, Cerebral Infarctions, and Transient Ischemic Attacks (mini-strokes). R16's current Physician Order Sheet (undated) documents a physician order for R16 to be weighed weekly, initiated 2/16/23. R16's Care Plan dated 1/17/23 documents R16 is at risk for nutritional problems, with a nursing intervention documented to weigh as ordered. R16's Weight Record documented R16 was weighed on 1/21/23 at 158 pounds, and 2/1/23 at 159 pounds. R16's Weight Record documents since the initiation of the physician order to weigh R16 weekly on 2/16/23, R16 was weighed on 2/23/23 at 145.3 pounds, on 3/1/23 at 145 pounds, on 3/16/23 at 134 pounds, on 3/30/23 at 135 pounds, on 4/3/23 at 138 pounds, on 4/20/23 at 137 pounds, on 4/27/23 at 137, on 5/1/23 at 133 pounds, on 6/1/23 at 131 pounds, on 6/8/23 at 132 pounds, on 6/29/23 at 132 pounds, on 7/3/23 at 138 pounds, on 7/27/23 at 141 pounds, on 8/3/23 at 143 pounds, on 8/10/23 at 141 pounds, on 9/1/23 at 151 pounds, and 9/21/23 at 157 pounds, having missed 10 out of 28 opportunities for R16's weekly weight from 2/16/23 to 9/21/23, and experiencing significant weight losses and weight gains during the same period. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, If a resident has a physician order for weekly weights, it should be done weekly. 3. R1's Diagnosis List (undated) documents R1 experienced medical diagnoses including Cardiogenic Shock, Coronary Artery Disease, Heart Failure, Peripheral Vascular Disease, hypertension, History of Malignant Rectal Cancer, Anemia, and Radiation Induced Diarrhea. R1's Census Detail (undated) documents R1 was admitted to the facility 7/24/23 and was in the hospital 8/1/23 through 8/8/23, then in the hospital from 8/17/23 to 8/20/23, and final discharge was 9/7/23. R1's historical Physician Order Sheet (undated) documents a physician order for R1 to be weighed every week for 4 weeks initiated 8/22/23 (for readmission) and discontinued 9/14/23 (after discharge date ). This historical Physician Order Sheet documents a second physician order for weekly weights initiated 7/24/23 (admitted ) and discontinued 8/3/23 (after discharge to hospital). R1's Weight Record documents 3 times R1 was weighed, for original admission 7/25/23, on 9/1/23, and 9/7/23, missing a readmission weight from on or around 8/8/23, on or around 8/16/23, readmission on or around 8/20/23, and on or around 8/27/23. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, If a resident has an order for weekly weight, then it should be done weekly. We do initiate orders for weekly weight for four weeks upon admissions and readmissions.

Based on observation, interview, and record review, the facility failed to supervise one dependent resident (R9) for safety to prevent a fall, and failed to complete fall risk assessments for three residents (R14, R15, R17) with known fall risks, out of five reviewed for falls and fall risks on the sample of 18. This Failure left (R9) alone sitting on edge of therapy table with no supervision and history of repeated falls, contributing to (R9) falling to floor causing injury and being sent to hospital. Findings include: 1. R9's Census Detail (undated) documents R9 was admitted to the facility 1/10/22. R9's Diagnosis List (undated) documents R9 experiences medical diagnoses including Epilepsy, Repeated Falls, Neuropathy of Right Lower Limb, Cerebral Infarction, Cataracts, Weakness, Need for Assistance with Personal Care, Unsteadiness on Feet, and Cognitive Communication Deficit. On 9/21/23 at 9:25 AM, R9 was seated in the common area by the nurses station on the facility's residential unit 200 Hall. R9 had a large (approximately 4 centimeter) round hematoma with deep purple bruising protruding from the right side of her forehead with dependent deep purple and yellow bruising down surrounding both eyes. R9, obviously exhibiting some level of cognitive deficit, stated, I took a fall outside, I went face down on the cement. I went outside with someone and they weren't with me and I ended up on the ground. (While R9 did not fall outside, she was off of her usual residential unit and in the therapy room of another unit). R9 continued, I did go to the hospital but they really didn't do anything with me, just checked me out and sent me back. R9 further stated, I would think the people would have been more careful with me, but I will live. R9's Minimum Data Set, dated dated dated [DATE] documents R9 requires extensive assistance of 2 staff members to accomplish bed mobility, surface to surface transfers, and toileting. This Minimum Data Set documents R9 does not ambulate, and has impairments in range of motion of one upper and one lower extremity. R9's Nurses Notes dated 9/15/23 document R9 had fallen off of the therapy table, incurred a large hematoma to the right forehead, was sent to the emergency room for evaluation, and returned to the facility the same day. R9's Care Plan dated 11/11/22 documents R9 is at risk for falls due to medical conditions of confusion, gait/ balance problems, weakness, history of falls, epilepsy, neuropathy of right lower limb, convulsions, hypertension, and has a history of scooting herself out of the wheelchair. The nursing interventions for fall prevention include to use side rails on the bed, handrails on the walls, chair alarm for safety, and dycem (sticky material) in the wheelchair. On 9/21/23 at 11:05 AM, in the therapy room on the facility's Haven Center Unit was a large (approximately 6 feet by 7 feet) flat padded table without raised edges which was 18 inches off the floor in it's lowest position, and 29 1/2 inches from the floor in the highest position. On 9/21/23 at 1:42 PM, V10, Physical Therapy Assistant, stated, I was working with (R9) the day she fell off the therapy table. I started out working with her doing some range of motion exercises while she was laying flat on the therapy table, then I had her sit up at the edge of the table so I could challenge her to hold her balance while pushing her a little bit side to side. Her legs were over the edge of the table and her feet were flat on the floor and the table was in the lowest position. (R9) was following instructions well and had maintained her sitting balance for about 15 minutes. Then I went across the room to walk with (R18). While I was walking (R18) outside of the therapy room, I didn't see the exact moment of (R9's) fall, but when I got to her she was holding a sock in her hand so I assume she was reaching down and messing with her sock when she fell . R9's Physical Therapy Evaluation dated 9/6/23 documents R9 was dependent for activities such as rolling right and left in the bed, going from lying to sitting on the side of the bed, going from sitting to standing, and transferring from a bed to a chair or toilet. This evaluation documents R9 experiences impairments in range of motion and strength of both right and left lower extremities. This Evaluation documents R9 could not sit unsupported for any amount of time. R9's Occupational Therapy Evaluation dated 9/11/23 documents R9 was dependent for activities such as transfers on and off the toilet, dependent for going from sitting to standing, and received a mobility assessment score of 0 (zero), the lowest possible score. This same Evaluation documents R9 had impairments in range of motion of both right and left upper extremities. This Evaluation documents R9 could not sit unsupported without a moderate amount of assistance for any length of time because R9 began leaning forward, and R9 had no ability to right herself when leaning forward. This Evaluation documents R9 had impaired safety awareness. On 9/27/23 at 2:25 pm, V14, Licensed Practical Nurse, stated, I am familiar with (R9), I would not feel comfortable for one minute leaving (R9) sitting alone on the edge of a bed or on the toilet, I wouldn't let her be any farther away than I could reach. 2:29 pm, V18, Certified Nursing Assistant, stated, Goodness gracious no, I wouldn ' t leave (R9) alone on the edge of a bed or toilet, she tries to get out of any type of sitting position she is in, she wiggles all over to get out of sitting. 2:35 pm, V19, Certified Nursing Assistant, stated, I wouldn't leave (R9) sitting alone on a bed or toilet, she doesn't sit up very well, she leans forward when she is sitting, that's why she is in a (heavily cushioned reclining rolling chair). 2. R14's Census Detail (undated) documents R14 was admitted to the facility 8/13/21. R14's Diagnosis List (undated) documents R14 experiences medical diagnoses including Unsteadiness on Feet, Weakness, Reduced Mobility, Need for Assistance with Personal Care, Lack of Coordination, and Abnormal Gait and Mobility. R14's Care Plan dated 8/13/21 documents R14 is at risk for falls due to multiple medical conditions and diagnoses. On 9/27/23 at 10:14 AM, R14's Assessments (undated) document R14's most recent fall risk assessment was dated 5/13/23. On 9/27/23 at 10:14 AM, V2, Director of Nursing, stated, We are supposed to be doing fall risk assessments on admission, on readmission, after every fall, and then quarterly. 3. R15's Census detail (undated) documents R15 was originally admitted to the facility 4/19/16, with a subsequent admission 8/23/22. R15's Diagnosis List (undated) documents R15 experiences medical diagnoses including Reduced Mobility, Need for Assistance with Personal Care, and Acquired Absence of (Left) leg Below the Knee. R15's Care Plan dated 8/29/22 documents (R15) has decided to stay at the facility long term due to feeling unsafe being alone because of experiencing dizziness and falls. This same Care Plan documents R15 is at risk for falls related to multiple medical diagnoses and health conditions. R15's Assessments (undated) document R15's most recent fall risk assessments was dated 9/29/22. 4. R17's Census Detail (undated) documents R17 was originally admitted to the facility 6/20/21, with a subsequent readmission 1/5/22. R17's Diagnosis List documents R17 experiences medical diagnoses including Unsteadiness on Feet, Weakness, Reduced Mobility, and Need for Assistance with Personal Care. R17's Care Plan dated 1/7/22 documents R17 is at risk for falls due to multiple medical diagnoses and health conditions. R17's Assessments (undated) documents R17's most recent fall risk assessment was dated 4/30/22.

Based on interview and record review the facility failed to follow physician's orders for insulin administration for one (R3) of three residents reviewed for medications in the sample list of ten. This failure resulted in R3 being hospitalized for hypoglycemia. Findings include: R3's Care Plan dated 11/5/22 documents R3 has Diabetes Mellitus and includes interventions to administer diabetic medication as ordered, monitor for side effects and effectiveness of the medication, monitor/document and report symptoms of hypoglycemia and hyperglycemia to the physician. R3's Physician Order with a start date 4/12/23 and end date 5/30/23 documents to administer Humalog (insulin) solution 100 units/milliliter inject 7 units subcutaneously before meals and hold the medication if R3's blood sugar is less than 120. R3's May 2023 Medication Administration Record documents R3 received Humalog 15 times when R3's blood sugar was less than 120, indicating the medication was not held as ordered. R3's Humalog was held or refused an additional 12 times. R3's blood sugar was 63 at 11:00 AM on 5/4/23, the medication was held and refers to R3's nursing notes. There are no nursing notes for this date or documentation that R3's physician was notified of R3's low blood sugar on 5/4/23 or that R3's Humalog was held frequently during the month of May. R3's Nursing Notes document on 5/28/23 at 5:40 PM R3 became unresponsive and was transferred the local emergency room . R3's Hospital Discharge Summary documents the following: R3 admitted on [DATE] at 1:39 AM with diagnoses of Altered Mental Status, Hypoglycemia, and Urinary Tract Infection. R3 was found unresponsive and transferred to the emergency room for concern of symptomatic hypoglycemia. R3's blood glucose was 59 in the emergency room and dextrose was administered by intravenous infusion. R3's mental status may cause R3's meal intakes to be inconsistent and R3's insulin was discontinued. On 6/6/23 at 12:00 PM V3 Licensed Practical Nurse/Nurse reviewed R3's May Humalog order/administration and blood glucose levels, and confirmed R3's insulin was administered when blood sugar was below 120. V3 stated V3 would expect the nurses to hold the insulin per blood sugar parameters and notify V5 Nurse Practitioner if the insulin is held frequently. V3 stated R3 was recently admitted to the hospital and R3's insulin was changed to oral diabetic medication. On 6/6/23 at 12:05 PM V5 Nurse Practitioner stated if the nurses were frequently holding R3's insulin V5 would expect to be notified to review and possibly adjust R3's insulin dosage. V5 did not recall being notified of R3's blood sugars or to review R3's insulin in May 2023. V5 stated V5 would have entered a progress note. V5 stated if the nurses had held R3's insulin as ordered and notified V5, it may have prevented R3's hospitalization . The facility's Medication Administration Policy dated March 2014 documents Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates.

Based on observation, interview, and record review, the facility failed to maintain a resident walkway free of obstacles and provide ambulation assistance, and failed to ensure a mobility device was within a resident's reach for two of three residents (R2 and R3) reviewed for falls on the sample of three residents. These failures resulted in R3 suffering a fractured wrist and R2 suffering a head laceration that required sutures. Findings include: 1.) R3's Medical Diagnoses Sheet last updated 4/21/23 documents diagnoses of Fractured Right Radius, Weakness, Unsteadiness on Feet, History of Falling, Fractured Right Femur, Dementia, Psychotic Disturbance and Anxiety. R3's Minimum Data Set (MDS) date 4/6/23 (nine days prior to fall 4/15/23) documents the following: R3 has a Brief Interview of Mental Status score of nine out of a possible score of 15, indicating moderate cognitive impairment. R3's same MDS documents R3 has had one fall with major injury since admission 10/08/21. The same MDS documents R3 is ambulatory with limited physical staff assistance of one, uses a walker, is not steady walking and requires physical staff assistance to stabilize during ambulation. R3's Illinois Department of Public Health, Long-Term Care Facility and IDD-Serious Injury and Communicable Disease Report dated 4/15/23 at 7:23 am documents a fall investigation as follows: (R3) was sent to the hospital. 'Incident Description' diagnosis (diagnoses), right wrist fracture, (and) hematoma to left shoulder. The same report includes an attachment sheet of interviews as follows: Interview with (V9, Registered Nurse) - got a call over intercom and resident (R3) was rolled over on (R3's) back on (the) floor. Assessed her (R3). Big skin tear on hand. Left leg bothering her (R3). Worried about head. Nursing Note (included with this witness statement): Resident was walking to the dining room with her walker, going to breakfast, when she fell forward on her face. Noted skin tear to left hand, blood coming from her (R3's) mouth, redness to (R3's) forehead, pain to left hip and left arm. Vitals (blood pressure) 185/92 (high), pulse 72, (temperature) 97.8 (degrees Fahrenheit), spo2 (blood oxygen level) 99 percent. (V3, Medical Director/ Physician), notified and (verbal order) to send out to hospital. (V11, R3's Family Member), notified of fall and sent to (community hospital). Interview with (V5, Certified Nursing Assistant)- last saw her (R3) walking up the main hall in front of the office (around corner from the chapel/activity room), right before she (R3) fell . She was using her walker and had both hands on it (the walker). Interview with (R3), - stated she (R3) does not remember falling and does not remember much anymore and that it is frustrating to her at times. Resident (R3) reported to the nurse (unidentified) at the time of the fall that she tripped and fell forward. The same Report attachment, documents the following: Staff reported that they think resident's (R3's) walker may have gotten caught on the activity table. Staff also reported that resident's shoes are slick. POA (V11, Family Member) contacted and agreeable to bringing resident in new shoes. R3's Hospital report dated 4/15/23 documents Chief Complaint, fall. Patient is here via ems (Emergency Medical Service) from (long-term care facility) after patient (R3) had a fall today. Patient was walking to (the) dining room and fell forward onto face. Patient (R3) has voiced complaints of pain to bil (bilateral) hip and patient has a wound to left hand. Patient has no visible injuries to her face. Patient is alert and oriented x 3. Acuity (Urgent). The same hospital report includes an X-ray report documenting R3 has a fracture at the distal radial metaphysis at the right wrist. On 4/20/23 at 5:30 pm V5, Certified Nursing Assistant (CNA) stated she worked, and had seen R3 just before and right after the fall 4/15/23. The fall itself was not witnessed. V5 confirmed her witness statement and added: I saw (R3) walking in the hall with her walker, by the front office that leads into the chapel and the dining room. She had on shoes, glasses were on and both hands on her (R3) walker, when I saw her. I was going through the dining room, over to skilled unit. I heard (V8, Office Manager) say on the overhead page that a nurse was needed in the dining room. I knew what that meant. (V9, Registered Nurse/RN) was already heading that way, and over by (R3) as I responded. (R3) was laying on her back. V5 stated We noticed (R3) had a big skin tear on her left hand. V5 stated (R3) told us she did not know what exactly happen. She said she knew she went over the top of the walker. (R3) is very confused at her baseline. We all saw the puzzle table was the cause of her (R3's) fall. The table stuck out a couple feet and blocked part of the dining room doorway. R3's walker was up against the table. On 4/20/23 at 5:50 pm V5, CNA walked over to the dining room entrance, at the edge of the chapel/activity room. There was a large table approximately three to four feet deep by five feet wide in this area and approximately 18 inches of the table protruded out into the walkway of the dining room doorway. V5, CNA stated This is where we have most all the activities. This is where (R3) fell . You can see the table is angled and sticks out too far. It blocks part of the doorway. This is the way residents go from (R3's) unit to the dining room. V5, CNA also stated Myself (V5, CNA), and (V9, RN) both think (R3's) walker struck the table corner because this table was so far out. Just like it is now. We mentioned that to (V2, Director of Nursing). She (V2) said it was a good idea to move the table, but she would have to talk to activities (Activity Department) first. Here it (the table) still sets, several days after the (R3's) fall (4/15/23). It had to be the table because (R3) went over the top of her walker. She had slip on shoes, so it would not be laces that caused (R3) to trip. V5 also stated They (unidentified) put an alarm on her dining chair. That will alert us when she gets up. That won't change the real issue. The puzzle table needs to be moved. On 4/20/23 at 6:20 pm V8, Office Manager stated I heard (R3) scream as she fell . I saw her immediately on the floor and her walker up against to table. It was obvious the walker ran into the table and caused the fall. That is my opinion. I can't be sure, but that is what it looked like. I called for a nurse on the intercom. (V9, Registered Nurse) and a couple (CNA's) were with (R3) when I rounded the corner to come back and help with what I could. On 4/20/23 at 6:40 pm V2, stated I was aware, the staff that responded to (R3) when she fell at the dining room entrance thought the table was the problem. I have moved it up against the wall now. I don't know where to put it yet. I could have done that (moved the table from the walkway) the same day (R3) fell . I don't know why I didn't. I focused on her shoes and asked her family to bring in new ones. Both the table and the slippery shoes were likely the cause of the fall. I realize that now. On 4/21/23 at 2:10 pm, V3, Physician/ Medical Director stated R3's wrist fracture was due to the impact of the fall and the fracture was not pathological in nature. V3 stated Wrists do not spontaneously fracture, hips can. V3 also stated If the facility identified an activity table was blocking part of the doorway, a likely intervention would be to move the table that played a part in the fall. It does not take a rocket scientist to figure that out. 2.) R2's Diagnoses Sheet documents diagnoses of Acute Respiratory Failure, Reduced Mobility, Need for Assistance with Personal Care, Localized Edema, Visual Disturbances, Cerebral Infarction, Orthostatic Hypotension, History of Falling and Repeated Falls. R2's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score as 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents R2 uses a walker and a wheelchair for mobility, requires extensive physical staff assistance with toileting and is not able to stabilize during ambulation without staff assistance. The same MDS documents R2 is continent of bowel and occasionally incontinent of urine. R2's Care Plan dated 4/3/23 documents; (R2) needs a safe environment with: clutter free, adequate, glare-free light, a working and reachable call light, (and) personal items within reach. R2's Illinois Department of Public Health notification Long-Term Care Facility and IDD-Serious Injury and Communicable Disease Report documents R2's fall occurred on 4/8/23 at 11:35 pm. The Report includes the following attachment (R2) Fall investigation, (R2) stated he was trying to get to the bathroom to pee and have a bowel movement. Had diarrhea and was afraid was going to make a mess. Stated he could not remember if he turned call light on or not, but was wearing glasses and had non-slip socks on, but did not use his walker or wheelchair.' R2's Hospital report dated 4/9/23 documents Chief Complaint, fall. Pt (Patient R2) to ER (emergency room ) from (long term care facility) via (local) EMS (Emergency Medical Service) with c/o (complaint of) unwitnessed fall and positive loss of consciousness. Pt (R2) reports he was attempting to hurry to the restroom and did not make it in time and accidentally slipped in his own stool on the floor, falling head first onto the floor. Pt (R2) is on eliquis (blood thinner) and did hit his head. Pt (R2) reports pain all over but reports the most pain is in his R (right) forearm/wrist and rates pain 10/10. Pt is noted to have deformity to the R wrist/forearm as well as swelling/bruising. EMS splinted R arm prior to arrival. Pt has bruise to L (left) upper arm. Pt has laceration and bruising above R eye and abrasion/bruising under R eye. Pt is also noted to have been bleeding from L side of head (parietal region)/bleeding controlled at this time. Pt denies chest pain. Pt has no other complaints at this time. The same Hospital report documents R2 has soft tissue swelling to the right elbow on X-ray and that R2 received three sutures to a forehead laceration. On 4/20/23 at 4:35 pm V4, Certified Nursing Assistant (CNA) stated R2's fall 4/8/23 was not witnessed. V4, CNA confirmed V4, CNA was the staff member that responded first when R2 fell . V4 stated (R2) fell on his left side, on his bathroom floor. It is strange that he had the right side of his head lacerated. I saw him last, at shift change maybe 9:30 or 10 pm. I round on everybody before I start my shift. He (R2) was laying down sleeping in bed. His (1/8) grab bar rails were up. He uses them for positioning. I had to go around the bed side table, in his room to see him. His wheelchair was not next to his bed. It was not within his reach. It (wheelchair) was up against his closet, several feet from his bed. I am not good with measurement. It might have been three, four, or more feet away. I am not for sure. He knows what is going on. He has no confusion. He can tell you how far away it was. I know from working other places the residents' walkers and wheelchairs are supposed to be by their bed. We were taught, if we move it away from their reach, it's considered restraining the resident in bed. I make sure call lights are within reach and all the residents are breathing, as I do rounds (checking on residents) at the beginning of the shift. I should have moved his wheelchair. I don't know why I didn't when I did my first round. (R2) was sleeping in bed evening shift. I was working part of evening shift too. I helped answer call lights on that unit, that evening. He (R2) was not my resident, until I started at 10:00 pm. I worked the whole unit, three halls with (V15) CNA. (R2) had his fall on my shift. He told me he did not have time to get to his (R2)wheelchair across the room. He had to go to the bathroom, quick. He is always continent of bowel. He was afraid he was going to mess in his pants. On 4/20/23 at 6:12 pm R2 was seated on the side of the bed. R2 had an (approximate) two inch wide laceration with stitches above the right eyebrow. R2 stated The fall I had in the bathroom (4/8/23) occurred because my (R2's) wheelchair was over there, up against the closet. R2 points to the far-left corner of his bedroom. The corner built-in closet was at an angle, approximately eight feet to the left, from the foot of R2's bed. R2 then points to the right and stated That bathroom door is about the same distance (at an angle, approximately eight feet from the head of the bed). I had to go immediately, or I would have been very embarrassed for the CNA's to clean me up. I made it to the bathroom okay. I lost my balance and fell inside the bathroom before I could make it to the toilet. Had my wheelchair been closer, I would have used it. I didn't have time to go the one direction, get the wheelchair then come back to the bathroom. I didn't have time to put on the call light and wait. It was emergent that I go right away, before I made a big mess for staff to clean up. That would have been terribly embarrassing. On 4/20/23 at 6:40 pm V2, Director of Nursing stated I was not aware that (R2's) wheel chair was being placed across the room instead of by his bed. I will be doing education with the staff. It should always be within the resident reach. On 4/21/23 at 2:10 pm, V3, Physician/ Medical Director stated he was informed of R2's fall and sent R2 out to the hospital. V3 also stated It is a given that mobility devices should always be within a residents reach. The facility Falls - Clinical Protocol dated as revised August 2008 documents the following: Assessment and Recognition 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician should document in the medical record a history of one or more recent falls (for example, within 90 days). c. While many falls are isolated individual incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause. 2. In addition, the nurse shall assess and document/report the following: a. Vital signs b. Recent injury, especially fracture or head injury c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in cognition or level of consciousness e. Neurological status, Pain g. Frequency and number of falls since last physician visit h. Precipitating factors, details on how fall occurred i. All current medications, especially those associated with dizziness or lethargy j. All active diagnose 3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. a. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affecting the central nervous system and blood pressure. The same protocol documents the following: Treatment/ Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on observation, interview, and record review the facility failed to follow physician ordered fall interventions for one of four residents (R25) reviewed for falls/accidents on the sample list of 25. Findings include: R25's Diagnoses List documents the following: Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Depression, Difficulty in Walking, Unsteady on Feet. R25's Clinical Physician Order Sheet (POS) dated 12/31/22-1/31/23 documents the following: Helmet to be worn when up out of bed, every shift for injury prevention and Hip protectors on at all times except during personal care every shift for fall intervention. R25's Minimum Data Set (MDS) dated [DATE] documents R25 has severe cognitive impairment. and requires supervision and set up for ambulation in room and corridors. The same MDS documents R25 has had two or more falls in the facility. R25's Care Plan updated 11/18/22 documents the following: Focus: (R25) is HIGH risk for falls r/t/ dx of (related to diagnosis) Dementia, COPD (Chronic Obstructive Pulmonary Disease), HTN (Hypertension), Weakness, GERD, abnormalities of gait/mobility, lack of coordination, hypokalemia, anemia, dysphagia, cognitive communication deficit, difficulty walking, HLD, depression, and osteoporosis.) Goal: (R25) will be free of minor injury through the review date. Intervention/Tasks: Hipsters to be worn for protection at all times. 04/16/22 PT/OT (Physical Therapy/Occupational Therapy) eval Evaluation) post fall and place helmet for safety 08/24/2022: (R25) will repeatedly take her helmet off and becomes agitated and aggressive at times when staff tries to place helmet on. On 01/10/23 at 01:15 pm an unidentified Certified Nursing Assistant (CNA) assisted R25's room and assisted R25 to lay down in low bed that was up against the wall. The unidentified CNA exited R25's room. R25 was layed in a fetal-like position in bed, facing the wall with a full hard shelled football-like helmet on. The helmet was strapped under R25's chin. R25 was tugging at the chin straps as R25 lay in a fetal-like position facing the wall. R25 was non-verbal and mumbled when interviewed. On 01/10/23 at 1:30 pm R25 continues with the hard shelled football-like helmet on in bed. R25 was trying to take off helmet, fidgeting repeatedly with the chin strap, tugging at the hard shell and intermittently picking motions hitting the wall next to bed in rapid succession while mumbling. On 01/10/23 at 1:40 pm R25 continues with helmet on while in bed. R25 was more restless and was scratching the wall assertively intermittently while tugging forcefully under chin helmet strap On 01/10/23 at 1:42 pm V4, CNA stated We just leave it (helmet) on when she is in bed because she has had falls. When she (R25) is asleep overnight they take the helmet off then. V4, CNA also stated I don think she has ever worn hipster. Not that I know of. On 1/10/23 at 1:55 pm V3, Licensed Practical Nurse (LPN) entered R25's room. R25 was tugging on the chin strap of her helmet. V3, LPN assessed R25's for the presence of hipsters by touching outside R25's pants, across R25's hips. V3, LPN then pulled the side of R25's pants to reveal R25's incontinence brief and bare thigh. [NAME] stated (R25) is only suppose to wear the helmet when out of bed. I will take that off. She (R25) can rest more comfortably without that (helmet) on. I don't know why she (R25) doesn't have the hipsters on. They are to be on except when she is being changed.

