Every finding on record at Rivaya Care of Des Plaines

Based on interview, record review, and policy review, the facility failed to follow its written abuse prevention policy when administration did not enforce policy rules after confirming a Certified Nursing Assistant (V3) crossed professional boundaries with a resident (R1) and deleted social media evidence during an internal investigation. This failure by management to enforce its abuse policy puts all 133 residents in the facility at risk for unchecked staff misconduct. Findings include:The facility's policy titled Abuse Prevention Policy states in part: Photographing and Recording Residents. Staff photographing or recording residents or their private space . for other than medical or facility purposes . is strictly prohibited. Staff posting or sending a photo or recording on social media or otherwise keeping or sending a photo or record through multimedia messaging . is strictly prohibited. Staff taking or using a photograph or recording of a resident in a manner that demeans or humiliates a resident . will be handled as an allegation of abuse in accordance with the procedures set forth below.On 7/24/26 at 1:50 PM, an interview with V3 (CNA) confirmed an ongoing failure to adhere to professional boundary expectations. V3 acknowledged initiating and maintaining an unapproved social media relationship via Instagram with R1 over a three-month period while assigned as R1's direct caregiver multiple times per week. V3 stated she was aware R1 had a diagnosis of clinical depression-having been informed by a facility nurse-and acknowledged personally observing R1 crying on multiple occasions. V3 additionally acknowledged awareness of R1's diagnosis of generalized anxiety disorder; however, V3 admitted that because she is not a clinician, she did not recognize the clinical difference between depression and generalized anxiety disorder. Despite knowing R1 suffered from these psychiatric conditions, V3 maintained private communications and admitted R1 obtained personal photos of her from her Instagram account. V3 stated that after her husband discovered the interaction, she abruptly severed contact, causing R1 to become emotionally distraught. V3 admitted to deleting her Instagram account, posts, and message history prior to and during the facility's internal investigation, thereby removing digital evidence of the boundary breach.On 7/24/26 at 2:30 PM, an interview with V1 (Administrator) revealed a failure of facility leadership to enforce written policy mandates upon confirming staff misconduct. V1 acknowledged V3 CNA crossed professional boundary policies with R1 and was placed on suspension. However, V1 confirmed administration elected not to enforce full policy sanctions or terminate V3, offering an unverified assertion that R1 was manipulative and citing R1's personal background as rationale for V3's involvement. V1 acknowledged that administration never inspected the digital messages or photographic evidence exchanged between V3 and R1 because V3 deleted the account prior to administrative review, yet leadership took no administrative or disciplinary action regarding the destruction of evidence during an active abuse investigation.On 7/25/26 at 10:20 AM, an interview with R1 corroborated the administrative breakdown in protecting residents from boundary breaches. R1 stated V3 initiated a private social media relationship while providing direct care, causing him significant emotional distress, depression, and a request to be discharged when V3 abruptly stopped communicating. R1 confirmed facility administration was aware of the incident and suspended V3, but noted he expressed a desire for V3 not to be fired due to feelings generated by the boundary violation, demonstrating the heightened vulnerability created when administrative controls fail to mitigate staff boundary crosses.On 7/26/26 at 12:30 PM, an interview with V5 (Human Resources Director) revealed that she served as manager on duty when V4 (Director of Nursing) instructed that V3 be removed from the floor and suspended pending investigation. V5 stated she conducts inservice training on abuse prevention, during which she emphasized the facility's policy prohibiting social media interactions with residents, and affirmed that all staff social media communication with residents is prohibited.On 7/26/26 at 1:00 PM, an interview with V4 (Director of Nursing - DON) confirmed she received a call and text message from R1 regarding his Instagram relationship with V3. V4 then directed V5 to suspend V3 pending an internal investigation. V4 stated V3 committed a clear boundary violation by allowing R1 access to her personal phone to connect on Instagram. V4 acknowledged that she could not verify the full nature of the communications because V3 deleted her account during the investigation, and acknowledged concerns regarding compromised transparency.