Based on observation, interview, and record review the facility failed to provide supervision and toileting assistance for one (R6) of three residents reviewed for falls. This failure resulted in R6 falling and sustaining a right hip fracture, right orbital (eye socket) fracture, and right wrist fracture. The facility also failed to implement post fall interventions for one (R6) of three residents reviewed for falls in the sample list of six. Findings include: R6's Diagnosis List dated 1/3/23 documents R6 has Dementia. R6's Minimum Data Set, dated dated dated [DATE] documents: R6 has a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. R6 requires limited assistance of one staff person for transfers, walking, dressing, and toileting. R6 uses a walker, is not steady, and only able to stabilize balance with staff assistance when turning around, moving on/off the toilet, and for surface to surface transfers. R6's Care Plan dated 11/7/22 documents R6 is at risk for falls related to confusion, gait/balance problems, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Osteoporosis, overactive bladder, and reflux disease. R6's care planned fall interventions do not include the use of an alarming device. R6's Nursing Notes document the following: On 12/15/22 at 12:46 PM R6 had an unwitnessed fall in a resident room. R6 was found lying on the floor holding R6's head. R6 had a laceration to R6's right eye, right face 5 cm (centimeters) long by 1.27 cm wide by 0.3 cm deep, right wrist, and right forearm 3.5 cm long by 1 cm wide by 0.1 cm deep. R6's right wrist was flaccid (limp). R6's right eye was swollen shut and R6 was unable to open R6's eye. This nurse (V10 Licensed Practical Nurse) applied pressure with ABD (abdominal) pads to orbital socket to stop hemorrhaging. R6 was transported by ambulance to the emergency room . Contributing factors include R6 was not using R6's cane/walker as instructed and R6 has diagnoses of Dementia and an unsteady gait. R6's undated Fall Investigation documents the following: R6's fall occurred in another resident room. V11 Certified Nursing Assistant (CNA) saw R6 in the bathroom approximately 3 minutes prior to the fall. V11 thought R6 was trying to put on different pants because resident's (R6's) pants were in the bathroom. R6 requires limited assistance of one person for activities of daily living and transfers. Root Cause: it is probable resident (R6) was attempting to dress without assistance resulting in (R6) becoming off balance and falling. Based on investigation, it is probable that resident (R6) took herself to the bathroom and took off her pants. Resident (R6) had a different pair of pants around her ankle upon staff assessment. R6 was transferred to the emergency room and diagnosed with a right hip, wrist, and orbital bone fracture. R6's Hospital emergency room Note dated 12/15/22 at 1:32 PM documents R6 had an unwitnessed fall at the nursing home and presented with right eye bruising/bleeding, right hip pain, right facial injuries, and fractured right wrist. R6's right wrist x-ray and right hip x-ray dated 12/15/22 document There is an acute dorsally impacted fracture distal metaphysis of the radius. There is an acute avulsion fracture styloid process distal ulna. Right hip x-ray shows a fracture in the subcaptial region extending to the mid cervical region medially. Acute pathology is right wrist fracture and right hip fracture. R6's head/facial bone Computed Tomography scan dated 12/15/22 documents Right orbital rim fracture. On 12/29/22 at 10:52 AM R6 was lying in bed on a motion sensor bed alarm. R6 had a cast to R6's right forearm and bruising/scabbed area to R6's right check. R6 did not remember falling and was unable to recall details of R6's fall. At 11:15 AM V12 and V6 CNAs used a gait belt and transferred R6 from the wheelchair into the shower chair. R6 had dark blue bruising to R6's right side and lower back/hip. At 1:51 PM R6 was sitting in a recliner in R6's room. R6 did not have a motion sensor alarm in R6's recliner. On 12/29/22 at 1:54 PM V12 CNA stated V12 was not sure who transferred R6 into the recliner. V12 confirmed R6's recliner did not have a motion sensor alarm. I put one (alarm) in (R6's) chair this morning and (R6) uses it (alarm) in bed. We have a binder at the desk that tells us fall interventions/alarms. On 12/29/22 at 1:57 PM the fall intervention binder did not contain information regarding R6's fall interventions. V9 Licensed Practical Nurse (LPN) confirmed the binder did not contain fall interventions for R6. V9 stated V9 was not sure if R6 uses motion sensor alarms and V9 would have to look up the information. V9 reviewed R6's Physician Orders and stated there is no order for R6 to have an alarm. There would be an order if (R6) was suppose to have one. On 1/3/23 at 10:18 AM V11 CNA stated: V11 was walking with R6 to the dining room (on 12/15/22). R6 told V11 that R6 needed to go to the bathroom. V11 told R6 to go ahead and go to the bathroom, and V11 would return later. V11 went to assist another employee with a resident transfer, and upon return R6 was found on the floor near the closet of another resident's room. V11 had last seen R6 sitting on the toilet in the adjoining bathroom of that room a few minutes prior. R6 was found to have on different pants that did not belong to R6. R6's walker was in the bathroom and not in the resident room near R6. V11 does not work R6's hall much, but R6 was pretty independent with toileting. The post fall intervention was not to leave residents in the bathroom by themselves. R6's fall probably could have been prevented if someone was in the bathroom assisting R6. R6 gets confused and mixed up. R6 was in the closet getting clothes to change into, because R6 was incontinent. On 1/3/23 at 10:45 AM V10 LPN stated V10 heard a scream and found R6 lying face down in another resident room. R6 was bleeding, R6's orbital socket had a big gash and R6's right wrist was limp. V10 supported R6's wrist with R6's fingers. R6 was unable to open R6's right eye due to swelling and a hematoma. Prior to the fall R6 was confused, had an unsteady gait, and required assistance of one staff person for transfers, ambulation, and toileting. R6 was not safe to be left in the bathroom by herself due to R6's confusion. On 1/3/23 at 1:25 PM V2 Director of Nursing stated R6 should have a motion sensor alarm in use when R6 is sitting in the recliner in R6's room. This information should be updated on R6's care plan and included in the binder at the nurse's station. V2 stated through investigation it is probable that R6 was attempting to pull up R6's pants that R6 had obtained from the room and fell . V12 stated V11 had witnessed R6 in the bathroom approximately 3 minutes prior to the fall, and staff should assisted R6 since R6 required one assist for activities of daily living. On 1/3/23 at 2:39 PM V4 Physician confirmed R6's injuries are consistent with a fall. The facility's Falls - Clinical Protocol revised August 2008 documents: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Failures at this requirement required more than one deficient practice statement. A. Based on record review and interview the facility failed to ensure one resident (R2) was not subjected to sexual abuse by another resident (R3) with known sexually inappropriate behaviors. R2 who is severely cognitively impaired wandered into R3's room and was found by staff sitting on R3 with R3's hand grasping R2's breast. R2 would have experienced humiliation, fear and anxiety related to this incident if R2 was cognitively intact. This failure affected two residents (R2, R3) out of eight residents reviewed for abuse in a sample list of 13 residents. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 10/22/22, the facility remains out of compliance at a severity level two. The facility continues to monitor the effectiveness of their plan to ensure staff are assigned to monitor R3 and the effectiveness of their staff education plan for identifying and responding to potential resident sexual abuse. Findings include: R2's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired and requires extensive assistance of two staff members for bed mobility and extensive assistance of one person for transfers, dressing, eating, toileting and personal hygiene. R2's Care Plan intervention dated 3/15/22 documents (R2) will at times get agitated and wander. Staff is to redirect to (R2's) room to engage in reminiscing about the flower pictures and pictures of (R2's) family on the wall, helping take care of (R2's) stuffed animals, providing home and garden magazines to look at and provide a drink or snack. R3's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. This same MDS documents R3 requires limited assistance of one person for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, toileting and personal hygiene. This same MDS documents R3 uses a walker for mobility device. R3's Care Plan documents a focus area initiated 10/8/19 that documents R3 makes inappropriate sexual comments to staff, has instances of sexual acts to self, at times exposes self. This same Care Plan documents an intervention dated 5/23/22 of (R3) makes inappropriate sexual comments to staff. (R3) also has instances of sexual acts to self. (R3) at times exposes himself. R3's Nurse Progress Note dated 10/7/22 at 7:03 PM documents Power of Attorney (POA) notified of incident with inappropriate fondling of female resident (R2) under the shirt. Residents (R2, R3) were separated. POA concerned as reports (R3) has a history of verbal sexual comments. POA states that (R3) did something inappropriate to her (POA) last weekend and she is not sure what to do about it. R2's Nurse Progress Note dated 10/7/22 at 7:10 PM documents Inappropriate fondling under the shirt to (R2) that had wandered into (R3's) room. As reported per (V11) Certified Nurse Assistant (CNA), (R3) grabbed tighter when attempting to separate the residents (R2, R3). R2's Nurse Progress Note dated 10/7/22 at 7:12 PM documents Incident occurred while (R2) was wandering the unit. (R2) was found in (R3's) room with (R3's) hand under (R2's) shirt. R2's Final Incident Report to Illinois Department of Public Health (IDPH) dated 10/14/22 documents (V11) Certified Nurse Aide (CNA) reported (R2) had been given a shower and escorted to sit in common area next to window across from nurses station. (V11) left to perform personal care for other residents and a few minutes later notices that the call light was on in (R3's) room and went to see what was needed. (V11) CNA observed (R2) sitting on (R3's) bed with (R2's) back to (R3) and half on (R3's) leg. (R2 and R3) were fully clothed. (R3) had (R3's) hand under (R2's) shirt near (R2's) chest area. (V11) immediately moved to separate both residents (R2, R3) and (R3) responded '(R2) was alright there and (R2) wasn't hurting anything.' (R3) also joked about (R2) sitting on (R3's) bed and joked that (V11) CNA could sit on (R3's) bed with (R3). This same report documents Outcome of Situation: (R2) was assigned a one to one to monitor for 72 hours and thereafter moved to another unit. Staff were educated regarding monitoring confused residents and the potential for wandering. (R3) was educated to use call light to request assistance redirecting residents who accidentally enter (R3's) room and agreed to do so. (R3) also counseled regarding use of appropriate language and behavior regarding female staff and residents and indicated (R3) understood and agreed. We (facility) were not able to determine if this was intentional or an awkward accident. On 10/18/22 at 2:10 PM R3 stated I don't remember anyone coming into my room. I wouldn't mind if they did. They are welcome to come on in and have a seat and talk a spell. If you see an [AGE] year-old red head around, please send them in. I would REALLY like to talk to them. On 10/18/22 at 3:30 PM V11 Certified Nurse Aide (CNA) stated I had just given (R2) a shower and assisted (R2) to the sitting area across from the nurses desk by the window. There were not any other staff around but (R2) will usually sit there for a little while and be ok. (R2) likes to sit there to look out the window. About 30 minutes later, the call light was ringing for (R3's) room. (R10) had put on the call light to use the bathroom. (R10) is (R3's) roommate. When I walked in (R3's) room (R2) was sitting half on (R3's) bed and half on (R3's) lap. (R2) had (R2's) back to (R3). (R3) had used his Right hand to directly hold on to (R2's) Right breast. (R2) did not have on a bra or undershirt and (R2's) shirt was loose. (R3) smiled and told me that I was being a 'killjoy' by attempting to remove (R2) from the situation. (R3) did not want to let go of (R2's) breast. (R3) then said 'if you are going to take (R2) away from me then you have to take (R2's) place in the bed'. V11 stated (R3) has had these behaviors before. The last time (R3) walked down the hall to another resident's room, stood in the doorway and began masturbating in front of another resident. I do not remember who the other resident was. She (unknown resident) was in her room on another hall from what (R3) lived on. (R3) is able to use a walker independently to get around the room and up and down the halls. I don't know what we will do with him because he keeps doing this. V11 stated R2 exhibited a flat affect and no response while R3 was grasping R2's breast. R2 is cognitively impaired and non-interviewable and no family or friends were available to offer an opinion of how this incident would have affected R2. On 10/19/22 at 1:55 PM V19 Social Service Director (SSD) stated (R3) has made inappropriate comments to female staff but not to any other residents that I am aware of. (R2) did like to walk down (R3's) hallway. (R2) would gravitate towards that hall so we (facility) thought moving (R2) off the unit completely would be best. (R3) has already been established with (V36) Psychologist. (R3) was already on [MEDICATION(S)] to help reduce (R3's) sexual urges. We (facility) should have sent (R3) out to the emergency room for an evaluation that day. Next time we (facility) will. On 10/19/22 at 2:20 PM V36 Psychologist stated I have been seeing (R3) for the last three years at this facility. I am not surprised to hear that (R3) has had inappropriate sexual behaviors. This is typical of (R3). I have not been made aware of any instances of other residents being involved. (R3) has complained of loneliness due to the death of (R3's) wife. (R3) is escalating in (R3's) behaviors. (R3) has moved from comments to groping to now grabbing. (R3) is progressing in sexually aggressive behaviors. (R3) asked me to get (R3) a laptop. I don't think that is a sound idea though because (R3) will use it for pornography. (R3) should be monitored closely if (R3) comes out of (R3's) room. An Immediate Jeopardy situation was identified on 10/22/22. V1 Administrator was notified of the Immediate jeopardy on 10/22/22 at 10:17 AM. The Immediate Jeopardy was identified to have begun on 10/7/22 when the facility failed to ensure one (R2) resident was not subjected to sexual assault from another resident (R3). The surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. R2 was provided a head-to-toe assessment and moved to a closed hallway on 10/22/22. 2. R3 was moved to a separate (from R2) unit on 10/21/22. V38 scheduler confirmed responsibility for assigning staff to monitor R3 when R3 is out of R3's room and confirmed that staff will be assigned to monitor R3 on a one to one basis when R3 is out of R3's room. 3. The Director of Nurses confirmed staff were trained regarding monitoring R3 when R3 is out of R3's room on 10/21/22 and a copy of the inservice sign in sheet was provided. 4. The Social Service Director confirmed all residents were reviewed for being predisposed to perpetrating sexual abuse on 10/22/22. 5. The Medical Director was notified of incident by the Director of Nurses on 10/7/22. V45 Nurse Practitioner evaluated R3 on 10/25/22 and V45 is consulting with V46 Medical Director concerning management of R3's behaviors. 6. V1 Administrator confirmed that training regarding identifying and responding to potential sexual abuse was initiated on 10/22/22 for staff and administration and training will continue until all staff have been trained. 7. V1 confirmed that the Administrator or designee will audit each new admission for potential of sexual abuse for 3 months. Any issues will be addressed immediately. 8. V1 confirmed that the Quality Assurance Committee will monitor the facility's performance to ensure that corrections are achieved. B. Based on record review and interview the facility failed to ensure residents were not subjected to mental and physical abuse by staff when staff threw food around residents and used a syringe to spray residents with water during a meal for seven of eight residents (R1, R2, R4, R8, R9, R11, R12) reviewed for abuse on the sample of 13 residents. This failure resulted in psychosocial harm to R1, R2, R4, R8 and R9 who were intentionally sprayed in the face with water by staff and expressed anger and anxiety during the abuse by crying and screaming at staff to stop throwing food and water. Findings include: R1's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as requiring supervision with eating. R2's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired. This same MDS documents R2 requires extensive assistance of one person for eating. R4's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 as requiring limited assistance of one person for eating. R4's Care Plan documents an intervention dated 8/18/22 (R4) is at risk for abuse related to being dependent on others, anxiety/fear/anger and depression. R8's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Minimum Data Set (MDS) dated [DATE] documents R8 as severely cognitively impaired. This same MDS documents R8 requires extensive assistance of one person for eating. R9's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set (MDS) dated [DATE] documents R9 as moderately cognitively impaired. This same MDS documents R9 as requiring total assistance of one person for eating. R11's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's Minimum Data Set (MDS) dated [DATE] documents R11 as severely cognitively impaired. This same MDS documents R11 requires extensive assistance of one person for eating. R12's undated Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Minimum Data Set (MDS) dated [DATE] documents R12 as severely cognitively impaired. This same MDS documents R12 requires extensive assistance of one person for eating. R1's Initial Incident Report to Illinois Department of Public Health (IDPH) dated 10/13/22 documents (V1) Abuse Coordinator was notified by (RN) that two Certified Nurse Aides (CNA) were throwing peas and squirting each other with water at mealtime and residents at the table were hit by the food and splashed with water. On 10/19/22 at 1:30 PM R7 stated I saw the whole mess. It was a supper meal on a Wednesday. There were two Certified Nurse Aides (CNA's) (V3, V4) sitting at a table of residents on the far end of the dining room. I sit at the Queen's table in the middle of the dining room. That end of the dining room was so loud, we (residents) could not hear anything. It was obnoxious. Then I saw (V3 and V4) CNA's throwing food at five different residents. One of the CNA's (V3) had a Styrofoam cup of water and some kind of medical syringe. (V3) would fill the syringe with water and point it at those residents and squirt them in the face. Those residents were (R1, R2, R4, R8 and R9). (R1) yelled at (V3) saying 'I am going to kick you're a** if you (V3) squirt me again!' and 'Come closer so I can kick you're a**.' There were residents crying, screaming and yelling for (V3, V4) to stop. They all have the Alzheimer's and don't know what is going on. There is a special place in hell for people that hurt those kinds of people. It made me so mad. I started yelling at those two (V3, V4) to cut it out. I had to yell really loud for them to hear me because they (V3, V4) were being so loud. They (V3, V4) still didn't stop so I started to push myself over there to tell them to stop throwing food and squirting water at people who cannot defend themselves. At that time, (V6) CNA walked over to me and told me to stay put. (V6) yelled at (V3, V4) and walked over to the table where (V3, V4) were sitting. (V6) CNA told them to knock it off and they (V3, V4) finally did. It was awful. I felt so bad for those ladies (R1, R2, R4, R8, R9). They did not deserve to be treated like that. I hope they (facility) fired those a*******. They (V3, V4) aren't [NAME] enough to pick on somebody who has their mind about them. On 10/19/22 at 11:30 AM V4 Certified Nurse Aide (CNA) stated (V3) CNA and I were sitting at a table in the dining room assisting residents with supper meal. (R1) was sitting at the table right next to ours (V3, V4). (V3) CNA took a plunger like the kind they (nurses) use to fill up a urinary catheter balloon out of (V3) pocket and squirted (R1) twice. (V3) squirted (R1) in the cheek and second time in (R1's) shoulder. The water didn't just hit (R1) in two spots but (V3) actually squirted (R1) two separate times. I was assisting another resident eating supper. I don't remember who that was. We (facility) had peas for supper that night. I scooped up the peas with the spoon and they (peas) fell off the spoon so I picked them up off table and tossed them over my shoulder behind me. Then (V3) took the peas off (V3's) spoon and tossed them in the air. That is when I told (V3) to stop throwing food around. (V3) stopped at that point. (V7) Licensed Practical Nurse (LPN) took me in the medication room right before I left at 6:00 PM. (V7) asked me what happened and I told her everything then I left for the day. The next day at the end of my shift, (V8) pulled me into a front office and questioned me about this incident. (V1) came in a few minutes later and suspended me. I haven't been back to work since. On 10/19/22 at 11:50 AM V6 Certified Nurse Aide (CNA) stated I remember that day. It was awful. It was so chaotic. I was on the other side of the dining room assisting residents with supper meal. The area where (R1) was sitting was so loud. Several residents complained it was too loud to eat so I went over to (R1's) table. (V3) CNA had a plunger (V3) kept dipping into a cup of water and filling it up. (V3) squirted water at R1, R2, R4, R8 and R9. I saw (V3) keep filling up the plunger with water and I saw (V3) squirt all those residents. I yelled at (V3) to stop. (R1) yelled, screamed and cussed at (V3). (R1) yelled 'I am going to kick your (V3) a**. You (V3) have no right to squirt me with water. Come over here so I can kick you're a**'. I had to stay with (R1) for a while because (R1) is a high fall risk and (R1) kept trying to get up to get to (V3). (V3) was laughing but (V3) stopped after we (staff) were all yelling at (V3) to stop. (R7) also yelled at (V3) to stop. (R7) is alert and oriented. (R7) could tell how bad it was that day. It was awful. On 10/21/22 at 10:00 AM V30 (R8) Power of Attorney (POA) stated (R8) has had Dementia for a very long time. Prior to (R8's) Dementia, (R8) would take very good care of herself. (R8) would dress well, wear make-up, you know, just look nice every day. (R8) always took pride in how (R8) looked. I am sure (R8) would be appalled at having food thrown and water squirted at (R8). (R8) would have been very mad about that if (R8) were in her right mind. On 10/20/22 at 1:30 PM V25 (R9's) Power of Attorney (POA) stated (R9) is in the end stages of Dementia. If (R9) had her right mind, (R9) would never appreciate having food thrown at her or water squirted at (R9). (R9) has always been on the stricter side and did not have much of a sense of humor. (R9) would have been very upset by this. (R9) would have told those staff (V3, V4) to stop that behavior immediately. On 10/20/22 at 12:35 PM V1 stated I was informed on 10/12/22 evening about 8:00 PM-9:00 PM of (V3, V4) two Certified Nurse Aides (CNA) throwing food and squirting water at residents including (R1) and others. I did not know who the other residents were until further into the investigation. I didn't ask who they were. I was just so shocked. On 10/20/22 at 3:15 PM V1 Administrator stated There are many types of abuse. I have done many educations on the types of abuse and what to do and who to report to with all my staff. The nurse (V7) Licensed Practical Nurse (LPN) contacted me about 8:00-9:00 PM the evening of 10/12/22. The date on the Initial and Final Reports to Illinois Department of Public Health (IDPH) are not accurate. This incident involving (R1, R2, R4, R8, R9, R11 and R12) did in fact happen at 5:00 PM 10/12/22. (V7) told me that (R1) had been hit with food and squirted with water by (V3 and V4) Certified Nurse Aides (CNA's). To be honest, I just could not believe the staff would do something like this. On 10/25/22 at 11:10 AM V45 Nurse Practitioner (NP) stated All residents have the right to dignity and respect. Throwing any kind of food and squirting water at residents is unacceptable. That is not treating them with the respect and dignity they (residents) deserve. That is abuse. It is discouraging to think this behavior happened at all but hopefully the facility will not allow that again. The undated facility policy titled 'Abuse Prevention Program-Policy' documents the following: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Sexual abuse is non-consensual sexual contact of any type with a resident. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by a licensee, employee or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. This includes, but is not limited to, harassing a resident, mocking, insulting, or ridiculing, yelling or hovering over a resident, with the intent to intimidate; threats of deprivation; and isolation.

Based on observation, interview and record review the facility failed to follow a Physician's Order to use an adaptive cup with a lid to prevent spills, failed to supervise residents drinking hot liquids, and failed to assess residents for safe handling of hot liquids for two of three residents (R6,R4) reviewed for accidents in the sample list of 13 residents. These failures resulted in R4 and R6 suffering second degree [CONDITION(S)] when they spilled hot coffee, supplied by the facility, on themselves. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 10/24/22, the facility remains out of compliance at severity level 2 as the facility continues to monitor the effectiveness of the re-education of direct care staff related to hot liquid management for residents. Findings include: The facility's Precautions for Handling Hot Beverages policy dated 2020 documents, Staff will monitor, serve, and hold hot beverages in a safe manner to prevent potential [CONDITION(S)]. Additional precautions may be implemented: a. Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. b. Ensuring staff monitor the identified high-risk resident(s) during meal times and/or when hot beverages are served. c. Utilizing specialized spill proof lids and cups for those individuals identified as high risk for spillage and potential for burning. 1.) R6's Face Sheet documents diagnoses including Dementia without Behavioral Disturbances, Need for Assistance with Personal Care, Facial Weakness, Cognitive Communication Deficit, Muscle Weakness (Generalized) and Dysphagia, Oral Phase. R6's Order Summary Report dated 10/19/22 documents an order for a regular diet, pureed texture add fortified foods three times a day with meals for diet with a start date 7/14/21. R6's care Plan dated 9/27/21 document R6 has an ADL (Activities of Daily Living) for eating with interventions to provide food, utensils, and drinks of preference. Placing items within R6's reach, open cartons and cut up food as needed, provide verbal/visual cues and physical prompts as needed. Staff to provide physical assistance as needed. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is severely cognitively impaired and requires extensive physical assistance of one staff for eating. R6's medical record does not document an assessment for safe handling of hot liquids until 10/19/22. R6's Hot Liquids Risk Screed dated 10/19/22 documents that R6 should have hot liquids cooled before handling. R6's Occupational Therapy Evaluation dated 10/12/22 documents the reason for referral is due to increase in spillage and documents R6's current level is moderate assistance (hands on assist, lifts, holds or supports). This Evaluation documents R6 is referred for Occupational Therapy visits five times a week for four weeks. R6's Nurse's Notes dated 10/6/22 at 7:47 PM by V26 Licensed Practical Nurse (LPN) documents that it was reported to V26 that R6 had spilled coffee on R6's self, noted reddened area on right thigh with blisters, small, reddened area on right abdomen with no blisters and another area on the left inner thigh with small blisters and POA (Power of Attorney) and Physician notified. R6's Nurse's Notes dated 10/6/22 at 8:44 PM by V26 documents the area on the right inner thigh measures 24cm (centimeters) x (by) 6cm with several blisters, the on call Physician notified and ordered to give Tylenol for pain and have the wound nurse follow up with R6 in the morning. This note documents the area on the inner thigh measures 5cm x 2cm with two small blisters and the area on the abdomen measures 2cm x 3cm with no blisters noted. R6's Investigation dated 10/6/22 documents R6 was sitting at the dining room table with R6's coffee cup in front of R6 and did not have a good grip on the cup causing R6 to drop and spill the cup into R6's lap. V27 Certified Nursing Assistant (CNA) witnessed the incident and responded immediately. V27 attempted to soak up the coffee with napkins. V27 started to take R6 back to the nurse's station and V28 CNA intercepted and took R6 the rest of the way to the nurse's station. V9 Wound Nurse assessed, and the areas were only red at that time with no blisters. The investigation documents that the evening shift noticed blisters develop and notified the Physician and POA. On 10/18/22 at 11:45 AM, V10 Wound Physician was evaluating R6's [CONDITION(S)]. V9 Wound Nurse was assisting V10. R6's left thigh wound was red but the skin was not open. The right inner thigh wound was large, approximately 9 to 10 cm (centimeters) long and approximately 1 to 1/2 cm wide with approximately 0.1 cm depth, the skin was open, the wound bed was red with yellow slough and looked red and inflamed around the edges. R6's wound area on the top of the right thigh was large, approximately 9 to 10 cm long and 1 to 2 cm wide and necrotic, blackish red scabbed over the entire wound. V10 stated R6's [CONDITION(S)] were second degree [CONDITION(S)] from a coffee spill and V10 stated V10 is ordering antibiotics for R6 as the [CONDITION(S)] appear infected. On 10/18/22 at 11:55 AM, V2 Director of Nursing stated R6 dropped R6's coffee cup on R6's lap and there was no staff sitting at the table with R6. V2 stated that staff was sitting at the table next to R6 when R6 spilled R6's coffee and burnt R6's self. V2 stated that V2 inserviced staff regarding serving hot beverages. On 10/18/22 at 12:10 PM, V9 Wound Nurse stated that V9 sent a picture of the [CONDITION(S)] to V10 to get a stage and a treatment order. V9 confirmed V10 stated R6's [CONDITION(S)] were second degree [CONDITION(S)]. On 10/18/22 at 12:24 PM, V29 Dietary Manager dispensed a cup of coffee from the coffee maker in the dining room and checked the temperature with a dial thermometer which read 152 degrees Fahrenheit (F.). The same cup of coffee was checked with a digital thermometer and read 154 degrees F. V29 stated the temperature should be between 160 degrees and 171 degrees F. to serve to the residents. V29 stated that they now take the temperature of the coffee before each meal and if it is above 170 degrees F. they are supposed to add ice to the coffee before giving it to the residents. V29 stated that they did not previously keep a log of the coffee temperatures, but they started a log on 10/13/22. V29 also stated that they ordered lids for the coffee cups, and they just came in and started using them today. V29 stated that V29 called the coffee machine company after R6's burn and they came in to see if the coffee temperature could be turned down, but it could not be turned any lower. The coffee temperature log dated 10/13/22 through 10/18/22 documents the highest temperature as 160 degrees F. on several days. On 10/19/22 at 11:20, V15 Certified Occupational Therapy Assistant stated that R6 would not be safe drinking hot liquids independently as that is the reason they are putting R6 on therapy. On 10/20/22 at 11:29 AM, V2 stated R6 should have had staff sitting at the table with R6 at the time of the burn incident because R6 had beverages in front of R6. On 10/21/22 at 1:31 PM, V27 CNA stated on 10/6/22 that V27 was taking residents to the dining room and R6 was sitting at the table without drinks when V27 went to get another resident. V27 stated when V27 returned to the dining room someone had given R6 a cup of coffee. V27 stated V27 looked at R6 and R6 was trying to pick up the cup and couldn't get R6's fingers through the handle and dropped the hot coffee on R6's lap. V27 stated that V27 ran to R6 and lifted R6's slacks away from R6's skin and the slacks were hot to touch. V27 stated V27 yelled for help and another staff member assisted V27 to wipe up the hot coffee and the other staff member took R6 back to the nurse's station for the nurse to assess R6. V27 stated that the residents at the feeding assisted table are not suppose to have their drinks until staff is with them. V27 stated that R6 doesn't hold onto things very well. 2.) R4's Face Sheet documents diagnoses including Diabetes Mellitus, Mild Intellectual Disabilities, [CONDITION(S)], Dysphagia Oral Phase, Dysphagia Oropharyngeal Phase and [CONDITION(S)]. R4's Order Summary Report dated 10/19/22 documents an order for a regular diet, pureed texture, honey consistency, orange/red adaptive cups with matching lids with a start date of 7/8/22. R4's Care Plan dated 1/31/19 documents R4 has an ADL (Activities of Daily Living) self-care deficit in eating with interventions to provide food/fluids as ordered and utensils placing items within reach, staff to open cartons and cut up food as needed, provide verbal/visual cues and physical prompts as needed for R4 to self-feed as R4 is able/willing, staff to provide physical assistance as needed. R4's Minimum Data Set (MDS) dated [DATE] documents R4 has moderately impaired cognition and R4 requires limited physical assistance of one staff member for eating. R4's medical record does not document an assessment for safe handling of hot liquids until 10/18/22. R4's Hot Liquids Risk Screen dated 10/18/22 documents that R4 should have hot liquids cooled before handling. R4's Speech Therapy Discharge Instructions dated 8/1/22 documents Drinks in adaptive cups/lids. R4's Nurse's Notes dated 10/13/22 at 7:10 PM documents R4 burnt self with coffee. R4's Investigation dated 10/13/22 documents V13 Certified Nursing Assistant (CNA) prepared coffee for R4 and gave it to R4. When R4 went to take a drink R4 missed R4's mouth and poured the coffee on R4's self. R4 was taken back to R4's room and clothing was removed from R4. Physician and R4's Power of Attorney (POA) were notified. Treatment orders were obtained and implemented. On 10/18/22 at 12:10 PM, V10 Wound Physician stated that R4's burn on R4's chest is a second degree burn from spilling hot coffee on R4's self. On 10/19/22 at 9:46 AM, R4 stated that on 10/13/22 R4 was drinking coffee and it went all over R4 and R4's clothes. R4 stated that R4 missed R4's mouth. R4 stated it burned and R4 hollered out. R4 stated staff brought R4 to R4's room and put a bandage on the burn. R4 stated that it hurts if it is touched. On 10/19/22 at 9:53 AM, V2 Director of Nursing stated when R4 spilled R4's coffee and burnt R4's self, there were no staff directly at the table with R4. V2 stated staff were passing out drinks in the dining room. V2 stated that R4 sits at an assisted feeding table because R4 needs additional assistance. V2 stated that staff were inserviced regarding serving hot liquids the day before R4 was burnt. On 10/19/22 at 11:32 AM, V13 Certified Nursing Assistant (CNA) stated that V13 got R4's coffee for R4. V13 stated that V13 put coffee in a regular cup, added the thickener to it and added several pieces of ice to the coffee then set it on the table in front of R4. V13 stated that V13 continued to pass out drinks to other residents when V13 heard R4 scream out. V13 stated V13 and the nurse V23 (Registered Nurse) immediately went to R4 and wiped up the coffee then took R4 to R4's room and removed R4's clothing and put a nightgown on R4. V13 stated that R4 wanted to eat supper so they brought R4 out by the nurse's station so R4 could eat supper. On 10/20/22 at 12:59 PM, V23 stated that V23 was passing medications in the dining room when V23 heard R4 holler. V23 stated that V23 immediately went to R4 and saw that R4 had spilled something on R4 so V23 started wiping it off and realized it was coffee because it was hot. V23 stated that they took R4 back to R4's room and removed R4's clothing and tried to put a cold washcloth on the area but R4 yelled and didn't want V23 to touch it. V23 stated that they put clothing on R4 and R4 wanted to eat so they brought R4 out to the nurse's station to eat. V23 stated that V23 notified the Physician and the POA. V23 stated that this happened at the supper meal and V23 left that day at 6:00 PM. On 10/20/22 at 1:20 PM, V24 Licensed Practical Nurse (LPN) stated that V24 was working on 10/13/22 when R4 spilled the coffee on R4's self. V24 stated that V24 assisted the nurse with notifications and received an order to apply a petroleum-based dressing to the burn and cover with a dry dressing and V24 stated V24 applied the dressing to R4 on 10/13/22. V24 stated that R4 did not complain of any pain that evening but V24 stated R4 receives scheduled pain medication. V10's Wound documentation dated 10/18/22 documents a burn wound to the chest with partial thickness measuring 9cm (centimeters) x (by) 12cm with light serous exudate. On 10/18/22 at 12:10 PM, R4's wound dressing was removed by V9 Wound Nurse. The area was large, approximately 10 cm x 10 cm and the skin was red and there were some areas of yellow slough. At that time V10 removed the slough with a cotton swab and R4 was yelling out as V10 touched the burn. After V10 removed the skin V10 measured the area then V10 applied the dressing to the open wound. On 10/20/22 at 11:11 AM, V18 Speech Therapist stated that V18 discharged R4 from Speech Therapy in July, 2022. V18 stated that R4 was supposed to have a cup with a lid because R4 needed to protect R4's airway and needed spill control. V18 stated that R4 would have liquid running down R4's face when R4 drank out of a regular cup. V18 stated that V18 would expect staff to follow those recommendations. V18 stated that V18's recommendations got sent to the Physician's and the Physician writes an order for those recommendations. On 10/20/22 at 11:29 AM, V2 DON (Director of Nursing) stated that R4 was supposed to and is still supposed to have staff at the table with R4 when R4 is in the dining room. V2 stated that there was no staff directly at the table with R4 when R4 spilled R4's coffee on R4 and burnt R4's self. V2 stated that they have so many residents that have to be fed that they don't all fit at one table, so staff must go back and forth to the tables. V2 stated that R4 should have had a staff member at R4's table at that time because R4 had beverages. V2 stated that V2 was aware that R4 should have had an adaptive cup with a lid and did not have it at the time of the spill with the burn. V2 stated that the kitchen did not have the cups out and available so V13 used a regular coffee cup. V2 stated V13 should have spoken to the kitchen staff and gotten a cup with a lid for R4. An Immediate Jeopardy situation was identified on 10/21/22. The Immediate Jeopardy was identified to have begun on 10/6/22 when R6 sustained second degree [CONDITION(S)] to R6's inner thighs as a result of mishandling a hot liquid beverage served by the facility. On 10/21/22 at 8:58 AM, V1 Administrator was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1.) R4 had a 'Hot Liquid Risk Screen Assesment' completed on 10/18/22. R4's Care Plan has been updated. R4 was evaluated by OT (Occupational Therapy) who made recommendations. R6 had a 'Hot Liquid Risk Screen Assesment' completed on 10/12/22. R6's Care Plan has been updated. R6 was evaluated to OT who made recommendations. Completed by Occupational Therapy. 2.) No new residents have been identified to have been affected. Completed by Director of Nursing and Occupational Therapy on 10/25/22. 3.) Seating chart has been made for all residents. Staff members are being assigned to speficic tables for residents who require feeding assistance. All residents have been assessed with 'Hot Liquids Risk Screen' Assessment and triggered residents are being evaluated by OT. Triggered residents were screened by therapy staff on 10/25/22. 10 residents were identified to need an OT evaluation. Seven of these 10 OT evaluations were completed 10/25/22 and the other three are supposed to be completed during supper meal on 10/26/22. Staff inservicing has been started and remains in progress. Staff are observing residents during meal times. Completed by Director of Nursing and Occupational Therapy. 4.) DON has assigned mealtime audits to be completed by the floor nurses for every meal. These audits have been intiated (10/24/22) and are in progress. Quality Assurance (QA) Committee will monitor the facility performance at next QA meeting on 11/9/22. 5.) All residents identified to be at high risk for mishandling hot liquids were restricted from independently handling hot liquids until they could be assessed for safety in doing so. Completed on 10/24/22 by Administrator.

Based on observation, record review and interview the facility failed to follow assessment recommendations for bed mobility and failed to ensure a care plan was updated to include known behaviors exhibited during repositioning for one of three residents (R7) reviewed for accidents in the sample list of seven residents. These failures resulted in R7 suffering nasal bone fractures when the facility failed to have two staff members present for care. Findings include: R7's Minimum Data Set (MDS) dated [DATE] documents R7 is severely cognitively impaired and that R7 requires extensive assistance of two people for bed mobility and transfers. R7's Care Plan does not document an intervention related to R7's preference to lay on R7's Left side with R7's head in a lowered position. R7's Physician Order Sheet (POS) dated July 1-31, 2022 documents a physician order for [MEDICATION(S)] (anti-coagulant) 20 milligrams (mg) daily. R7's Nurse Progress Note dated 7/26/22 at 10:20 PM documents (V22) Registered Nurse (RN) was alerted by (V21) Certified Nurse Aide (CNA) that (R7) was being provided incontinence care and was being rolled towards the wall, at the same time (R7) turned (R7's) head downwards and hit the bridge of (R7's) nose on the side rail of the bed. (R7's) nose was bleeding and there is a one centimeter (cm) skin tear on the bridge of (R7's) nose, and redness. R7's Initial Incident Report to IDPH (Illinois Department of Public Health) dated 7/27/22 documents R7 received a serious injury at 10:20 PM on 7/26/22. This same IDPH report documents Interview with (V21) Certified Nurse Aide (CNA)-(R7) had been combative since 6:00 PM. (V21) put (R7) to bed. (R7) was laying on back and reached up and grabbed (V21's) shirt. After (R7) let go, (V21) rolled (R7) on Left side and (R7) tried to roll into a ball and hit (R7's) nose on the side rail. (R7) started bleeding and (V21) got the nurse. (R7) almost always curls up when (R7) gets rolled to the Left side. R7's Hospital Record dated 7/27/22 documents medical diagnoses of Acute Nasal Fracture and history of [CONDITION(S)], Dementia, Current Use of Long-Term Anti-Coagulation, [CONDITION(S)] ([CONDITION(S)]), Lumbar Spinal Stenosis, Alzheimer's Disease, [CONDITION(S)] and Polyneuropathy. R7's Computed Tomography (CT) scan of Facial Bones Without Contrast report dated 7/27/22 documents Indication: Trauma. This same report documents Impression: There are acute comminuted fractures involving the bilateral nasal bones, nasal processes of the maxillary bones and the nasal septum. On 7/28/22 at 1:15 PM R7 was observed with extensive dark purple/blackish bruising to both eyes and the bridge of the nose. The bruising extended down towards R7's upper cheeks on both sides of R7's face. On 7/29/22 at 1:30 PM V2 (DON) stated (V21) CNA repositioned (R7) without any help from other staff and that most likely caused the serious injury. Other staff that were interviewed all stated (R7) always bends (R7's) head down like that and so this was common knowledge. This should have been care planned as a preference for (R7) and the staff should have been educated on it so that maybe (R7) would not have been injured.