Based on interview and record review, the facility failed to maintain an accurate personal property inventory and failed to safeguard personal belongings for 1 of 3 resident (R2) reviewed for missing personal property. Specifically, the facility failed to complete or provide an itemized personal inventory list upon admission or during care, and failed to investigate or provide objective evidence to substantiate the whereabouts of R2's missing wedding ring and fur coat.Findings include:R2 is an [AGE] year-old female with medical diagnoses including atrial fibrillation, bradycardia, chronic gout, and stage 4 chronic kidney disease, and is wheelchair-dependent. A review of R2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 7/24/26 at 11:15 AM, an interview was conducted with Assistant Administrator V2 regarding the facility's tracking of missing resident property. When requested to provide a missing items log, V2 stated that the facility did not maintain a dedicated missing items log and only maintained a general concern/complaint log. A subsequent review of the facility's concern/complaint log revealed no entry or record documenting R2's reported missing wedding ring or fur coat. On 7/24/26 at 11:50 AM, Administrator V1 was asked to provide R2's completed personal property inventory sheet and any investigative documentation regarding the missing items. V1 was unable to furnish an inventory list for R2 or any record of a missing property investigation. V1 stated he believed R2 may have lost the items during a prior hospitalization; however, when asked to provide documentation, transfer logs, hospital transport checklists, or any corroborating evidence showing the items left the facility with R2 during her hospital transfer, V1 stated that no proof or documentation was available. On 7/25/26 at 2:35 PM, an interview with R2 revealed that her wedding ring and a fur coat went missing while residing at the facility. R2 reported that facility staff did not provide her or her representative with a personal property inventory list upon admission, nor was an established facility protocol, inventory log, or tracking method provided to identify or locate lost or missing personal items. On 7/26/26 at 11:15 AM, V1 was requested again to provide an inventory sheet as evidence of R2's personal property. No evidence was provided to demonstrate that the facility maintained an inventory sheet to account for the resident's personal belongings, nor was evidence provided showing that R2's property was located or replaced.On 7/26/26 at 12:30 PM, an interview with V5 (Human Resources Director) revealed she was unaware of any complaints regarding staff involvement in missing items. V5 stated it was the responsibility of the nursing staff to inventory resident belongings upon admission. V5 noted she had previously observed nurses writing resident items on loose paper, but stated she was unaware of what happened to those records afterward.On 7/26/26 at 1:00 PM, an interview with V4 (Director of Nursing - DON) confirmed that R2 admitted from another facility with numerous personal items, including a refrigerator. V4 acknowledged that nursing staff failed to document or itemize any of R2's belongings on an inventory sheet or official record upon admission.A subsequent review of R2's clinical and administrative records revealed no documented personal property inventory form completed upon admission or updated during her stay. Furthermore, the facility record contained no documented investigative report, missing item log, or follow-up entries regarding the reported disappearance of R2's wedding ring or fur coat.

Based on interview and record review the facility failed to ensure 1 of 3 residents (R1) reviewed for abuse was protected from staff boundary violations and potential emotional exploitation when Certified Nursing Assistant (V3) established an unauthorized personal social media relationship with R1, causing R1 emotional distress, and deleted her account history during the facility's investigation.Findings Include:R1 is a [AGE] year-old alert and oriented resident with diagnoses including diabetes, heart failure, protein-calorie malnutrition, and radiculopathy of the lumbar region. A review of R1's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, confirming intact cognition (alert and oriented x 3), with no documented diagnoses of mental illness or behavioral symptoms.On 7/24/26 at 1:50 PM, an interview with V3 (CNA) confirmed an improper personal relationship and awareness of the resident's psychological vulnerability. V3 admitted to initiating and maintaining an unapproved social media connection via Instagram with R1 while providing direct care over a three-month period. V3 stated she was aware that R1 had a diagnosis of clinical depression, noting that a facility nurse had informed her of the diagnosis, and V3 acknowledged personally witnessing R1 crying on multiple occasions. Despite knowing R1 suffered from depression, V3 engaged in private social media communications and admitted that R1 obtained personal photos of her from her Instagram account. V3 stated that after her husband discovered the interaction, she abruptly severed communication, leading R1 to become distraught. V3 acknowledged knowing that maintaining a private social media relationship crossed professional boundaries and placed a resident with known emotional vulnerabilities at risk of distress and potential exploitation. V3 further admitted to deleting her Instagram account, posts, and message history prior to and during the facility's internal investigation. On 7/24/26 at 2:30 PM, an interview with V1 (Administrator) revealed that V1 acknowledged V3 crossed professional boundaries and was suspended. However, V1 stated he believed the conduct did not warrant termination, offering an unverified assertion that R1 was manipulative and citing R1's prior personal history as rationale for R1's involvement with V3. When asked by the surveyor if he reviewed any of the posts or messages sent between V3 and R1, V1 stated he did not view any because V3 had deleted the Instagram account prior to administrative review. On 7/25/26 at 10:20 AM, an interview