Based on observation, record review and interview the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R2 missing four doses of scheduled narcotic pain medication and experiencing severe pain when the medication was not available at the facility. Finding include: The facility policy titled 'Medication Administration Policy' effective March 2014 documents the following: Medications not received and/or from a pharmacy and/or not administered within twenty-four (24) hours from the ordered time to be administered will be considered a medication incident. 1.) R2's undated Face Sheet documents an original admitted [DATE] and a re-admitted [DATE]. This same Face Sheet documents medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Electronic Medical Record (EMR) documents R2 was hospitalized from 7/15/22-7/23/22 and again on 7/28/22. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status Score of 15 out of 15 possible points indicating no cognitive impairment. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/28/22 at 12:31 PM V5 Licensed Practical Nurse (LPN) assessed R2 for pain in R2's room. R2 stated the pain is 'terrible'. V5 LPN explained to R2 that R2's [MEDICATION(S)] (HCL) 30 milligram (mg) tablets are not available yet but V5 does have the [MEDICATION(S)] Hcl 5 mg to give. R2 stated I do not understand what is taking so long to get my pain medication. The Nurse Practitioner (V10) told me it would not be a problem. Why can't I have my [MEDICATION(S)] Hcl 30 mg? V5 LPN informed R2 that the prescription was faxed to (V9) Physician and they (facility) are waiting for (V9) to send over the signed prescription. On 7/28/22 at 12:40 PM R2 stated Both of my hips and knees are bone on bone which is horribly painful. R2 stated it is very difficult to move at all. R2 stated the pain is so intense, it is like I am going through withdrawal. The [MEDICATION(S)] Hcl 30 mg was scheduled and now I can only have [MEDICATION(S)] Hcl 5 mg. R2 stated They (staff) told me the doctor approved of it but they (staff) forgot to have the doctor sign the prescription so I have been without for days. I hurt all over. It is awful. On 7/28/22 at 1:30 PM V2 Director of Nurses (DON) stated R2 readmitted from hospital on 7/23/22 with orders for [MEDICATION(S)] (Hcl) Extended Release (ER) 30 milligrams (mg) every twelve hours with an end date of 7/26/22 and [MEDICATION(S)] Immediate Release (IR) 5 mg every six hours as needed for pain. V2 stated V10 Nurse Practitioner reviewed this order on 7/25/22 and gave order to continue both narcotic pain medications with no end date. V2 stated V20 Licensed Practical Nurse (LPN) should have asked V10 to sign the prescription while V10 was in facility but did not. V2 stated V9 Physician/Medical Director was in facility on 7/26/22 and the staff nurses again neglected to have V9 sign R2's prescription for both pain medications. V2 stated Whenever a prescription changes, the nurses should obtain a new prescription and have the Physician or Nurse Practitioner sign the new prescription to prevent any delay in obtaining the medications and so that the resident does not have to endure needless pain or suffering. (R2) had been receiving the [MEDICATION(S)] Hcl 5 mg IR but not the [MEDICATION(S)] Hcl ER 30 mg. V2 confirmed R2 missed four doses of [MEDICATION(S)] Hcl ER 30 mg between the evening dose on 7/26/22, both doses on 7/27/22 and the morning dose on 7/28/22. 2.) R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This same POS documents R4's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R4's Medication Incident Report dated 7/22/22 documents (R4) received a [MEDICATION(S)] at 2:00 PM and additional dose at 4:00 PM. This same report documents V15 Licensed Practical Nurse (LPN)/Nurse Manager was notified of a narcotic discrepancy on 7/22/22 at 7:24 PM. R4's Medication Detail Report dated July 1-31, 2022 documents R4 was administered [MEDICATION(S)] at 3:54 PM on 7/22/22. R4's Narcotic Count Sheet dated 7/22/22 documents V13 Registered Nurse (RN) administered [MEDICATION(S)] at 2:00 PM and V14 Licensed Practical Nurse (LPN) administered [MEDICATION(S)] at 4:00 PM on 7/22/22. On 7/29/22 at 1:35 PM V2 Director of Nurses (DON) stated R4 received an extra dose of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) 10-325 milligrams (mg) on 7/22/22. V2 stated the day shift nurse V13 Registered Nurse (RN) gave the 2:00 PM scheduled dose of [MEDICATION(S)], signed the medication out as given on the Narcotic Count Sheet but did not sign the Electronic Medical Record (EMR). V2 stated V14 Licensed Practical Nurse (LPN) was the oncoming second shift nurse on 7/22/22 who counted the narcotics with V13 RN. V2 DON stated the count was correct and verified by both nurses. V2 stated V14 LPN gave this same narcotic pain medication again because the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated V14 LPN gave the medication at 3:54 PM on 7/22/22. V2 stated this medication error was reported to V15 LPN/Nurse Manager on call at 7:24 PM 7/22/22. V2 stated administering additional doses of narcotic medications could have very detrimental effects on residents. V2 stated this error could cause obvious effects like sleepiness, but it could also cause more serious effects of respiratory and cardiac issues. 3.) R5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Medication Incident Report dated 6/30/22 documents (R5) received 1 milligram (mg) of [MEDICATION(S)] instead of the prescribed dose of 0.5 mg. R5's Care Plan dated 4/16/21 documents R5 has impaired thought processes and instructs staff to Administer medications as ordered. R5's Nurse Progress note dated 6/30/22 at 8:40 PM documents During shift count noted discrepancy in amount of [MEDICATION(S)] remaining in card and what was signed out as given. (R5) had 30 [MEDICATION(S)] in card and 29 documented as remaining. Upon looking it was noted that another resident (R1) was short 1 tab of [MEDICATION(S)]. One mg of dose of [MEDICATION(S)] that was given to (R5) was from wrong card. (R5's) dose is 0.5 mg. On 7/29/22 at 1:45 PM V2 Director of Nurses (DON) stated R5 was given the wrong dose of [MEDICATION(S)]. (V23) Licensed Practical Nurse (LPN) had inadvertently administered R5 a 1 milligram (mg) [MEDICATION(S)] from (R1) another resident's card sitting just in front of (R5's) card of [MEDICATION(S)] in the narcotic drawer of the medication cart. V2 stated (V23) made an error. V2 stated whenever a nurse administers a medication, the nurse should verify the correct medication and dose are given to the correct resident at the correct time. V2 stated This medication error did not cause (R5) any negative problems but certainly could have caused increased sedation, confusion or problems with eating due to being overly sedated.

Based on record review and interview the facility failed to implement a baseline care plan for skin breakdown prevention, failed to complete assessments and wound treatments and failed to follow up on dietician recommended wound supplements for one of three residents (R1) reviewed for pressure sores in the sample of 13 residents. These failures resulted in the worsening of R1's stage three and unstageable pressure sores. Findings include: The facility policy titled 'Prevention of Pressure Ulcers' revised 2008 documents the following: Review the resident's Care Plan to review for any special needs of the resident. The following are additional clinical conditions, treatments and abnormal lab values that indicate a resident is at risk for Pressure Ulcers: Impaired/decreased mobility and decreased functional ability, co-morbid conditions such as Diabetes Mellitus, Drugs such as steroids that may affect wound healing and Exposure of skin to urinary and fecal incontinence. The following will be necessary when providing preventative skin care: Pressure Risk Assessment Form and Intervention Preventative measures such as: use a draw sheet to assist in moving from side to side and up in the bed, skin to skin contact needs to be avoided by placement of pillows, folded sheets or clothing and change position every two hours as needed. R1's undated Face Sheet documents an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15 points which indicates no cognitive impairment. This same MDS documents R1 as requiring two person extensive assistance with bed mobility, transfers and toileting. R1's Clinical Admission Evaluation dated 8/14/21 documents reddened buttocks. R1's Baseline Care Plan does not document Pressure Ulcer interventions. R1's Initial Wound Evaluation and Management Summary dated 8/20/21 documents a sacral wound initial visit by Wound Physician (V6). This same summary documents R1's Sacral wound as partial thickness with light clear pink drainage. R1's Electronic Medical Record (EMR) documents a hospital stay from 8/20/21-8/24/21. R1's EMR does not document a skin/wound assessment for R1 upon return from hospital stay on 8/24/21. R1's Wound Evaluation and Management Summary dated 8/27/21 documents R1's Sacral Pressure Ulcer as Stage 3 as deteriorated due to larger size. This same Summary documents R1's Left Medial Buttock wound and Left Lateral Buttock wounds as new wounds. V6 Wound Physician ordered Therahoney sheet covered with bordered foam dressing daily for 30 days. R1's Treatment Administration Record (TAR) dated August 1-31, 2021 documents R1's Physician prescribed wound treatments were not signed off on 8/29/21 and 8/31/21. R1's Nutritional Assessment completed by V7 Registered Dietician (RD) dated 8/31/21 documents recommend Prostat 30 milliliters (ml) daily and [MEDICATION(S)] one packet daily for wound support. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Wound Evaluation and Management Summary dated 9/3/21 documents R1's sacrum wound as stage 3 with no change, R1's Left Medial Buttock Unstageable Pressure Ulcer as deteriorated due to infection and larger size; and Left Lateral Buttock Unstageable Pressure Ulcer deteriorated due to infection and larger size. V6 Wound Physician ordered [MEDICATION(S)] and probiotic and ¼ strength bleach solution, gauze and dressing daily for all three wounds. On 9/6/21 at 9:45 PM V21 Licensed Practical Nurse (LPN) documented Five small areas noted to Left Buttock, Wound Physician (V6) aware and treatment in place. Areas continue with greenish slough to wound bed with redness noted around wounds. Small shearing area noted to Sacrum. (R1) complained of burning sensation to Left Buttock during treatment. On 4/12/22 at 3:00 PM V5 Nurse Practitioner stated Normally the Registered Dietician will make recommendations based on nutritional status of the resident. The recommendations for (R1) from the Registered Dietician were never received. We have no record of that. On 4/13/22 at 2:00 PM V7 Registered Dietician stated 'With my corporation, the expectation would be to recommend any dietary changes based on resident nutritional needs and give those recommendations to the facility, usually the DON (Director of Nursing) or ADON (Assistant Director of Nurses) and they get the Physician to sign, and then those orders get added to the system. On 4/8/21 at 3:00 PM V1 Administrator stated (R1) was very compliant. She (R1) was very sweet and would do anything the staff asked of her (R1). I (V1) would not see how the wounds would have gotten any worse. We (facility) do not have any documentation that (R1)'s wounds were unavoidable. She (R1) admitted as a short term resident for therapy. She (R1) was supposed to return home. The pressure wounds (R1) had were obtained at this facility and also worsened at this facility. On 4/8/21 at 3:05 PM V3 Assistant Director of Nurses (ADON) stated (R1) admitted to facility after a hospital stay for knee surgery and a Urinary Tract Infection ([CONDITION(S)]). V3 stated the purpose of (R1) stay was short term rehabilitation. We (facility) do not have any documentation that shows that (R1) pressure wounds were unavoidable, by all accounts (R1) should not have had any pressure wounds and they certainly should not have gotten worse. (R1) went out to the hospital from 8/20/22-8/24/22. When (R1) came back from that hospital stay (R1) did not have had a complete skin and wound assessment completed. We (facility) do not have any documentation for that. On 4/12/21 at 3:00 PM V5 Nurse Practitioner stated did not personally lay eyes on wounds of (R1). My (V5) admission assessment was based on the documentation from the hospital discharge records on 8/14/21. Staff should enter orders when they are received. This facility does have a (V6) Wound Physician who makes rounds on Friday afternoons with a facility nurse. Sometimes the hardcopy of (V6) orders are not received until two days after (V6) makes rounds. If a resident such as (R1) has multiple comorbidities, uncontrollable high blood sugars and is on a steroid for (R1) Gout flare up then (R1) would be high risk for those wounds to worsen. Those wound orders should have been put in the same day they were received. If there is a delay, the wound could get worse or could get infected. V5 Nurse Practitioner stated wounds need to be addressed and treated to have optimal healing potential and that any delay in wound care could mean that the wound could deteriorate and possibly cause infection in the wound. On 4/13/22 at 10:55 AM (V4) Medical Director/PCP stated 'We (facility) failed this resident (R1). This facility has gotten much better at notifying the providers of areas of care that need addressed but obviously we dropped the ball for this person (R1). The facility staff are being re-educated on documentation and importance of providing timely interventions. She (R1) was very compromised with all of her medical conditions. She had acute hyperglycemic episodes, uncontrolled Diabetes Mellitus and Gout flare up. The [MEDICATION(S)] was ordered to help regulate the Gout, but that also can elevate blood sugars and deter wounds from healing. She (R1) had many chronic conditions that could contribute to the formation and worsening of her wounds, but this facility also did not treat these wounds as they should have. I can't say 100% that her wounds were preventable due to all of her other conditions and especially the Diabetes. The facility has had some major communication and documentation errors in this case and they are working on those.

Based on record review and interview the facility failed to provide supervision (R1) and remove an accident hazard (R3) to prevent falls for two of three residents reviewed for falls on the sample of 12 residents. Failing to supervise R1 resulted in R1 falling and suffering a laceration to R1's head when R1 pulled a linen cart over on top of R1. Findings include: 1. R1's undated Face Sheet documents diagnoses of Alzheimer's Disease, Dementia, Repeated Falls and Muscle Weakness. R1's Minimum Data Set (MDS) dated [DATE] documents cognitive decision making skills as severely impaired. This same MDS documents R1 as requiring extensive assistance of one person for transfers, dressing, toileting, personal hygiene and bed mobility and one person assist for walking in corridors. R1's Physician Order Sheet (POS) dated February 1-28, 2022 documents a physician order to walk to dine and restroom dated 9/21/21. R1's Initial Fall Report to Illinois Department of Public Health (IDPH) dated 2/3/22 documents R1 fell on [DATE] receiving physical harm or injury. R1's Nurse Progress Note dated 2/3/22 at 12:05 PM V26 Licensed Practical Nurse (LPN) documented this nurse (V26) was at the medication cart, the cnas (Certified Nurse Aides) were in the dining room feeding residents lunch when heard a thump. (R1) was laying flat on (R1's) back with the linen cart on top of (R1). With the assistance of staff (V27 and V28 CNA's), the linen cart was removed from on top of (R1), upon assessment, eyes were open, pupils reactive, but did not respond to verbal or physical stimuli. (V26) immediately called 911. On 2/7/22 at 11:00 AM V2 Director of Nurses stated (R1) was eating lunch in the dining room on the dementia unit. (R1) was finished eating so (R1) got up from table and walked out to commons area. V26 Licensed Practical Nurse (LPN) was at the medication cart with (V26's) back to (R1). (V26) stated (V26) heard a loud thump and turned to see (R1) on the floor with the linen cart laying on top of (R1). There were other staff in the dining room but did not witness (R1) fall. (V28) Certified Nurse Aide (CNA) and (V27) CNA were both in the dining room and saw (R1) walk out but did not witness (R1) fall. V2 stated the staff should monitor residents on the dementia unit. On 2/7/22 at 11:10 AM V3 Assistant Director of Nurses (ADON) stated (R1) normally walks independently about dementia unit with supervision from staff. V3 stated this fall was reported to the Illinois Department of Public Health (IDPH) on 2/3/22. V3 stated (R1) received serious injury as a result of this fall. (R1) ended up with two staples in the back of (R1's) head. (V3) think that is very serious. On 2/8/22 at 11:30 AM V26 Licensed Practical Nurse (LPN) stated (V26) was at the medication cart with (V26) back to the residents. (V26) heard a loud thump sound. (V26) turned around and saw (R1) laying on floor with entire linen cart laying on top of (R1). The staff immediately ran over to help (R1). (V26) did not hear anything prior to the thump sound. (R1) was pretty dazed for three or four minutes. It took a few minutes for (R1) to come around. (V26) called 911. V26 stated (V26) think (R1) must have lost balance and tried to pull at the linen cart to steady herself (R1) ending up pulling it on top of (R1). (V27 and V28) CNA's were not supervising (R1) at that time because (R1) had left the dining room. All of our (facility) residents need supervision that is why they (residents) are here. On 2/8/22 at 11:45 AM V28 Certified Nurse Aide (CNA) stated (V27) and (V28) were in the dining room cleaning tables after lunch. (R1) had already left. (V28) did not see (R1) fall. All the residents back here (dementia unit) need supervision. I (V28) feel bad for (R1). (R1) hasn't walked right since. Before (R1's) fall (R1) walked a lot more. Now it seems really hard for (R1) to get around. 2. R3's undated Face Sheet documents diagnoses of Alzheimer's Disease, History of Falling, Dementia, Cognitive Communication Deficit and Abnormalities of Gait and Mobility. R3's Care Plan intervention dated 9/28/17 documents to maintain a clear pathway free of obstacles. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 4 out of 15 possible points indicating severely impaired cognitive impairment. This same MDS documents R3 as requiring extensive assistance of one person for locomotion on unit. R3's Nurse Progress Note dated 2/7/22 at 9:45 AM V32 Registered Nurse (RN) documented Therapist (V10) was pushing (R3) in wheelchair over vacuum cord, which tipped (R3) forward and onto the floor. On 2/8/22 at 2:00 PM V10 Physical Therapy Assistant (PTA) stated The first thing (V10) should have done is not touch (R3) because (R3) is not even on therapy. We (therapists) are not supposed to help those that are not on our case load. (R3) wheeled herself (R3) into another resident's room on the dementia unit. (V10) was in the next room and heard something. (V10) was just trying to help (R3) out of the other room. The housekeeper was vacuuming the common area just outside the resident rooms. (V10) tried to push (R3) in the wheelchair over the vacuum cord. (R3) must have not been sitting back in (R3) wheelchair. (R3) fell forward out on to floor directly landing on (R3) head. (V10) stated it (fall) happened when (V10) was trying to maneuver the wheelchair over the vacuum cord. Next time (V10) will just unplug the cord or take another route. (V10) am lucky (R3) did not get seriously injured. (V10) will never do that again. (V10) do not know what I (V10) was thinking. (V10) am a therapist. (V10) am trained in safe transfers and transports! V10 PTA stated this fall was completely avoidable. (V10) should have not tried to push R3 over the vacuum cord which caused R3 to fall. (V10) was only trying to help (R3) because I (V10) couldn't find any staff to assist.

Based on record review, observation and interview the facility failed to provide increased supervision for a resident (R11) with known history of falls. This failure resulted in a fall for R11 who sustained a [CONDITION(S)], facial fracture, and subarachnoid hemorrhage, that required treatment and hospitalization . The facility also failed to provide a safe environment to prevent a fall for R9 which resulted in an ankle fracture. R11 and R9 are two of three residents reviewed for falls on the sample list of 16. Findings include: 1.) R11's current Medical Diagnoses List includes the following: [CONDITION(S)] and [CONDITION(S)] (severe or complete loss in strength or paralysis on one side of the body) Following [CONDITION(S)] (Stroke) Left Side Affected, [CONDITION(S)] (Neurological) , Need for Assistance With Personal Care, Difficulty Walking, Overactive Bladder, and Anxiety R11's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview for Mental Status (BIMS) score of 9 out of 15 (moderate cognitive impairment). The same MDS documents R11 requires supervision when ambulating in R11's room, one person physical assist with toileting, has frequent incontinence of bladder, and had a history of two falls. The facility Resident Council minutes dated November 4,2021 document the following: Old business: Residents feel that call lights are not being answered in a timely manner. The facility Resident Council minutes dated 11/4/21 and 12/6/21 document this issue is not resolved. The facility Resident Council minutes dated November 4,2021 document the following:Residents feel they are at times waiting to go to the bathroom. The facility Resident Council minutes dated 12/6/21 document this issue is not resolved. R11's Incident by Incident Type dated 8/22/21 - 12/22/21 documents R11 has had four falls dated 9/4/21, 9/16/21, 11/27/21, and 12/15/21. R11's Fall Risk Assessment 11/27/21 documents R11's has intermittent confusion and is at High Risk for falls. R11's Care Plan current, documents an updated fall intervention was added 9/27/21 as follows: Falling Star (increase observations). The same Care Plan documents a fall intervention as follows: Educate resident (R11), (R11 has moderate cognitive impairment as documented on the above MDS), family, and caregivers (facility staff) about safety reminders and what to do if a fall occurs. The same Care Plan documents: Remind (R11) to surroundings for getting up in the middle of the night. Offer (R11) toileting assist. R11's Facility Incident Report Form facsimile to Illinois Department of Public Heath Final Report dated as 12/21/21 documents (unidentified staff) were alerted of R11's fall 12/15/21, by R11's roommate R16 who called out for help. R11's Incident Note dated 12/15/2021 at 7:47 pm, documents the following: Incident Note, Note Text: This nurse (V12, Licensed Practical Nurse/LPN) (was) called to res' (residents, R11) room, per CNA (unidentified Certified Nursing Assistant), to note (notice) res (resident, R11) laying on floor, on right side, head partially under bed. Res (R11) noted to have blood on hand et (and) blood noted to (on) floor under (R11's) head. Upon assessment, blood coming from right brow on (R11's) forehead. MAE/ROM (Moves All Extremities/ Range of motion) without diff (difficulty), hand grips equal bialt (bilateral). Res (R11) slid out from under bed et (and) head assessed, laceration noted to right eye brow, cleansed et (and) cold compress (was) applied. 911 (Emergency Medical Service) called for transport to (Local) ER (emergency room ) for eval/tx (evaluation/treatment), for possible internal injuries and/or sutures. POA (Power of Attorney/ Residents Representative unidentified) notified et gave consent. (V47, Physician,) on-call for (Physician Medical Director), notified et gave order (Physician). Amb (Ambulance) arrived et left without diff (difficulty). No c/o (complaints) voiced from res (R11). Report called to (Local) ER. R11's (Local Hospital) emergency room report dated 12/15/21 at 8:20 pm documents the following: Chief Complaint: Patient (R11) brought to ED (Emergency Department) via EMS (Emergency Medical Service/ Ambulance) post unwitnessed fall, lac (laceration)/obvious swelling to right eye. The same report dated 12/15/21 at 9:56 pm documents ED Course Fracture at the superior lateral aspect of the right orbit, five millimeter fragment is displaced into the orbit (upper facial bones). Right extraconal orbital hematoma measuring up to four millimeters thickness. The right globe is minimally proptotic (bulging eyeball) relative to the left globe (eyeball), however the posterior aspect of the right globe still intersects the interzygomatic line (horizontal line of the anterior cheek bone). Trace amount of subarachnoid hemorrhage in right frontal lobe. No mass-affect. Fracture at the superomedial aspect measuring up to four millimeters thickness. The same report documented at 10:00 pm,as follows: All imaging reviewed by myself (V51, Physician) and the radiologist (V52, unidentified). I discussed the case with Trauma Surgeon (V53) from (distant hospital) who accepts the transfer (from local hospital to distant hospital). He (V53, Trauma Surgeon) has viewed all images. Of note, we (local hospital) are unable to fly a helicopter due to inclement weather and our ambulances are out on calls transporting previous trauma patients. There may be a delay in transfer. Patient (R11) is hemodynamically stable and mentating appropriately. The same report documents on 12/16/21 at 1:23 am Patient (R11) has left our facility (local hospital) in route to (distant hospital) without incident. Vital signs are stable upon departure. The same report summarizes R11's diagnoses as follows: Multiple Face Fractures- Primary - Onset 12/15/21, and Subarachnoid Hemorrhage- Primary- Onset 12/15/21. On 12/22/21 at 12:45 pm, V2, Director of Nursing (DON) reviewed fall investigations and stated the following: (R11) has had four falls (since annual survey 8/23/21). (R11's) last fall was unwitnessed and was reportable (fall with major injury). We (the facility) reported to IDPH (Illinois Department of Public Health). (R11) was first sent out to (Local) Hospital then transferred to (Distant Hospital) for head injury, and a facial fracture. I (V2, DON) investigated this one (R11's fall 12/15/21) and have my (V2, DON) full investigation completed. I give reportables (falls with serious injury) to (V1, Administrator) when I (V2, DON) have finished my investigation. R11 was in his closet and lost his balance turning around. This fall was unwitnessed. R11 BIMS (Brief Interview of Mental Status) is recorded as a nine which shows some cognitive impairment but on any given day he can be a lot higher on his BIM's. He knows to put on his call light and just doesn't. V2 also stated The Falling Star program is to increase staff awareness to check on the residents more often due to increased risk for falls. (R11) on the Falling Star (documented on above Care Plan) program. On 12/23/21 at 12:30 pm R11 was lying in R11's bed. R11 had dark blue bruising under R11's right eye and a one-and-a-half-inch scab over the right eye. R11 also stated the following: When I (R11) fell in my (R11) room the other night and got the stitches (12/15/21), I (R11) was trying to go to the bathroom then too. R11 stated I (R11) have had several falls but usually I end up on my (R11) butt. R11 also stated,I (R11) can't remember to put on my call light, when I have to go (use the bathroom), I have to go. There is no time for waiting. I really can't tell you anything more, I just know I didn't end up on my butt that (fall 12/15/21) time and got this (points to facial injury). On 12/23/21 at 12:40 pm R16, R11's roommate stated The staff don't come in here (R11 and R16's room) to check on us unless we put on the call light. I don't need much help. Usually (R11) does need some help going to the bathroom. I (R16) saw (R11) on the floor (12/15/21) and I had to go down to get a nurse. No one (staff) responded to the call light when I put it on to come down here and help him (R11). I heard him fall but I didn't see him till (until) he (R11) was on the floor next to his bed bleeding. 2.) R9's Minimum Data Set (MDS) dated [DATE] documents R9 requires supervision and setup with walking and toileting. The same MDS documents R9 is continent of bowel and bladder. The same MDS does not document that a Brief Interview of Mental Status assessment was completed. On 12/28/21 at 1:20 pm V7, Social Service Director (SSD) stated the MDS requirement is to conduct the BIMS one day before up through one day after, and R9 was not available during that time frame. V7, SSD stated (R9) is alert and oriented. On 12/28/21 at 1:30 pm V7 returned and had competed a BIMS assessment for R9. dated 12/28/21. R9's BIMS score is documented as 15 out of 15, cognitive intact. R9's Care Plan Focus area for Falls was initiated on 11/30/20 and continued through the last revision 11/16/21, which documents the following: (R9) is at risk for falls and has had a fall related to weakness, depression, hypertension, unspecified [CONDITION(S)], and unspecified cataract. The same Care Plan documents an intervention for the Fall Focus area initiated 11/30/20 and still an active intervention that includes: (R9) needs a safe environment with even floors, free from spills and/or clutter: adequate glare free light; a working and reachable callight, and personal items within reach. On 12/17/21 at 10:33 am, R9 was laying in bed with a cast on R9's lower left leg. R9 stated the following: I do not use the bathroom (uses bed pan) anymore. I fell in the bathroom and fractured my ankle. I slipped on the wet floor. (R1, R9's roommate) had an accident (incontinence episode). I (R9) had surgery around 11/12/21 (per hospital report 11/9/21). R9 also stated (R1) is very meticulous about her things and keeps everything in order. (R1) even tries to clean the bathroom when (R1) finishes in there (bathroom). It is okay for us (R1 and R9) to ask the staff to do the same (keep the bathroom clean). On 12/22/21 at 12:25 pm V2, Director of Nursing (DON) reviewed the fall log and fall investigations regarding R9's fall 11/8/21. V2, DON stated the following: (R9's) fall was unwitnessed. (R9) went to (local) hospital after an X-ray here in the facility. It (R9's fall 11/8/21) was reported to IDPH (Illinois Department of Public Health). (R9) had a fracture to (R9's) ankle (left). Interventions were reviewed. She (R9) is independent (MDS above documents ambulatory with supervision) and alert and oriented. She (R9) said she (R9) slipped in her roommate (R1) b m (feces). R9's Fall Incident note dated 11/8/21 at 1:15 am documents the following: (R9) is alert and oriented to person, situation, place and time, had an unwitnessed fall in the bathroom which resulted in left ankle swelling. The same Fall Incident note documents the following: Summary of events/situation: (R9) is alert and oriented and has been independent in ambulation (above MDS with supervision and set-up) in room. She (R9) got up during the night to go to the bathroom. Prior to her (R9) getting up she was observed by staff in bed asleep. Per resident she (R9) slipped in between the toilet and sink on what she (R9) believes was her (R9's) roommate (R1) feces. Staff (unidentified) entered the room and found (R9) on the floor. Nurse (unidentified) completed assessment and resident was complaining of pain to ankle (not specified) and stated she (R9) thought she (R9) had sprained it (left ankle). Physician (unidentified) was notified with orders for an X-Ray. X-Ray was completed revealing a fracture and resident was sent to the hospital. Root Cause: Resident slipped on bathroom floor. R9's (local hospital) Discharge Summary dated 11/10/21 documents the following: Visit Summary Discharge Diagnoses: Bimalleolar Fracture of (the) Ankle-Primary and Acute Urinary Tract Infection. Hospital Course: (age) year old patient (R9) who lives at (this facility), with a history of [CONDITION(S)], open angle [CONDITION(S)] as well as dyslipidema and [CONDITION(S)] accidentally tripped on something, fell to the ground and had a Bimalleolar fracture of the left ankle on 11/8/21. She (R9) was admitted to the hospital. (R54, Physician) did an open reduction internal fixation (orthopedic surgical procedure to repair the fractured bone) of her ankle on 11/9/21, without any complications. She (R9's left ankle) is casted now.

Based on interview and record review, the facility failed to effectively supervise R3 to prevent a traumatic fall. This failure resulted in R3 falling to the ground on R3's face and sustaining a temple laceration, temple contusion, hand fracture, and a frontal lobe brain bleed requiring emergency hospitalization and treatment. R3 is one of three residents reviewed for falls in the sample of 14. Findings include: R3's Physician Orders (11/12/2021) documents R3's diagnoses include: Dementia, Coagulation Defect, Unsteadiness on Feet, Abnormality of Gait and Mobility, Repeated Falls, [CONDITION(S)] of Hip, [CONDITION(S)], Abnormal Posture, and Reduced Mobility. The same record documents: Ensure proper placement and function of BED, CHAIR, and MOTION SENSOR alarms each shift for Fall Prevention. R3's Minimum Data Set (10/21/2021) documents R3 has severe cognitive impairment, requires two person physical assistance for transfers, R3 is not steady and only able to stabilize with staff assistance during transfers, and has a history of falls with injury. R3's Care Plan (11/9/2021) documents R3 is at High Risk for falls and has bed and chair alarms as a fall intervention. The facility incident report (10/25/2021) documents on 10/25/2021 V4 (Housekeeping) observed R3 stumble out of R3's room backwards into the hallway, hitting the door frame and spinning around and falling face first into the floor. The same record documents R3 sustained a laceration and hematoma (bruise) to the head, hand fracture, traumatic right frontal brain bleed, and required emergency transfer to the hospital for treatment. The facility fall investigation report (10/25/2021) documents R3 fell flat on (R3's) face during the fall on 10/25/2021. The same record documents predisposing factors for R3's fall included Confusion, Gait Imbalance, Impaired Memory, Weakness, and Ambulating without Assistance. The same record also documents R3 was seated in R3's recliner in R3's room prior to the fall after previously being out of the room with physical therapy staff. R3's hospital report (11/8/2021) documents R3 sustained a head laceration, acute brain bleed, and hand fracture from R3's fall on 10/25/2021. On 11/10/2021 at 10:29AM, V5 (Licensed Practical Nurse) reported assessing R3 after R3's fall on 10/25/2021. V5 reported R3 had a bleeding left temple laceration and contusion and was dazed and quiet after the fall. V5 reported R3 had a history of falls from R3's recliner in R3's room. V5 reported R3 was in R3's recliner prior to the fall on 10/25/2021 and R3's fall intervention of chair alarm was effective in the past and R3's alarms were always going off. V5 reported not hearing R3's alarm sounding at the time of the fall and the alarm (if operable at the time of the fall) could have helped, to an extent. On 11/10/2021 at 11:13AM, V3 (Registered Nurse) reported assisting R3 after R3's fall on 10/25/2021. V3 reported R3 was located on the ground in the hallway face down and was bleeding. V3 reported R3 had used bed and chair alarms in the past and I feel like they (the alarms) were (effective in preventing falls for R3). The Emergency Medical Services (EMS) report (10/25/2021) documents EMS staff found R3 laying on the floor in the facility with a laceration to R3's head. The same record documents facility Staff advised that physical therapy staff had not placed patient on an alarm after therapy and that they heard a scream and patient was on the floor. Patient is normally on an alarm due to fall risk. On 11/10/2021 at 1:44PM, V7 (Physical Therapy Assistant) reported helping R3 out of R3's chair in R3's room to go to therapy on 10/25/2021 and then returning R3 to the same chair after physical therapy. V7 stated I honestly beat myself up, I still do, when we stood up and left the room, the alarm didn't go off, when we headed out it didn't click in my brain, the alarm isn't sounding. V7 reported R3 likes to rock in his chair and V7 usually has to unplug or reset a button to shut an alarm on or off when taking a resident to therapy, but V7 reported not doing so for R3 before R3's fall on 10/25/2021. The facility Fall Prevention policy states: It is the policy to provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on interview and record review the facility failed to supervise a resident (R1) with a known history of inappropriate sexual resident to resident contact, to prevent resident to resident sexual abuse. This resulted in R2 being sexually abused by R1. R1 and R2 are two of 22 residents reviewed for abuse in the sample list of 27. Staff allowed R1 unrestricted access, exposing residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24) on the unit who are unable to consent to sexual interactions, to potential sexual abuse. This failure resulted in an immediate jeopardy. While the immediacy was removed on 9/15/21, the facility remains out of compliance at a severity level 2. Findings include: The facility's Abuse Investigative Summary dated 9/3/21 documents the following: On 8/27/21 R1 and R2 were discovered exhibiting sexual behavior. V13 (Certified Nursing Assistant/CNA) responded to a sounding bed alarm and called for V12's (CNA) assistance. When V12 left the nurse's station, R1 was sleeping in a recliner and R2 was sitting in the dining room. When V12 and V13 returned, R1 was in the dining room performing sexual acts on R2. R1 and R2 were separated. V18 (CNA) was on R1's and R2's unit all night, and V18 had to go to the skilled unit to assist with a resident's care. R2 was the only resident awake when V18 left the unit, a few minutes before the incident between R1 and R2 occurred. There was no documentation that R1 and R2 were supervised by staff at this time. R1 and R2 were separated and were upset with staff intervening. This summary documents, (local police) do not feel a crime was committed as no one was forced against their will to participate therefore abuse was not substantiated. R1's Admission Record dated 9/13/21 documents R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Care Plan revised on 9/13/21 documents: R1 has sexual behaviors as well as physical aggression towards staff and residents. R1 had sexual behaviors towards another resident on 6/28/21, accidental physical contact with a resident on 7/5/21, physical/intimate contact with a resident 7/16/21, and physical contact with another resident on 8/27/21. R1 has a history of inappropriate sexual interactions with R2 on 6/28/21 and 7/16/21, with R7 and R9 on 6/6/21. R1's Progress Note dated 6/28/21 at 10:39 AM by V19 (Nurse Practitioner) documents: R1 was evaluated for dementia with behaviors and sexual behaviors. R1 was found to have R1's hand up another resident's shirt and fondling breasts. V19 recommended to keep distance between female residents. R2's Admission Record dated 9/13/21 documents R2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 has disorganized thinking. R2's Care Plan documents R2 has shown an interest in a specific male resident (R1), (R2) seeks (R1) out, and shows a romantic interest in (R1). R2's care plan includes interventions to monitor time spent with other resident (in which there is a history of intimate contact), provide reality orientation, engage in an activity that does not involve the other resident, redirect with a snack/drink, if (R1 and R2) are together, monitor their behaviors, if showing romantic physical attention towards each other attempt to separate, and assure R2's safety. On 9/13/21 at 3:46 PM V13 (CNA) stated, On 8/27/21 between 2:30-3:00 AM I (V13) heard a bed alarm sounding and went to assist the resident. I (V13) called for V12's assistance leaving R1 and R2 unsupervised. At that time R2 was sitting in a chair in the dining room and R1 was asleep in a recliner across from the dining room. When V12 and I (V13) returned to the unit R2 was sitting in a chair in the dining room with R2's pants down. R1 was on R1's knees in front of R2, and R1's face was in R2's genital area. I (V13) and V12 immediately separated R1 and R2. We try to keep one person watching R1 at all times and keep R1 and R2 separated. A lot of times I (V13) am assigned to that unit by myself, sometimes there are two CNAs. The nurse doesn't come to the unit until 4:00 AM. It is hard to keep an eye on (R1) when we are in resident rooms completing rounds. On 9/14/21 at 2:19 PM V12 (CNA) stated, I (V12) and V13 worked night shift on R1's unit on 8/26/21. Prior to R1's/R2's incident R2 was in the dining room and R1 kept trying to go into the dining room with R2. I (V12) and V13 had to keep separating R1 and R2 and tried to redirect R2 to R2's room. R2 kept returning to the dining room. R1 was combative with me (V12) and V13 when we separated R1 and R2. Sometime close to 3:00 AM V13 went to a resident's room to respond to a bed alarm. V13 called for my (V12) assistance and I (V12) left R1 and R2 to assist V13. When I (V12) and V13 returned from providing resident care, R1 and R2 were in the dining room. R2 was sitting with R2's pants pulled down. R1 was kneeling in front of R2, and R1 was licking R2's genital area. I (V12) and V13 immediately separated R1 and R2. R1 and R2 like to kiss and hug each other, and we try to watch them and keep them separated. We try to have three CNAs on the unit but that doesn't always happen. V12 confirmed there were no other staff on the unit to monitor R1 and R2 when V12 and V13 left them unattended. On 9/14/21 at 9:15 AM V1 (Administrator) stated, The facility has been trying to staff three employees on R1's/R2's unit, with the intention of having one employee supervising the residents on the unit. V13 called me about 3:15 AM on 8/27/21 to report R1's/R2's incident that happened around 3:00 AM. V18, V13, and V12 (CNAs) were assigned to R1's/R2's unit. V18 had left the unit to assist with a resident's care on the skilled unit. V13 responded to a resident's bed alarm. V13 called for V12's assistance. At that time R1 was asleep in the recliner near the entrance to the unit, and R2 was in the dining room. When V12 and V13 returned, R2 was sitting in the dining room with R2's pants pulled down. R1 was kneeling in front of R2 and was kissing R2's thighs. Staff have been trained to call the other unit to have staff come assist or monitor the unit. Residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 confirmed all residents on (R1's/R2's) unit have cognitive impairment. The facility's Daily Census dated 8/27/21 documents 22 residents (R1, R2, and R5-R24) reside on R1's/R2's unit. The facility's Facility Assessment updated on 8/19/21 documents: This unit (R1's/R2's unit) is where our residents live that are suffering from Dementia or Alzheimer's and are still able to participate in programming for this condition, or are an elopement risk and cannot be placed outside of a locked unit. The staff of this unit undergo additional training for Dementia/Alzheimer's disease to ensure that they are equipped for the behaviors and occurrences on this unit. An Immediate Jeopardy was identified on 9/15/21. The Immediate Jeopardy was identified to have begun on 8/27/21 when R1 and R2 were left unsupervised, resulting in R1 engaging in inappropriate sexual behavior with R2. Staff allowed R1 and R2 unrestricted access to each other and all residents on the unit (R1, R2, and R5-R24) who are unable to consent to sexual interactions, exposing them to potential abuse. Residents remain at risk until R1 and R2 are provided supervision and behavioral services to meet their needs. On 9/15/21 at 10:23 AM V1 (Administrator) was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 (Administrator) and V28 (Certified Nurse Aide Scheduler) confirmed by interview and provided documentation that a one-on-one care giver was assigned to R1 to be present at R1's side at all times from 9/15/21 at 6:00 PM until R1 was discharged to a behavioral facility on 9/16/21 at 4:17 PM. V31 (CNA), V35 (CNA), V36 (CNA), and V38 (Restorative Aide) confirmed they provided one on one care for R1 on 9/15/21 and 9/16/21. 2. V1 (Administrator) provided documentation of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff interviews confirmed that staff are aware that R2 needs frequent monitoring to ensure R2 is having appropriate interactions with other residents. 3. V1 (Administrator) provided documentation of a schedule for management staff assigned to verify that R1 has one on one care at all times while at the facility. 4. On 9/20/21 R1 was not observed at the facility, and R2 was observed to have frequent staff monitoring. 5. V1 (Administrator) provided documentation and confirmed by interview that V1 reviewed the facility Abuse Policy with V39 (Corporate Consultant) on 9/15/21 and that all staff attended an in-service regarding abuse prevention, recognition and reporting including sexual abuse on 9/15/21 and 9/16/21. 6. V1 (Administrator) confirmed by interview that R1 will not return to the facility after treatment at the behavioral facility. R1's Medical Record and an interview with V30 (Social Services Director) confirmed that discharge planning is in progress for R1 and that the facility is planning for R1 to be admitted to another facility after being discharged from the behavioral facility.

Based on observation, interview and record review the facility failed to: develop and implement fall interventions for self-transfers for a resident, complete post fall neurological assessments after a resident's unwitnessed fall, ensure thorough fall investigations were completed and ensure resident fall interventions were implemented. This failure affects three of three residents (R3, R4, R5) reviewed for falls on the sample list of 27 residents. R3 was known to be at high risk for falls, required staff assistance for ambulation, had incontinence care needs, and was at risk for life threatening complications including hemorrhage and internal bleeding due to receiving antiplatelet medication. R3 fell , suffered a subdural hematoma, and died after staff failed to develop and implement fall interventions for self-transfers. R4 fell and suffered a fractured arm after staff failed to ensure a motion sensor alarm was present in R4's room. The Facility's failure to develop and implement fall interventions, complete assessments, and ensure thorough fall investigations for residents resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity level 2. Findings include: 1. The Facility Clinical Admission Evaluation dated [DATE] documents R3 has some confusion, disorganized thinking, and short-term memory loss and that R3 is continent of bowel and incontinent of urine. The Admission Evaluation documents R3 has an unsteady gait and poor balance. The Fall Risk assessment dated [DATE] documents R3 is at high risk for falls. The Hospital Discharge Summary dated [DATE] documents R3 has a diagnosis of Cognitive Decline and Impairment and that R3 has had recent falls at home. The Discharge Summary documents R3 has speech difficulty and gait impairment and that R3 was brought to the Emergency Department by R3's family due to concerns related to worsening cognitive decline and ability to care for R3's self at home. The Nurse's Note dated [DATE] documents R3 was admitted to the facility on that date from the hospital. The Physician Order Sheet dated [DATE]-[DATE] documents R3 has diagnoses of Dementia, Anxiety Disorder, [CONDITION(S)], Overactive Bladder, Retention of Urine and Repeated Falls. The Physician Order Sheet also documents an order for R3 to have [MEDICATION(S)] (antiplatelet) 75 milligrams in the morning for a history of [CONDITION(S)] and Cerebral Infarction. The undated [MEDICATION(S)] Prescribing Information sheet states [MEDICATION(S)] increases the risk of bleeding. R3's Baseline Care Plan dated [DATE] documents R3 is unsafe with independent transfers, has poor standing balance and should transfer with staff assistance and a gait belt. The Baseline Care Plan documents R3 needs staff assistance for walking, locomotion, dressing, hygiene, and toilet use. The Baseline Care Plan does not document that R3 self-transfers or include interventions to address self-transferring. The Baseline Care Plan does not document a plan for toileting or incontinence care for R3. The Care Plan dated [DATE] documents R3 is at high risk for falls due to deconditioning and gait and balance problems and documents the following fall interventions: Be sure R3's call light is within reach and encourage R3 to use it for assist and as needed; Ensure R3 is wearing proper footwear when ambulating or mobilizing in wheelchair; Follow facility fall protocol; R3 needs activities that minimize the potential for falls while providing diversion and distraction; Keep furniture in locked position; Keep needed items (water, etc.) in reach; R3 needs a safe environment; Maintain a clear pathway in room. R3's care plan does not document that R3 self-transfers or include interventions to address self-transferring. R3's Care Plan dated [DATE] does not address a plan for toileting or incontinence care for R3. The Fall Incident Description dated [DATE] documents, (R3) was found on the floor in (R3's) bathroom. (R3) had apparently taken (R3's self) in to use the toilet. (R3's) dementia gives (R3) poor safety awareness. There was feces and urine in (R3's) depends and on the outside of them. (R3) apparently felt an urgency to use the bathroom and did not use the call light or wait for assistance. Nurse Practitioner (V19) was first to respond and noted a laceration approx. (approximately) one inch on the back of (R3's) head. First aid immediately performed to control the bleeding. Vitals taken. Nurse Practitioner ordered to send to ER (emergency room ) for an evaluation. The Fall Summary of Events dated [DATE] documents, Nurse Practitioner (V19) entered room at 2:45 PM (on [DATE]) to do an initial assessment and to meet (R3) and discovered (R3) on the floor in the bathroom. (R3) was laying at a diagonal on the floor with (R3's) head bleeding. There was feces and urine all over the floor as well as smeared on the toilet paper dispenser and the wall above it. There was feces and urine on the inside and outside of (R3's) (brief). (Brief was) pulled down. The Fall Summary of Events, Staff Interviews and Fall Timeline dated [DATE] for R3's [DATE] fall and the Fall Incident Description dated [DATE] do not document when R3 was last toileted or received incontinence care before being found on the floor in the bathroom. R3's Bowel and Bladder Continence Records dated [DATE] do not document R3 was toileted or received incontinence care during the day or evening shifts on [DATE]. The Hospital Discharge Summary dated [DATE] documents R3 was admitted to the hospital on [DATE] after falling at the facility and a Computed Tomography of R3's brain showed a large subdural hematoma. The Discharge Summary dated [DATE] documents Although patient's (R3) code status is DNR (Do Not Resuscitate), family requested intubation. Neurologic status continued to deteriorate. The Discharge Summary documents R3 died at the hospital on [DATE]. On [DATE] at 2:15 pm V6 (Certified Nursing Assistant/CNA) stated on [DATE] R3 was up and down and up and down by R3's self. V6 stated V6 observed R3 standing by the bed in R3's room a couple of times and found the urinal with urine in it on the night table, which was not located within arm's reach of the bed. V6 stated V6 guessed R3 got out of bed, used the urinal, and then got back in bed. V6 stated the evening of [DATE] V6 assisted R3 to the chair and R3 was weak and unsteady. V6 stated later that evening V6 found R3 back in bed. V6 stated R3 had the call light in the chair, but R3 did not use it to call for assist to get back in the bed. V6 stated V6 reported to the (unknown) nurse that R3 was getting up and down by R3's self. On [DATE] at 12:55 PM V5 (CNA) stated R3 was incontinent at times and they also took R3 to the bathroom. V5 stated V5 remembers walking by R3's room and seeing R3 standing in R3's room unassisted. V5 stated V5 assisted R3 to walk to the bathroom and R3 was unsteady. On [DATE] at 1:20 pm V7 (CNA) stated V7 was assigned to R3's unit on [DATE] for the 6:00 am to 2:00 PM shift. V7 stated in the morning V7 observed R3 in the bed. V7 stated V7 spoke with R3 between breakfast and lunch and at that time R3 was in the doorway of R3's room in the wheelchair and R3 wanted an incontinence brief and ice water. V7 stated V7 picked up R3's lunch tray around 12:30 pm and R3 was back in the bed. V7 stated V7 assumed R3 was transferring R3's self. V7 stated V7 did not see R3 on [DATE] after picking up R3's lunch tray. V7 stated V7 did not transfer R3 during the shift, and V7 did not take R3 to the bathroom or check R3's incontinence brief during the shift. On [DATE] at 5:30 pm V9 (Registered Nurse/RN/Assistant Director of Nursing/ADON) stated V9 was R3's nurse for the 6:00 am to 2:00 PM shift on [DATE]. V9 stated V9 checked on R3 when the CNA (V7) was picking up R3's lunch tray between 12:30 and 1:00 pm. V9 stated at that time R3 was lying in bed. V9 stated V9 did not transfer R3 or take R3 to the bathroom during V9's shift. V9 stated V9 did not ask R3 if R3 needed to use the bathroom during V9's shift. V9 stated V9 did not know R3 was getting up by R3's self. On [DATE] at 8:45 am V8 (Licensed Practical Nurse/LPN) stated V8 relieved another nurse (V9) at 2:00 PM on [DATE]. V8 stated V8 did not see R3 during the shift until R3 was found on the floor in the bathroom by V19 (Nurse Practitioner). V8 stated when V8 arrived R3 was on the floor in the bathroom under the sink, and R3 had a head wound that was bleeding. V8 stated R3 had been incontinent of bowel and bladder. V8 stated R3 was not supposed to be up by R3's self. V8 stated R3 had fallen prior to being admitted to the facility, and R3 was a high fall risk. V8 stated V8 did not know R3 was getting up without assist. On [DATE] at 11:25 am V3 (Assistant Director of Nursing/ADON) stated V3 initiated R3's Care Plan with the standard facility fall interventions. V3 stated after the fall assessment was completed, staff should have implemented fall interventions appropriate for R3. V3 stated V3 did not know R3 was self-transferring until R3 fell on [DATE]. V3 stated if V3 had known R3 was self-transferring, V3 would have placed (bed and chair) alarms to alert staff R3 was getting up. V3 stated R3 was a high fall risk and had a bedside sitter at the hospital before being admitted to the facility. V3 also stated staff should have been providing incontinence care for R3 and toileting R3. V3 confirmed R3's fall investigation and medical record do not document when R3 was last toileted or received incontinence care before R3 was found on the floor in the bathroom. V3 stated the nurses should have included this information in their documentation. On [DATE] at 1:30 pm V19 (Nurse Practitioner) stated on [DATE], V19 was going to see R3 as a new admit and found R3 on the floor in the restroom. V19 stated R3 had a laceration on R3's head. V19 stated R3 suffered the head injury when R3 fell . V19 stated V19's concern and fear was that R3 was on [MEDICATION(S)] and had had a brain bleed. V19 stated emergency responders arranged for R3 to be flown by helicopter to the hospital. V19 stated later the nursing home staff told V19 that R3 died at the hospital. V19 stated R3 had cognitive impairment and tried to get up independently, but R3 was not capable of being up independently. V19 stated V19 would expect facility staff to have interventions in place to prevent falls. On [DATE] at 4:40 pm V29 (Physician) stated V29 reviewed R3's hospital record and stated, The fall is the culprit. V29 stated according to the medical record the subdural hematoma resulted from the fall and the subdural hematoma caused R3's death. 2. The Physician Order Sheet dated [DATE] through [DATE] documents R4 has diagnoses of Dementia with Behavioral Disturbance, Unsteadiness on Feet and a History of Falling. The Minimum Data Set (MDS) dated [DATE] documents R4 is severely cognitively impaired, requires staff assistance with transfers, ambulation and toileting and that R4 is continent of bowel and bladder. The Fall Care Plan initiated [DATE] documents an intervention dated [DATE] for R4 to have a motion sensor alarm in order to alert staff of R4's movements and an intervention dated [DATE] for staff to ensure proper placement and function of motion sensor alarm Q (every shift). R4's Self Care Deficit Care Plan initiated [DATE] states, Provide incontinence care when any episode of incontinence occurs, and Encourage and assist (R4) in using the restroom upon rising/before bed, before/after meals and upon request. V22's (Licensed Practical Nurse/LPN) Nurse's Note dated [DATE] documents R4 noted sitting on the floor hit left forehead small 2 cm (centimeter) laceration area cleansed and steri strip applied. The Fall Report dated [DATE] does not document R4's motion sensor alarm was in place when R4 was found on the floor. The Fall Report documents a root cause of (R4) continues with poor safety awareness and impaired judgement related to cognitive impairments ambulating in room without staff assistance. Intervention: Staff to ensure proper placement and function of motion sensor alarm Q (every) shift. V24's (Registered Nurse/RN) Nurse's Note dated [DATE] at 7:16 pm states, Incident Note Text: resident (R4) found on floor in room skin tear on left elbow denies other injuries denies hitting head states was trying to go to bathroom. The Post Fall Evaluation Note dated [DATE] at 7:25 pm documents Fall was not witnessed. Fall occurred in the Resident's room. Resident was attempting to self-toilet at time of the fall. The Evaluation documents (R4) was sitting out in common area next to nurse's desk but needed to use the restroom, so resident got up with walker and walked to (R4's) bedroom. Staff heard resident fall. Staff went to resident's room and found resident on the floor and Resident states (R4) was coming out of bathroom and lost balance. The Evaluation documents R4 suffered a skin tear and complained of left elbow pain. The Evaluation documents an alarm was not sounding when R4 was found. The Fall Report dated [DATE] and the Post Fall Evaluation Note dated [DATE] do not document when R4 was last toileted or received incontinence care prior to the fall. The Late Entry Fall Follow Up Note dated [DATE] documents (R4) started c/o (complain of) pain left elbow, bruising and swelling noted. X-ray performed (on [DATE]) and found to have fx (fracture). The X-ray Report dated [DATE] documents R4 has a [MEDICATION(S)] olecranon (bony prominence of the elbow) fracture of R4's left elbow. The Nurses Note dated [DATE] documents R4 had a cast placed for the left elbow fracture. On [DATE] at 10:00 am V24 (RN) stated when R4 fell on [DATE], R4 broke R4's arm. V24 stated R4 fell in R4's room. V24 stated R4 would not stay in the chair or call for help. V24 stated the CNA staff found R4 on the floor and alerted V24. V24 stated initially R4 complained of left arm pain and then after they assisted R4 off the floor, R4 stated R4 had no pain. V24 stated over the next few days R4 complained of arm pain and was not using R4's arm, so a portable x-ray was obtained which indicated R4 had a fractured arm. V24 stated V24 was not aware R4 should have had a motion sensor in R4's room. V24 stated no alarm was sounding to alert staff R4 was up in R4's room. V24 stated R4 could propel R4's self quickly in the wheelchair, and R4 would go to R4's room. V22's (LPN) Nurse's Note dated [DATE] documents observed (R4) sitting on the floor by nightstand; noted hematoma right forehead and two skin tears left thumb; movement of all ext (extremities) WNL (within normal limits); skin tears on thumb cleansed et (and) bandage applied; Ice pack to hematoma. The Post Fall Evaluation dated [DATE] states on [DATE] R4 fell in R4's room. The Evaluation documents no alarm was sounding. The Fall Report dated [DATE] documents the root cause of R4's fall was that R4 was attempting to transfer and ambulate without staff assist. The Fall Report dated [DATE] does not document an alarm was sounding when R4 was found on the floor. On [DATE] at 9:30 am V22 (LPN) stated on [DATE] R4 got up out of bed and was found sitting on the floor leaning on the night table. V22 stated R4's roommate (R25) turned on the call light to alert staff that R4 had fallen. V22 stated R4 suffered a hematoma to R4's forehead when R4 fell . V22 stated R4 frequently gets up by R4's self. V22 stated an alarm was not in use when R4 fell on [DATE]. On [DATE] at 2:40 PM R4 was seated in a wheelchair at the nurse's station with a cast on R4's left arm and bruises to R4's right forehead and cheek. On [DATE] at 11:25 am V3 (Assistant Director of Nursing/ADON) stated residents should be toileted upon rising, before and after meals and at bedtime. V3 confirmed R4's [DATE] fall investigation and medical record do not document when R4 was toileted or received incontinence care on [DATE]. V3 stated the nurses should include this information in their documentation. On [DATE] at 10:45 am V3 (ADON) stated if R4 is taking R4's self back to R4's room, the motion sensor alarm should be on in R4's room at all times. V3 stated the intervention for R4 to have a motion sensor in R4's room to alert staff when R4 is up was implemented in [DATE]. V3 confirmed R4 should have had the motion sensor on in R4's room when R4 fell on [DATE], [DATE] and [DATE]. On [DATE] at 10:45 am R4's room was observed with V3. At that time no motion sensor was present in R4's room. V3 stated the motion sensor box should be on R4's night table and the alarm box should be at the nurses station. V3 located the motion sensor box and alarm box at the nurse's station. On [DATE] at 1:15 PM V8 (LPN/R4's nurse) stated V8 did not know R4 was supposed to have a motion sensor alarm in R4's room. On [DATE] at 1:30 pm V19 (Nurse Practitioner) stated R4 has had multiple falls at the facility, and R4 fractured R4's arm during one of the falls. V19 stated R4 has cognitive impairment and tries to get up independently. V19 stated V19 would expect facility staff to have interventions in place to prevent falls. 3. R5's Admission Record dated [DATE] documents R5 admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Dementia, and [CONDITION(S)] and [CONDITION(S)] of right dominant side. R5's MDS dated [DATE] documents R5 has severe cognitive impairment and requires extensive assistance of one staff person for transfers. R5's Care Plan revised on [DATE] documents R5 is at risk for falls. R5's care plan includes interventions to ensure call light is within reach, encourage participation in activities, ensure appropriate footwear is worn, physical therapy to evaluate and treat, ensure items are within reach, and follow the facility's fall protocol. There are no documented post fall interventions after [DATE]. R5's Fall Report dated [DATE] at 3:45 AM documents: R5 was found lying on the floor without injuries, and R5 stated R5 needed to use the bathroom. R5's Fall Report dated [DATE] at 4:00 PM documents R5 was heard yelling for help and was found in an unidentified resident room lying on R5's left side. R5 had a 2 cm (centimeter) by 0.2 cm laceration above R5's left eyebrow, and 2 cm by 2 cm scrape to R5's left knee. R5's Post Fall Worksheet dated [DATE] documents an intervention to add chair alarm. R5's Nursing Note dated [DATE] at 5:53 AM documents R5's roommate notified staff that R5 was on the floor. R5 was sitting in front of the bed. R5 had an abrasion to R5's right lower back. There is no documentation that an alarm was in use or sounding at the time of R5's fall. There is no documentation that a post fall investigation was completed to identify the root cause of R5's falls or that post fall interventions were implemented. There are no documented post fall neurological assessments completed for R5 after [DATE] at 9:45 AM. On [DATE] at 1:46 PM R5 was sitting in a wheelchair in the dining room. There was no alarm observed on R5's wheelchair. On [DATE] at 3:39 PM V25 (Human Resources) was pushing R5 in a wheelchair onto R5's unit. R5's wheelchair did not contain an alarm. On [DATE] at 2:38 PM V14 (CNA) stated R5 does not utilize an alarming device in the wheelchair or bed. On [DATE] at 2:17 PM V3 (ADON) stated: V3 is responsible for completing post fall investigations and updating the care plan with post fall interventions. V3 has not completed post fall investigations for R5's falls on [DATE], [DATE], and [DATE]. V3 confirmed R5's care plan has not been updated with post fall interventions for R5's falls. After R5's fall on [DATE], V26 (LPN) requested an alarm be implemented for R5. V3 provided an alarm for R5, and R5 should have an alarm in the bed and wheelchair. V3 stated, On [DATE] R5's fall occurred around 3:00 AM, so we initiated toileting assistance scheduled between 2:30 and 3:00 AM. V3 wasn't aware of R5's fall on [DATE] since an incident report had not been completed for R5's fall. V3 stated, If a fall is not witnessed, then neurological assessments must be completed according to the facility policy. V3 confirmed that R5's fall on [DATE] was unwitnessed. On [DATE] at 3:29 PM V1 (Administrator) provided R5's neurological assessment flow sheet for R5's fall on [DATE]. V1 confirmed the flow sheet does not document neurological assessments were completed after [DATE] at 9:45 AM. The facility's undated Fall Prevention policy documents: It is the policy to provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Additionally, all resident falls in this facility are analyzed and trended through the QA (Quality Assurance) process to maintain a safe environment. Clinically appropriate interventions will be put into place to reduce the risk for falls and/or to prevent recurrence of falls. The interdisciplinary team will review and modify the fall risk prevention plan at a minimum of quarterly, after each fall, and as clinically indicated. Interventions for the fall prevention plan will be modified following the interdisciplinary review and changes will be made to the plan of care. This policy documents neurological assessments will be completed per protocol for unwitnessed falls and documented in the medical record, incident/accident reports will be completed for tracking and trending and an investigation will be completed with a documented summary. The facility's undated Neurological Assessment protocol documents: Neurological assessments should be performed as follows for a 72-hour period, unless otherwise ordered by the attending physician. This protocol documents to complete post fall neurological assessments every 15 minutes for 4 times, every hour for 4 times, every two hours for 8 times, and then every four hours until 72 hours has been completed. The facility's undated Fall Prevention policy documents, It is the policy to provide each resident with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Additionally, all resident falls in this facility are analyzed and trended through the QA (Quality Assurance) process to maintain a safe environment. Clinically appropriate interventions will be put into place to reduce the risk for falls and/or to prevent recurrence of falls. An Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when facility failed to implement interventions to prevent falls for R4. On [DATE] at 2:40 pm V1 (Administrator) was notified on the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the immediate jeopardy: 1. On [DATE] Nursing staff received instruction through a text message to complete training on assessing residents for fall risk upon admission, including resident specific interventions on the baseline care plan, completing the post fall assessment and implementing post fall interventions. 2. On [DATE] all staff received instruction through a text message to complete training on the use of a yellow star sign on resident's doors to indicate they are at high risk of falling. 3. On [DATE] and [DATE] audits were conducted for all residents identified as being at high risk for falls to ensure resident specific interventions are in place and falling star signs were placed the resident room doors and name plates. 4. On [DATE] and [DATE] audits were completed by V2 (Director of Nursing) to ensure newly admitted residents and readmitted residents were assessed for fall risk and interventions were in place. 5. On [DATE] R5's fall care plan was reviewed and updated by V3 (Assistant Director of Nursing) and fall interventions were in place for R5.

These failures resulted in two deficient practice statements. A. Based on observation, interview, and record review the facility failed to provide prescribed anticoagulant therapy without adequate monitoring for a resident. This failure affects one of five residents (R28) reviewed for anticoagulant use in the sample list of 33 residents. This failure resulted in R28 sustaining lab results for anticoagulant use in the critical range, causing R28 being at unnecessary risk for life threatening complications including hemorrhage and internal bleeding. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 7/30/21, the facility remains out of compliance at a severity level 2. The facility is in the process of educating staff on the facility's anticoagulant orders policy, anticoagulant monitoring, physician notification, and the process for entering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] B. Based on interview and record review the facility failed to administer anticoagulant medications with adequate monitoring as ordered resulting in significant medication errors for four of five residents reviewed for anticoagulants in the sample list of 33 residents. Findings include: A. R28's Admission Record dated 7/28/21 documents R28 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's Hospital History and Physical dated 5/21/21 documents R28 had a fall at home resulting in a left femur fracture. R28's Fall Risk assessment dated [DATE] documents R28 is at high risk for falls. R28's Care Plan revised on 6/10/21 documents R28 has Hypertension, [CONDITION(S)], and [CONDITION(S)]. This Care Plan documents the following interventions: Administer anticoagulant medications as ordered. Have antidote Vitamin K on hand for emergencies. Obtain laboratory values as ordered and notify the physician of abnormal results. Monitor, document, and report to the physician signs of anticoagulant complications including blood in urine or stools, black tarry stools, sudden severe headaches, nausea/vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, sudden or significant changes in vital signs. R28's Order Summary Report dated 6/2/21-7/31/21 documents the following orders: [MEDICATION(S)] (antibiotic) DS (Double Strength) 800-160 milligrams (mg) by mouth twice daily for 10 days starting on 7/19/21, [MEDICATION(S)] (anticoagulant) 1.5 mg by mouth daily from 6/8/21-7/14/21, [MEDICATION(S)] 2 mg daily beginning on 7/14/21, and obtain R28's [MEDICATION(S)] (PT) and International Normalized Ratio (INR) weekly on Tuesdays and on 7/22/21. Hold [MEDICATION(S)] from 7/20-7/22/21. R28's July 2021 Medication Administration Record (MAR) documents R28 received [MEDICATION(S)] 1.5 mg daily from 7/1/21 -7/13/21, [MEDICATION(S)] 2 mg daily from 7/14/21-7/19/21, and 7/22/21 -7/26/21, and received [MEDICATION(S)] DS 800-160 mg from 7/20-7/28/21. R28's PT-INR Tracking Forms document the following: On 7/6/21 R28's PT was 31.3 and INR was 2.8. On 7/13/21 R28's PT was 20.8 and INR was 1.8. V23 (Nurse Practitioner) gave orders to increase R28's [MEDICATION(S)] to 2 mg daily beginning on 7/14/21 and recheck R28's PT/INR on 7/20/21. On 7/20/21 R28's PT was 77.4 (normal range 8 to 15) and INR was 7.6 (normal range 0.7 to 1.2). There is no documentation in R28's medical record that a PT/INR was obtained on 7/22/21 as ordered. R28's INR/[MEDICATION(S)], PT, Therapeutic laboratory results dated [DATE] at 5:05 PM documents R28's INR was 8.05 (critical value.) R28's Nursing Notes document that on 7/12/21 R28 did not receive [MEDICATION(S)] 1.5 mg as ordered with the documented reason as none available. On 7/19/21 the [MEDICATION(S)] DS order entry triggered a warning of a possible drug interaction with [MEDICATION(S)] that could cause a severe interaction of increased hypoprothrombinemic (prolonged bleeding) effects. There is no documentation in R28's medical record that the potential drug interaction warning was communicated to V16 (Physician) or V23 (Nurse Practitioner) to review. On 7/20/21 at 6:21 AM V16 was notified of R28's critical level of 7.6 and gave orders to draw INR and send to the laboratory for testing. At 2:41 PM R28's INR was 5.47 and orders were received to hold [MEDICATION(S)] until Thursday (7/22/21) and recheck INR on 7/22/21. On 7/27/21 at 4:50 PM V23 (Nurse Practitioner) was notified of R28's INR results and gave orders to hold [MEDICATION(S)] for 2 days, administer Vitamin K 1 mg Intramuscularly, monitor for bleeding, and repeat INR daily for 2 days. On 7/28/21 at 10:58 AM the facility's (PT/INR monitoring system, machine) was reviewed with V2 (Director of Nursing) and contained an electronic entry for R28's results on 7/27/21 of PT 94.7 and INR 8. On 7/27/21 at 4:16 PM V13 (Registered Nurse) stated on 7/12/21 there was no [MEDICATION(S)] medication card for R28 in the medication cart. V13 stated V13 did not contact the pharmacy or access the (Emergency Medication System) to obtain the medication and did not notify V16 (Physician) or V23 (Nurse Practitioner). V13 stated, I documented the medication wasn't available and passed it onto the next shift. On 7/27/21 at 2:27 PM V31 (Licensed Practical Nurse/LPN) stated that on 7/20/21 around 6:21 AM V31 notified V16 (Physician) of R28's elevated PT/INR results. V16 gave orders to hold [MEDICATION(S)] until 7/22/21 and redraw PT/INR on 7/22/21. On 7/27/21 at 2:30 PM V2 (Director of Nursing) stated that the PT-INR Tracking Form is returned signed by the physician, and the nurse should enter the order in the electronic medical record (EMR). V2 confirmed there is no documentation in R28's medical record that a PT/INR was obtained on 7/22/21. On 7/27/21 at 3:43 PM V2 stated that when V31 entered the order to draw PT/INR on 7/22/21 into R28's EMR, it did not carry over to the MAR to prompt the nurse to obtain the PT/INR and sign the MAR. V2 would expect R28's PT/INR to have been drawn as ordered and the results reported to the physician prior to resuming R28's [MEDICATION(S)] on 7/22/21, since R28's previous PT/INR was high. On 7/28/21 at 9:40 AM V2 stated the facility has a (Emergency Medication System) that contains a supply of medications for backup or emergencies. If the resident does not have a medication available, the nurse should check the (Emergency Medication System) to obtain the medication. If the medication is not available, then the nurse should contact the pharmacy to have the medication delivered. The physician should be notified if a resident misses a dose of medication. On 7/29/21 at 1:55 PM V2 stated the nurses should notify the physician of potential drug to drug interactions and document in the nursing notes. On 7/29/21 at 2:27 PM V2 stated V32 (LPN) told V2 that V32 did not notify V16 or V23 of the potential drug interaction between [MEDICATION(S)] DS and [MEDICATION(S)], and there is no documentation in R28's medical record that V16 or V23 were notified. On 7/28/21 at 11:14 AM V16 (Physician) stated, Ideally with R28 I should have been notified of the missed dose of [MEDICATION(S)], since the next day R28's PT/INR was low, and the dosage of [MEDICATION(S)] was increased. Missing one dose of [MEDICATION(S)] could affect the PT/INR depending on the resident's sensitivity to the medication and each resident is different. V16 was notified of R28's PT/INR results on 7/20/21 and gave orders to hold [MEDICATION(S)] for 3 days and obtain PT/INR results on 7/22/21. V16 intended for the [MEDICATION(S)] not to be held until after V16 was notified of the PT/INR results on 7/22/21. R28's PT/INR results on 7/27/21 put R28 at risk for bleeding if R28 were to fall, and at risk for GI (gastrointestinal) or nose bleeding, which can be life threatening. GI bleeding can go undetected. On 7/29/21 at 12:29 PM V33 (Pharmacist) stated the therapeutic target INR for someone with [CONDITION(S)] would be between 2 and 3. The most common risks associated with prolonged critical INRs would be bruising, and bleeding such as in the stool or urine. Without monitoring PT/INR it may not be known that the resident has a high level. The PT/INR should be checked every couple of days following a dosage change until the INR returns to the target range. If there would be uncontrolled bleeding it could be life threatening. On 7/29/21 at 1:28 PM V34 (Pharmacist) stated R28's elevated INR was likely due to the interaction between [MEDICATION(S)] and [MEDICATION(S)] DS. [MEDICATION(S)] is one of the worst medications to give with [MEDICATION(S)]; it has the potential for severe interaction and increases the effects of [MEDICATION(S)]. INR is recommended to be checked 48 hours after starting [MEDICATION(S)]. The facility's undated (Emergency Medication System) Inventory List documents the system contains [MEDICATION(S)] 1 mg, 2.5 mg, and 5 mg tablets, and [MEDICATION(S)] (anticoagulant) 60 mg/0.6 ml (milliliter) syringes. The Prescribing Information for [MEDICATION(S)] revised August 2012 documents an INR of greater than 4 is associated with a higher risk of bleeding, and the most common adverse reactions are fatal and nonfatal hemorrhage (bleeding) from tissues or organs. Maintain a target INR of 2.5 (INR range 2.0-3.0). The facility's (PT/INR Monitoring System) User's Manual with a copyright date of 2019 documents: Blood-Clotting Time: The rate at which blood clots is measured in units is called International Normalized Ratio (INR). It is very important for patients to stay within their individual target INR range. If the INR is too low, the risk of blood clots increases. If the INR is too high, the risk of hemorrhaging increases. The patient's physician will determine the most appropriate INR range for the patient, depending upon the patient's indication and how they respond to the oral anticoagulants. This manual documents the normal range for PT is 8.0 to 15.0 and INR is 0.7 to 1.2. The facility's Orders for Anticoagulants Policy dated February 2014 documents the following: 1. Prior to initiating a [MEDICATION(S)] regimen, a baseline International Ratio (INR) will be obtained and results reported to the Attending Physician. Follow-up INRs will be determined by the Attending Physician. 2. Anticoagulant therapy orders will be administered as ordered by the Attending Physician. 3. The Attending Physician must periodically review the recorded results of the laboratory monitoring and review for complications. 4. Should a resident receiving an anticoagulant have a fall and sustain a serious injury, (i.e. (for example) head injury, laceration, etc. (etcetera)) the Attending Physician must be notified and the resident must be observed closely for bleeding or changes in mental status. (Note other medications or foods may interact with the anticoagulant and increase the risk of bleeding.) An Immediate Jeopardy was identified on 7/29/21. The Immediate Jeopardy was identified to have begun on 7/22/21 when the facility failed to obtain R28's PT/INR as ordered and resumed the administration of [MEDICATION(S)] 2 mg daily. This failure resulted in R28 sustaining lab results for anticoagulant use in the critical range, causing R28 being at unnecessary risk for life threatening complications including hemorrhage and internal bleeding. On 7/29/21 at 3:32 PM V1 was notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 7/27/21 V16 (Physician) was notified of R28's PT/INR and gave orders to hold [MEDICATION(S)] for 2 days, administer Vitamin K 1 mg intramuscularly, monitor for bleeding and repeated PT/INR daily for two days. 2. On 7/28/21 R28's PT was 4.3 and INR was less than 0.8 and V23 (Nurse Practitioner) was notified. On 7/29/21 R28's PT was 24.3 and INR was 2.1. V16 was notified and gave orders to start [MEDICATION(S)] 1 mg daily, and repeat INR 8/3/21. On 8/3/21 R28's [MEDICATION(S)] was discontinued and R28 was started on [MEDICATION(S)] (anticoagulant) 5 mg twice daily. 3. On 7/28/21 and 7/29/21 V2 (Director of Nursing/DON) completed a review and audit of all residents who receive anticoagulant medications to ensure labs were obtained as ordered. 4. On 7/30/21 V38 (Registered Nurse/Minimum Data Set Coordinator) conducted training and education with the facility's nursing staff on the facility's anticoagulant orders policy, keeping PT/INR log current, physician notification of test results and missed doses of medications, order entry, and maintaining therapeutic blood levels. 5. On 8/3/21 at 12:09 PM V1 (Administrator) stated V1 or designee will complete weekly audits for a total of four weeks, of residents who receive anticoagulant medications. V2 (DON) completed the first audit. The results of the audits will be reviewed at the facility's monthly Quality Assurance meetings. B.1. R33's Care Plan revised 8/20/20 documents R33 receives [MEDICATION(S)] with interventions including to obtain labs as ordered and report results to the physician, and monitor/document/report to physicians signs of blood in urine and stools, sudden severe headaches, nausea/vomiting/diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status or vital signs. R33's Progress Note dated 5/26/21 at 3:08 PM by V16 (Physician) documents R33 receives an anticoagulant due to a valve replacement, and R33's INR goal is 2.5-3.5. R33's Order Review Report dated 8/2/21 documents the following orders: [MEDICATION(S)] (anticoagulant) 3 mg (milligrams) by mouth daily on Monday-Thursday, Sunday, and 4 mg daily on Friday and Saturday from 5/26/21-7/6/21. [MEDICATION(S)] 4 mg daily from 7/6/21-7/23/21. [MEDICATION(S)] 3 mg daily from 7/23/21-7/25/2. [MEDICATION(S)] 3.5 mg daily from 7/25/21-7/31/21. INR weekly on Tuesdays starting on 6/15/21. Administer [MEDICATION(S)] 20 mg by mouth daily, multivitamin one tablet by mouth daily, Tylenol 1000 mg by mouth at bedtime, and [MEDICATION(S)] 75 mcg (micrograms) by mouth daily. R33's July 2021 Medication Administration Record (MAR) documents to refer to the nursing notes for [MEDICATION(S)] administration on 7/4/21 and 7/28/21. R33's Progress Note dated 7/4/21 at 5:13 PM by V13 (Registered Nurse/RN) documents [MEDICATION(S)] 3 mg was not administered, not available. R33's Progress Note dated 7/28/21 at 6:15 PM by V13 documents [MEDICATION(S)] 3.5 mg was not administered, none available. There is no documentation in R33's medical record that V16 (Physician) or V23 (Nurse Practitioner) was notified of R33's missed doses of [MEDICATION(S)]. There is no documentation in R33's medical record that INR was completed on 6/15/21 and 7/20/21 as ordered. R33's PT-INR Tracking Forms document the following: R33's INR was 2.6 on 6/8/21 and 2.5 on 6/16/21. R33's INR was 2.7 on 7/13/21 and 4.5 on 7/22/21. R33's Progress Note dated 7/21/21 at 9:50 PM by V23 (Nurse Practitioner) documents R33 was evaluated for vaginal bleeding, R33's last PT/INR was 7/13/21, and an order to continue weekly INR. R33's Progress Notes on 7/6/21 and 7/23/21 document R33's [MEDICATION(S)] order entry triggered a warning of a possible drug interaction with [MEDICATION(S)] that could cause a severe interaction of increased hypoprothrombinemic (prolonged bleeding) effects, and moderate risk of interaction with [MEDICATION(S)], Multivitamin, and Tylenol. There is no documentation in R33's medical record that V16 or V23 were notified of the potential drug interactions. On 8/2/21 at 1:10 PM V31 (Licensed Practical Nurse/LPN) stated on 7/20/21 the residents were participating in an activity outside and V31 did not complete R33's INR. V31 passed it on to the next shift to be completed. On 8/2/21 at 11:49 AM V3 (Assistant Director of Nursing) stated that on 7/30/21 V3 re-entered orders for PT/INR to populate onto the MAR. Prior to 7/30/21 the orders for PT/INR were not populating to the MAR/TAR to be signed out by the nurse. V3 confirmed R33's [MEDICATION(S)] was not given on 7/4/21 and 7/28/21. V13 (RN) should have obtained the [MEDICATION(S)] from the facility's (Emergency Medication System) to administer to R33. V13 needs more one on one supervision on following this procedure. On 8/2/21 at 3:07 PM V3 stated V3 was unable to provide documentation that an INR for R33 was drawn on 6/15/21 or 7/20/21 as ordered, or that V16 or V23 were notified of the potential drug interactions with [MEDICATION(S)]. On 7/28/21 at 9:40 AM V2 (Director of Nursing) stated the facility has an (Emergency Medication System) that contains a supply of medications for backup or emergencies. If the resident does not have a medication available, the nurse should check the (Emergency Medication System) to obtain the medication. If the medication is not available, then the nurse should contact the pharmacy to have the medication delivered. The physician should be notified if a resident misses a dose of medication. B.2. R15's Admission Record dated 7/19/21 documents R15 admitted to the facility on [DATE] and R15 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's Order Review History Report dated 7/28/21 documents an order to administer [MEDICATION(S)] (anticoagulant) 5 mg by mouth twice daily. R15's July 2021 MAR does not document R15 received [MEDICATION(S)] as ordered on 7/4/21 at 5:00 PM and 7/24/21 at 5:00 PM with the documented reason as Absent from home/hospitalized . R15's Nursing Notes document the following: On 7/4/21 R15 was transferred to the local hospital at 3:05 PM and returned to the facility at 6:00 PM. On 7/24/21 R15 was transferred to the local hospital at 2:01 PM and returned to the facility at 9:50 PM There is no documentation that R15 received [MEDICATION(S)] as ordered, or that the hospital was contacted to determine if R15's evening medications were administered. There is no documentation that V16 (Physician) or V23 (Nurse Practitioner) were notified of R15's missed doses of [MEDICATION(S)]. On 7/29/21 at 1:04 PM V2 (Director of Nursing) stated that if (R15) returned at 6:00 PM the nurse should have given R15's scheduled 5:00 PM medications after verifying that the hospital did not administer the medications, and document in the medical record. V2 confirmed there is no documentation that R15 received [MEDICATION(S)] 5 PM dose on 7/4/21 and 7/24/21, that the hospital was contacted to determine if medications were given, or that V16 or V23 were notified of the missed doses. On 7/28/21 at 11:14 AM V16 (Physician) stated that if a resident returns from the emergency room , the facility staff should verify with the hospital whether or not medications were given, and notify V16 if medications are not given. V16 stated, This has been a problem. We have discussed medications not being delivered from pharmacy and medications not being administered at the facility's last Quality Assurance meeting. The facility's undated (Emergency Medication System) Inventory List (on site) documents the system contains [MEDICATION(S)] 1 mg, 2.5 mg, and 5 mg tablets, and [MEDICATION(S)] (anticoagulant) 60 mg/0.6 ml (milliliter) syringes. The facility's Orders for Anticoagulants Policy dated February 2014 documents the following: 1. Prior to initiating a [MEDICATION(S)] regimen, a baseline International Ratio (INR) will be obtained and results reported to the Attending Physician. Follow-up INRs will be determined by the Attending Physician. 2. Anticoagulant therapy orders will be administered as ordered by the Attending Physician. 3. The Attending Physician must periodically review the recorded results of the laboratory monitoring and review for complications. 4. Should a resident receiving an anticoagulant have a fall and sustain a serious injury (i.e. (for example) head injury, laceration, etc. (etcetera)) the Attending Physician must be notified and the resident must be observed closely for bleeding or changes in mental status. (Note other medications or foods may interact with the anticoagulant and increase the risk of bleeding.) The facility's Guidelines for Notifying Physicians of Clinical Problems dated as revised April 2007 documents the physician will be notified of significant medication errors. B.3. R29's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R29's Discharge Transfer Orders dated 7/17/21 documents rest and elevate extremity as needed to control pain and swelling for fracture of right femur, right fibula, right shoulder. R29's Care Plan dated 7/19/21 documents R29 is at risk for falls related to gait/balance problems due to fracture of right femur, right shoulder, and right fibula. This same Care Plan documents R29 is unaware of safety needs. There is no documentation on R29's current Care Plan that addresses to give anticoagulants as ordered or to monitor, document, and report complications of bleeding to the physician. R29's Medication Administration Record (MAR) dated 7/1/21 - 7/31/21, documents a number 3 which according to the MAR, indicates R29 was absent from the facility on 7/21/21. There is no further documentation in R29's Medical Record that the anticoagulant ([MEDICATION(S)]) was ever given to R29 on7/21/21. On 7/28/21 at 11:16 AM, V6 (R29's Physician) stated if a medication, specifically [MEDICATION(S)] (anticoagulant) is missed because a resident had an appointment, V6 would expect nursing staff to give the medication when the resident returns to facility. V6 also stated the risk of missing a dose of an anticoagulant would be developing a blood clot due to immobility. V6 also stated the nursing staff document that medications have not arrived to the facility from the pharmacy when the medication is at the facility in the emergency medication dispensing system. V6 stated management is aware the staff nurses are not aware of the medications in the emergency medication dispensing system and that the staff nurses need to be re-trained to use the emergency medication dispensing system correctly. B.4. R32's routine physician visit dated 6/30/21 documents R32's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's Order Review Report, dated 4/1/21 through 8/21/21, documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This same report documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This same report documents an order to repeat R32's International Normalized Ratio (INR) on 4/27/21. R32's Nursing Progress Notes dated 4/27/21 documents INR less than 0.8 and Prothrombin Time (PT) 3.0, continue same dose (of [MEDICATION(S)]) and repeat PT/INR on 4/28/21. This repeat PT/INR was not done until 5/4/21. This documentation was verified by V3 (Licensed Practical Nurse/LPN/Assistant Director of Nursing/ADON) on 8/2/21 at 3:12 PM. R32's Order Administration Note dated 6/1/21 at 5:36 PM, documents PT 47, INR 4.4, hold [MEDICATION(S)] for 3 days and restart at 2 mg. R32's Medication Administration Record (MAR) dated June 2021, documents [MEDICATION(S)] held on 6/2/21, 6/3/21, 6/4/21, 6/5/21, 6/6/21, and 6/7/21, and restarted on 6/8/21 at 2 mg. R32's Progress Note dated 6/8/21, documents PT 13.7 and INR 1.2 and restart [MEDICATION(S)] 2 mg daily, repeat INR next Tuesday (6/15/21). On 8/2/21 at 3:12 PM, V3 (LPN/ADON) verified this information. R32's Progress Note dated 7/6/21 documents repeat INR on Friday the 9th (June). R32's Progress Note dated 7/14/21, documents the next lab draw on 7/14/21. On 8/2/21, at 3:12 PM, V3 (LPN/ADON) verified the lab for R32 was not drawn on 6/9/21 as ordered. R32's Care Plan dated 6/3/21 documents R32 is on an anticoagulant and to give medications and labs as ordered.

Based on interview and record review, the facility failed to implement individualized interventions to prevent falls for a resident with a known risk of falls and on blood thinners. This failure affects one (R9) of three residents reviewed for falls in the sample of thirty-three. R9 sustained a subdural hematoma from an unwitnessed fall. Findings include: The facility's Falls and Fall Risk, Managing Policy dated Revised August 2008, documents The staff, with input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls; and The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. R9's current Electronic Medical Record (EMR) documents R9's diagnoses as: Traumatic Subdural Hemorrhage without loss of consciousness, sequela, Need for assistance with personal care, muscle weakness, repeated falls. R9's Minimum Data Set (MDS) dated [DATE] documents R9 requires extensive assistance of one physical assist for toilet use, is not steady moving from seated to standing position and walking, is cognitively impaired, moderately impaired for daily decision making, and has short and long term memory problems. R9's Baseline Care Plan dated 5/27/21, documents R9 requires assistance for walking/ambulation and toilet use - no individual interventions for walking/ambulation and toileting are documented. This same Baseline Care Plan documents R9 is a fall risk - there are no individual interventions for falls documented. On 7/7/21, at 2:52 PM, V3 (Licensed Practical Nurse/LPN/Assistant Director of Nursing/ADON) stated baseline Care Plans need interventions. R9's Care Plan dated 6/8/21, documents R9 is at risk for falls related to repeated falls. R9's Nursing Progress Notes from 5/28/21 through 6/28/21 document nineteen times that R9 had poor balance and gait is unsteady before R9's fall on 6/30/21. On 7/7/21 at 2:50 PM, V3 (LPN/ADON) stated R9's injuries were not present before R9's fall on 6/30/21, so the injuries must have been caused by the fall. V3 also stated when a resident is a fall risk, the fall protocol is encouraged so all initial interventions are applied to all residents, then after a fall, more specific interventions are added. On 7/7/21 at 3:00 PM, V13 (Registered Nurse/RN) stated it looked like R9 caught the hinge on the door with R9's head. V13 stated R9 was not using R9's walker at the time and stated R9 is not good about using R9's walker or R9's call light. V13 stated V13 has not documented or reported that R9 does not use R9's walker or call light. V13 stated V13 is not aware of any falls prior to the 6/30/21 fall. V13 stated at the time of R9's fall, R9 was not using R9's walker nor did R9 use R9's call light prior to the fall. On 7/9/21, at 12:28 PM, V1 (Administrator) stated, The ideal would be for those interventions to be listed in the care plan. The hospital report for R9 where R9 was first taken after R9's fall on 6/30/21 documents chief complaint as a fall and a diagnosis of Subdural Hematoma. V15 (emergency room (ER) doctor from 6/30/21) documents patient presents with a fall, having an unwitnessed fall at the nursing home, has dementia and does not recall falling; sustained a laceration to the back of head; R9 is on [MEDICATION(S)] (a blood thinner) for [CONDITION(S)]. This same hospital report documents R9 is positive for a back of head wound which is 2.5 centimeters and positive for dizziness and headaches. The imaging results for R9 dated 6/30/21, titled Commuted Tomagraphy (CT) head or brain without contrast documents an impression of Acute Anterior Falx Subdural Hematoma. R9's ER provider notes also document R9 as altered mental status with the hematoma seen extending inferiorly between the low anterior frontal lobes as well. R9's Emergency Department (ED) report dated 6/30/21 also documents patient (R9) is accepted for transfer to another hospital by V17 (ER doctor). The Physician Certification Statement (PCS) dated 6/30/2 at 7:30 PM, documents Is this a transport to another facility for services not available at the originating facility? YES.

Based on observation, interview and record review the facility failed to report pressure wound changes to the physician and family, failed to provide prescribed pressure ulcer treatment and pressure relieving devices, failed to manage pain during dressing change, and failed to develop care plan interventions to promote wound healing for residents. These failures affect two (R1 and R2) of three residents reviewed for pressure wounds in a sample list of 3 residents. These failures resulted in R1's pressure wound developing then deteriorating to an unstageable wound requiring hospitalization and intravenous antibiotics. Findings include: 1. R1's skin assessment upon admission (12/22/20) documents R1 as at mild risk for pressure sores with skin warm, dry and intact. R1's skilled evaluation dated 12/23/20 documents R1 as continent of urine and stool. R1's order dated 12/23/20 documents barrier cream to buttocks for redness. R1's skin assessment dated [DATE] documents R1 as at mild risk for pressure sores. R1's skilled evaluation dated 2/6/21 documents R1 as incontinent of urine and uses an adult brief. R1's shower sheet dated 2/18/21 documents no wounds or excoriation on R1's body. On 3/1/21 at 1:10 PM V11 (Licensed Practical/LPN/Wound Nurse) stated, I was told that (V13 Wound Doctor) needed to look at R1's skin because it was excoriated. R1's wound evaluation dated 2/19/21 documents a stage three wound of the right buttock measuring 0.6 x 2.5 x 1centimeter (cm). R1's wound was debrided and a treatment order was given for dressing the wound with calcium alginate and silicone foam dressing every day. R1's shower sheet dated 2/22/21 documents Sore on right buttock with strong odor; no nurse follow up was documented on the forms signature line. R1's progress notes do not document notification of 2/22/21 shower sheet foul odor of wound to R1's physician. R1's order dated 2/22/21 documents Calcium alginate with silicone foam dressing to wound daily was not documented as done on 2/22/21 and 2/23/21. On 3/3/21 at 11:21 AM V2 (Corporate Director of Nursing) stated, If it wasn't documented, then it wasn't done. The facility policy dated 12/5/20 documents Weekly skin assessments will be completed for residents who are at mild and moderate risk for breakdown and daily skin assessments will be completed for residents who are at high and severe risk for breakdown. On 3/2/21 at 12:00 PM V2 stated, We don't have (R1's assessments). The facility policy dated 12/5/06 documents Each facility will develop an interdisciplinary wound committee and minutes of each meeting will be recorded and maintained. On 3/3/21 at 11:20 AM V2 stated, We don't have a wound meeting, we are starting that tomorrow. The facility policy dated 12/5/06 documents #7 Care Plans will be developed for any resident who is identified at risk (mild/moderate/high/severe) according to the Braden risk assessment score. R1's most recent care plan dated 1/18/21 does not document skin integrity or interventions until 3/1/21, five days after R1 was transferred out of the facility to the hospital. On 3/1/21 at 3:30 PM when asked why the care plan had been changed, V1 (Administrator) stated, We were trying to clean up the care plans once we knew what you were looking at. R1's progress note dated 2/25/21 documents R1 was sent to (a local hospital) for evaluation. On 3/1/21 V12 (Physician Assistant) stated, I saw (R1's) right buttock wound when (R1) came into the hospital. The wound was at least a stage three and possibly unstageable. We consulted surgery to see if it needed to be debrided. (R1) was difficult to arouse when (R1) came in. The wound was infected with three types of bacteria. We put her on two different types of (intravenous) antibiotics and now (R1) is just on one, [MEDICATION NAME]. I believe that this infection in (R1's) coccyx is what caused her decline and hospitalization and to require (intravenous) antibiotics. Today (R1) is on day five of her antibiotics and is doing much better. (R1) is now alert. On 3/1/21 at 8:30 AM V15 (Power of Attorney for R1) stated, The hospital physician asked me if I knew about R2's wound. I did not. I have never been informed that (R2) had a wound. All they told me was that she had some cream for redness. I won't be sending her back to that facility. The Facility Policy Prevention of Pressure Ulcers revised 8/2008 documents, #6 the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. 2. R2's Minimum Data Set Care Area Worksheet dated 12/15/20 documents, At risk for pressure ulcer, none noted at this time, has pressure relieving mattress and cushion to wheelchair. The facility policy dated 12/5/21 documents Weekly skin assessments will be completed for residents who are mild and moderate risk for breakdown and daily skin assessments will be completed for residents who are high and severe risk for breakdown. R2's Progress Note dated 1/7/21 documents Resident noted to have a small open area to right hip 0.3 x 0.3. Area cleansed (and) calcium alginate with foam dressing applied. Change daily (and) as needed. (Nurse Practitioner) is in the facility (and) agrees with (treatment). (Power of Attorney) is aware. On 3/2/21 at 11:45 AM V1 (Administrator) stated, We didn't do any skin assessments for R2. On 3/2/21 at 12:00 PM V2 (Corporate Director of Nursing) stated, We don't have any skin assessments for R2. On 3/2/21 at 1:25PM V2 (Director of Nursing) stated, (R2) is on a turning and repositioning program every two hours, but we have got to get the Certified Nursing Assistants (CNA's) to start documenting again, the documentation looks like (due to lack of documentation, the turning and repositioning) was only done a couple times this month. R2's wound evaluation and management summary documents the following: 1/15/21 documents a stage one pressure wound of the right hip. The wound size measures 5 cm x 4 cm x not measurable. A physician order [REDACTED]. 1/23/21 documents a stage one pressure wound of right hip. The wound size measures 2 cm x 1 cm x not measurable. The physician documented the wound is improving. 1/29/21 documents an unstageable deep tissue injury of the right hip. The wound size measures 1.2 cm x 0.5 cm x 0.1 cm. The physician documented the wound has improved. Surgical excision debridement was performed. 2/5/21 documents a stage three pressure wound of the right hip. The wound measures 1.5 cm x 1 cm x 0.1 cm. The physician documented that the wound has deteriorated. Surgical excision debridement was performed. A new physician order [REDACTED]. 2/12/21 documents a stage three pressure wound of the right hip. The wound measures 1.5 cm x 1 cm x 0.1 cm. The physician documented no change in wound. R2's wound evaluation dated 2/19/21 documents a stage three pressure wound of the right hip. Wound size 3 x 2.2 x 0.3cm. The wound has deteriorated. Surgical excision and debridement procedure was performed. The Physician ordered Add honey to wound bed three times a week as needed. R2's wound evaluation dated 2/27/21 documents a stage four pressure wound of the right hip. Size 11 x 7 x 0.3cm. Deteriorated. Surgical excision debridement procedure. The order was changed to Thera-honey sheet apply three times per week with silicone foam and transparent film. On 3/2/21 at 12:10 PM V2 stated, We got (R1) the alternating air mattress two weeks ago. On 3/3/21 at 1:11 PM V2 stated, I would expect the facility to request a specialty mattress after doing an initial (1/15/21) skin assessment. On 3/1/21 at 10:00 AM R2 was sitting at the nurse's station in positioning chair. No cushion or positioning aid was observed in the chair. On 3/1/21 at 1:00 PM R2 was sitting at the nurse's station in the positioning chair without a cushion or positioning aid observed. On 3/1/21 at 1:10 PM V7 (Licensed Practical Nurse/Assistant Director of Nursing) stated, Sitting in a chair for hours isn't ideal for (R2's wound). On 3/2/21 at 8:45 AM V9 (Certified Nursing Assistant) stated, (R2) has declined. (R2) has to be in a positioning chair because (R2) can't sit in the wheelchair and (R2) tries to crawl out of bed. He is so thin and bony, and he wants to lay on his right side, no matter how we position him. We usually put him in his recliner in his room if we can. I don't know why they had him up so long yesterday. On 3/2/21 at 8:50 surveyor observed R2 in bed laying on right side with no cushion in R2's recliner. On 3/2/21 at 10:30 AM V7 stated, We need to get more creative with positioning (R2) off of his wound. The Facility Prevention of Pressure Ulcers Policy dated 8/2008 documents, #3 If Pressure Ulcers are not treated when discovered, they quickly get larger, become very painful for the resident and often times become infected. R2's Care Plan dated 12/15/20 documents (R2) is at risk for pain or discomfort. On 3/2/21 at 9:10 AM V3 (LPN) and V9 (CNA) rolled R2 in bed to perform stage four wound dressing change. R2 cried out loudly and wailed when the wound was touched. R2 yelled Let me die! The wound was open with bone visible. The outer surface of the wound was red and draining yellow/red exudate. On 3/2/21 at 9:15 AM V3 stated, I will call the doctor and get him some pain medicine. On 3/2/21 at 10:16 AM V11 (Licensed Practical Nurse/Wound Nurse) stated, Anytime that you touch (R2's) wound, he is in pain. It looks pretty awful.

Based on record review and interview the facility failed to prevent a fall and failed to ensure the safety of a medically compromised resident by not developing and implementing an individualized baseline care plan with specific targeted interventions to prevent falls for R4. The failure resulted in a fall for R4 who sustained an intertrochanteric [MEDICAL CONDITION] hip. R4 is one of three residents reviewed for falls. Findings include: R4's Electronic Medical Record documents R4 admitted on [DATE] and discharged on [DATE]. R4's Physician order [REDACTED].#9) Compression Fracture and Urinary Tract Infection. R4's Minimum (MDS) data set [DATE] documents R4 as being independent in self-care and mobility prior to facility stay and requiring extensive assistance of two staff for transfers during stay. R4's Electronic Medical Record does not document a baseline Care Plan initiated. R4's Care Plan documents a focus area of falls with a fall intervention initiated on 6/6/20 of 15-minute checks. There was no intervention on this same Care Plan for R4's fall the morning of 6/7/20. Nurse Progress Notes dated 6/6/20 at 10:54 AM document R4 is constantly up and down from bed to chair. These same Nurse Progress Notes dated 6/6/20 at 1:36 PM document R4 fell and received a skin tear to Left Elbow; 6/7/20 at 6:02 AM documents R4 had a fall with no injury; and documents another unwitnessed fall for R4 on 6/7/20 at 10:00 PM. The Nurse Progress Note dated 6/7/20 at 10:00 PM documents (R4) is able to move legs but not completely stretched out. Upon rising, (R4) would not stand up straight and kept crossing right leg/ankle over left foot. Staff assisted R4 from floor position to wheelchair and again from wheelchair to bed without completing full assessment after fall. Nurse Progress Note documents R4 attempted to cross right leg/ankle over left foot with both transfers. This same progress note documents R4 is unable to express self and very difficult to know if there is a problem or not. This same Nurse Progress Note documents a temporary fall intervention after R4's 6/7/20 at 10:00 PM fall of placing R4 closer to nurses' station. R4's Diagnostic X-Ray obtained on 6/7/20 documents result of Acute Right Intertrochanteric [MEDICAL CONDITION] Hip with varus deformity. On 12/4/20 at 2:35 PM V7 (Nurse Practitioner/NP) stated facility was aware that R4 had history of falling and was being admitted with a [MEDICATION NAME] Vertebrae (#9) Compression fracture which required R4 to wear a back brace, and a urinary tract infection which made R4 confused. V7 stated facility should have placed R4 on alarms, frequent checks and placed closer to the nurses' station from the time of admission. V7 stated R4 should have been more closely monitored by staff. V7 stated any new admission should require closer monitoring initially to check mobility status. V7 stated R4's [MEDICATION NAME] (#9) Compression Fracture put R4 at higher risk for injury. V7 stated facility may have prevented R4 from a fall with major injury if facility more closely monitored R4. On 12/4/20 at 3:45 PM V1 (Administrator) stated the facility did not create a baseline care plan for R4. V1 stated every resident should have a baseline care plan to allow staff information specific to resident and to be able to provide adequate care. V1 stated facility should have monitored R4 more closely to possibly prevent falls.

Based on observation, interview, and record review the facility failed prevent falls by failing to implement a fall intervention (R1) and provide a safe transfer (R2) for two of three residents (R1, R2) reviewed for resident injury on the sample of three. This failure resulted in R1 requiring emergency services for lacerations to the right forehead, bridge of nose, right inner elbow, right knee and right shoulder and in R1 sustaining fractured nasal bones. Findings include: 1. On 2/18/20 at 1:40 PM, R1 was sitting in R1's wheelchair in the hallway. R1 had bruising covering the forehead, bridge of nose, and cheek bones. R1 had a nose laceration and [MEDICAL CONDITION]. R1's Incident report dated 9/16/19 at 9:00 PM, documents V13 (Certified Nursing Assistant/CNA) was pushing R1 in wheelchair down the hallway to R1's room, R1 dropped feet to floor and R1's feet went under chair causing R1 to fall forwards onto floor. This report documents an intervention to have wheelchair pedals on the wheelchair when R1 is in the wheelchair. R1's Care Plan documents a 10/1/19 intervention for Foot pedals to be on wheelchair when (R1) is in wheelchair. R1's Incident report dated 2/12/20 at 4:25 PM documents R1 flung self out of wheelchair, landing on face. Injuries noted and sent to the emergency room . On 2/18/20 at 11:35 AM, V5 (CNA) stated that at dinner time, V5 was taking residents down to the dining room. V5 stated V5 was pushing R1 in the wheelchair and R1 went forward out of the chair. V5 stated V5 is not sure if the wheelchair pedals were on R1's wheelchair. On 2/18/20 at 11:45 AM, V3 (Licensed Practical Nurse/LPN) stated V3 was heading out to the dining room with the medication cart. V3 stated V3 turned around and R1 had fallen out of the wheel chair. V3 stated R1's foot pedals were not on the wheelchair. V3 stated V3 sent R1 out to the hospital due to hematoma to her forehead, laceration to the bridge of nose, hematoma to the right shoulder, skin tear to the right inner elbow, and an abrasion to the right knee. On 2/18/20 at 1:08 PM, V9 (Fall Coordinator) stated V9 investigated R1's 2/12/20 fall. V9 stated V5 was just beginning to push R1 down the hall and then R1 fell out of the wheelchair. V9 stated the wheelchair pedals were not on R1's wheelchair. V9 told V5 that the wheelchair pedals were not on. On 2/19/20 at 11:12 AM, V2 (Director of Nursing) stated the intervention of the wheel chair pedals was put into place after the fall on 9/16/19. V2 stated R1 would drop R1's feet to the floor causing R1 to fall forward when being pushed in the wheel chair. V2 stated when R1 was being pushed the wheel chair pedals should be in place to prevent R1 from falling forward out of the chair. V2 stated when investigating R1's 2/12/20 fall it was determined that R1's wheelchair pedals were not in place. R1's emergency room notes dated 2/12/20 documents under Chief Complaint, (R1) was sitting in wheelchair and had a witnessed fall out of (R1's) wheelchair hitting (R1's) right side of (R1's) forehead and bridge of (R1's) nose from (R1's) glasses, right (inner elbow) lacerations and right knee and shoulder. These notes also document under Diagnoses, fractured nasal bones - Onset: 2/12/2020. These notes contain a radiology report dated 2/12/20 that documents, right nasal bone fracture. On 2/19/20 at 12:01 PM, V14 (Hospital Radiologist) stated the fracture to R1's nose was an acute fracture caused by R1's 2/12/20 fall. 2. On 2/18/20 at 10:05 am, R2 was observed to have a left below knee amputation. On 2/18/20 at 10:05 am, R2 was asked about previous falls. R2 stated that R2 was dropped by a little gal in the shower a little while ago. V4 (Certified Nursing Assistant/CNA) needed another person and V4 just couldn't transfer me. I hit my head in the shower and it really hurt. On 2/18/20 at 11:43 am, V3 (Licensed Practical Nurse/LPN) stated V4 came and got V3 and she found R2 sitting on the floor of the shower. V3 also said V3 educated the staff after the fall that a gait belt had to be used when transferring R2. V3 confirmed no gait belt was used on the R2 at the time of the fall (1/11/20). On 2/18/20 at 12:20 pm, V4 stated when R2 fell on [DATE], V4 failed to use a gait belt, failed to ensure that the wheel chair was locked before transferring R2, and failed to have non-slip footwear on R2 for transfer. On 2/18/20 at 12:45 pm, V2 (Director of Nursing/DON) stated R2 fell on [DATE]. V2 reported that V2 would expect that staff would use a gait belt, expected that they would lock wheelchair wheels and expected that they would put non-slip footwear on residents before transferring them. R2's fall documentation form dated 1/11/20 at 10:45 am, documents that R2 was in the shower room transferring from wheelchair to shower chair with V4. R2 lost R2's balance and was assisted to the floor but hit R2's head. R2 verbalized needing more assistance to transfer. R2's Care plan dated 10/8/19 documents, Apply gait belt and provide verbal/visual cues as needed (i.e. push up from bed/chair to stand and reach back before sitting) for safe transfer technique. Ensure that (R2) is wearing appropriate footwear when ambulating or mobilizing in wheelchair.

Based on interview, observation, and record review the facility failed to identify a pressure sore, failed to monitor a pressure sore, and failed to provide treatment to a presure sore for two of three residents (R1 and R2) reviewed for pressure sores on the sample of eight. This failure resulted in R2's pressure sore deteriorating to an unstageable pressure sore. Findings include: 1. R2's Minimum Data Set ((MDS) dated [DATE], documents R2 as cognitively intact and that R2 requires extensive assistance with dressing, personal hygiene, and bathing. R2's MDS documents that R2 is at risk for developing pressure sores and that R2 has a [DIAGNOSES REDACTED]. The Pressure Ulcer report documents that the pressure sore measured 2.5 centimeters (cm) by 2.0 cm and the wound bed contained 100% dark black tissue and had a small amount of serosanguineous drainage. The report also documents that the pressure sore treatment was calcium alginate (antimicrobial) covered with a dry dressing. On 4/6/15 at 12:15 pm, R2 stated that the pressure sore to the right foot started "about two weeks ago." R2 stated that the pressure sore hurts and it is caused from his new shoes. R2 stated that "today the nurse applied a dressing to the pressure sore." On 4/6/15 at 3:45 pm, E6 Wound Nurse stated that she faxed Z2 today regarding a pressure sore to right lateral foot. E6 stated that she thinks the pressure is due to pressure caused from R2's new shoes. R2's Nurses Notes dated 3/5/15 at 3:45 pm documents that R2 received new shoes. R2's Bath Look Back Report documents that R2 received a shower on 4/2/15 at 1:26 pm and that R2 required extensive assistance with the shower. On 4/7/15 at 8:00 am, E4 Certified Nurse's Assistant (CNA) stated that on 4/2/15 at 1:26 pm she assisted R2 with a shower. E4 stated that R2 complained of pain and discomfort to the right foot. E4 stated that she noticed a wet white spot to the side of the right foot. E4 stated at that time she notified E5, Licensed Practical Nurse. On 4/7/15 at 10:30 am, E5 stated that on 4/2/15 she assessed R2's right foot after his shower. E5 stated that she noticed a "pinky tip sized" white area to the side of R2's right foot. E5 stated that she applied triple antibiotic ointment and a gauze pad to the area per her own nursing judgment. E5 stated that she does not usually work with R2. E5 stated that she did not call the physician or R2's power of attorney. E5 stated that she did not document her findings in the nurse's notes. E5 stated that she did not pass the information on to the next nurse in report and did not add R2 to the twenty four hour shift report. On 4/7/15 at 9:35 am, R2 was sitting in his wheelchair in his room. E3 Registered Nurse and E6 assessed R2's pressure sore to the right lateral foot. The wound measured 4.2 centimeters (cm) by 4.3 cm. The center of the wound was necrotic. The necrotic area of the wound measured 3.0 cm by 3.2 cm. The necrotic area was surrounded by a bright red ring of tissue with yellow slough inside. The wound was draining moderate amount of bloody yellow drainage. At that time R2 stated that the pressure sore to his right foot was very painful and that the shoes have not fit right since he got them. E6 stated that she has not assessed R2 ' s shoes for proper fit or irregularities. R2 ' s Nurses Note dated 4/7/15 at 10:32 am documents, that Z2 was paged and a new order was received to "cleanse the wound with wound cleanser, pat dry, apply Santyl ([MEDICATION NAME] agent) to black tissue, cover wound with calcium alginate (antimicrobial agent) cover with dry dressing until healed. [MEDICATION NAME] DS (antibiotic) to be started today, twice a day times ten days." On 4/7/15 at 3:30 pm, E2 Director of Nursing stated that E5 should have notified Z2 immediately concerning the pressure sore to R2's right lateral foot. E2 stated that E5 should have notified E6 so that an appropriate treatment could be started to R2's pressure sore and so that the pressure sore was monitored. The facility's Change in Condition policy dated 12/7/11, documents that the Physician and responsible party will be notified of an onset of pressure sore. The policy also documents that the nurse will document in the clinical record and that all significant changes will be recorded on the twenty four hour report 2. The Quality Assurance Worksheet dated week of 2/23/15 documents that R1 has "blister that has opened" measuring 2.9 cm by 3.1 cm. The Nurses Note dated 2/15/15 documents that an area which appeared to be a broken blister was identified on R1's right heel and a treatment was initiated on that date. The facsimile cover sheet dated 2/15/15 documents that on that date E3 Registered Nurse notified R1's Physician, Z2 of the new area and sent a request to "continue the treatment of [REDACTED]." The same facsimile documents that on 2/16/15 Z2 sent an order for [REDACTED]. On 4/7/15 at 8:25 AM E6 Wound Nurse reviewed R1's February 2015 TAR and confirmed that R1's right heel wound treatment was not initialed as being completed 2/16 and 2/17, and 2/19 through 2/23. At that time E6 could not provide documentation that R1's heel wound treatment had been completed on those days and stated staff nurses should have been completing the treatment daily. On 4/8/15 at 10:30 AM E2 Director of Nurses stated that R1's right heel wound treatment order was mistakenly entered in the computer as a one time order so the nursing staff were only prompted by the computer to complete the treatment on 2/18/15.

Based on record review and interview the facility failed to provide supervision for R3 while sitting in a wheelchair which resulted in R3 falling from the wheelchair and sustaining a subdural hematoma. The facility failed to ensure the fall prevention interventions for R5 (alarm & bolsters) were working appropriately and applied correctly which resulted in R5 having three falls. R3 and R5 are two residents reviewed for falls in a sample of 5. Findings include: 1. The physician's orders [REDACTED]. The MDS (Minimum Data Set) dated 3/19/12 states that R3 is moderately impaired in cognitive skills for daily decision making and requires extensive assistance with two plus (persons) physical assist for all transfers. R3's balance is not steady and is only able to be stabilized with human assistance. The facility's Fall Assessments dated 2/17/12 and 3/14/12 for R3 reflects that R3 is at High Risk for falls. The facility's Fall Investigation Conclusion report dated 3/19/12 in the section titled "Incident Description" for R3 states "(R3) was sitting up in the wheelchair next to the nurses station. When a loud thump was heard and (R3) was observed laying on floor, wheelchair tipped on her.(R3) was laying more on right side with right arm under her and blood present under forehead......." On 4/6/12 at 10:45 AM E5, CNA (Certified Nursing Assistant) stated that (R3) was confused that day and was trying to get out of bed so she helped E5, CNA get (R3) up and put into a wheelchair. E5 continued to state R3 was placed at the far east corner of the nurses station. E5 stated R3 did not have any type of safety belt or alarms on the wheelchair and that R3 was sitting on her own in the wheelchair. On 4/6/12 at 9:30 AM E6, RN (Registered Nurse) stated "No I did not have visual view of (R3) when they placed her at the end of the nurses station. I heard a thump and found (R3) on the floor with the wheelchair on top of her. We sent (R3) to the hospital for evaluation." The Hospital Report dated 3/21/12 titled " Finalized Diagnostic Report" "CT (Computerized Tomography) Without Contrast" states under the section titled "Impression" reads "Head CT on (R3) shows stable appearance of the right parietal extra-axial hemorrhage, probably a subdural hematoma." 2. The Facility's "Investigation Conclusion Report" on a fall dated 1/14/12 for R5 states Resident (R5) was observed on floor at bedside at 7:45 a.m. The report also reflects that there was an alarm in place at this time but the alarm did not sound. The interventions listed for implementation are "Staff to have resident up for the day at 7:30 a. m., bed et (and) chair alarm in place. Continue bladder wheel to establish toileting pattern". The facility's "Investigation Conclusion Report" on a fall dated 3/2/12 for R5 states Resident (R5) was observed in a sitting position on floor mat at bedside at 5:30 a.m. The report also reflects that there was no alarm present. The interventions listed for implementation are "Medication Review, Low Bed and a Body Pillow". The Facility's "Investigation Conclusion Report" on a fall dated 3/3/12 for R5 states the staff was alerted by a sounding alarm and R5 was observed on right side lying position on floor mat. The report also reflects that the Bolsters were not on correctly. The interventions listed for implementation are "Bolsters for safety d/t (due to) decreased safety awareness. Low bed at all times". On 4/5/12 at 2:15 p.m. E3 (Assistant Director of Nursing) confirmed that Bolsters were implemented for R5 at the time of the 3/2/12 fall as a nursing intervention. E3 and E2 (Director of Nursing) both at this time on 4/5/12 acknowledged that the alarm on R5's bed, had it been working, may have prevented the 1/14/12 fall. Also acknowledged by E2 and E3 was, had the Bolsters been on R5's bed correctly, the 3/3/12 fall may have been prevented.