with R1 revealed that V3 (CNA) established an improper personal friendship outside of professional duties via Instagram messaging and posts while R1 resided in the facility. R1 reported feeling distraught, emotionally manipulated, and led on by the ongoing digital interactions and subsequent circumstances. R1 stated he became depressed and emotionally distressed when V3 abruptly ended communication without explanation. R1 expressed that this emotional distress was severe enough that he requested to be discharged from the facility. R1 confirmed that facility administration was aware, noting he learned V3 was suspended, but stated he did not want V3 fired because he still held feelings for V3 as a result of the unmitigated boundary violation. On 7/26/26 at 12:30 PM, an interview with V5 (Human Resources Director) revealed that she was the manager on duty when V4 (Director of Nursing) requested that V3 (CNA) be removed from the floor and placed on suspension pending the investigation into her personal relationship with R1. V5 stated that she conducts inservice training on abuse prevention for all staff, during which she recently emphasized the facility's policy prohibiting social media interactions with residents. V5 affirmed that staff are prohibited from engaging in any social media communication with residents, as doing so violates professional standards. On 7/26/26 at 1:00 PM, an interview with V4 (Director of Nursing - DON) revealed that she received a call and text message from R1 regarding his Instagram relationship with V3 (CNA). V4 then contacted the facility and instructed V5 (HR Director), who was serving as manager on duty, to remove V3 from the floor pending an internal investigation. V4 stated that V3 made a clear boundary violation by allowing R1 access to her personal phone to set up or connect via Instagram. V4 acknowledged that while she did not believe the relationship was sexual, she could not verify the full nature of the communication because V3 deleted her Instagram account during the investigation. When asked by the surveyor whether deleting the account compromised transparency during the investigation, V4 acknowledged the concern but did not provide a direct answer. A review of the facility's policy titled Abuse Prevention Policy revealed that it reads in part: Photographing and Recording Residents. Staff photographing or recording residents or their private space (even if the resident is not present) for other than medical or facility purposes, as described in a signed Audio, Video and Photographic Release Form, is strictly prohibited. Staff posting or sending a photo or recording on social media or otherwise keeping or sending a photo or record through multimedia messaging other than for facility purposes as described in a signed Audio, Video and Photographic Release Form is also strictly prohibited. Staff taking or using a photograph or recording of a resident in a manner that demeans or humiliates a resident, regardless of the resident's cognitive status or whether the resident consented, is strictly prohibited and will be handled as an allegation of abuse in accordance with the procedures set forth below.

Based on interview and record review, the facility failed to implement fall preventive measures for R1 who require floor mats next to bedside for safety precautions. This deficiency affects one (R1) of three residents reviewed for Falls prevention program. Findings include:R1 is a [AGE] year-old, alert and orientated to person, place and time, with the following diagnosis in part but not limited to: Chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic combined systolic congestive and diastolic congestive heart failure, unspecified asthma, insomnia, epilepsy, unspecified, Chron's disease, muscle wasting and atrophy.Facility incident reported dated 3/31/26 documents unwitnessed fall episode. Resident noted on floor lying in supine position bleeding from head, staff applied first aid to head. Upon assessment R1 remains alert and oriented x 3 (person, place and time), neuro-checks within normal range. Vital signs stable. Small laceration noted to right side of head. On 4/14/26 at 12:04 PM, R1 observed in room, lying in bed. R1 said he does recall fall on 3/31/26 and said he was asleep and must have rolled out of bed. R1 said floor mats were not in place during fall. R1 said the facility placed floor mats after the fall. R1 said he had two staples to back of head from the fall.On 4/14/26 at 12:10PM, V5 (Certified Nurse Aide) stated V5 has been working with R1 for a while prior to fall and prior to fall R1 did not have any floor mats in place. R1 now has floor mats in place after fall on 3/31/26 occurred. On 4/14/26 at 12:19PM, V9 (Certified Nurse Aide) said she heard R1 screaming for help on 3/31/26 and entered room and saw R1 on the floor on his back on the left side of the bed. R1 was bleeding from back of his head. V9 said R1 had both side rails up. V9 said she thinks the floor mats were in place.On 4/15/26 at 11:30 AM, V2 (Director of Nursing) said R1 should have had floor mats in place prior to fall. R1's fall intervention was updated for PT/OT for strengthening post fall on 3/31/26. V2 said R1's fall investigation was completed by restorative nurse, restorative nurse not available for interview.On 4/15/26 at 1:25PM, V11 (Agency Nurse), said she worked on 3/31/26 and said the nurse in charge of R1 had stepped off the floor when R1 had a fall. V11 said she heard V9 screaming for help and when she arrived at R1's room she saw R1 on the floor laying on his back with lots of blood on the floor. V11 said she does not recall seeing any floor mats in place. V11 gave first aid to R1 and left V9 with R1 and called 911 to transfer R1 due to head injury.On 4/16/26 at 12:01 PM, V1 (Administrator) said R1 did not have floor mats in place during fall.4/16/26 at 12:03 PM, V2 said R1 did not have floor mats in place during fall. V2 said her expectations are for all staff to follow fall prevention interventions in residents' care plan to promote resident safety.The Minimum Data Set (MDS) dated [DATE] section C- Cognitive Patterns- Brief Interview for Mental Status (BIMS) documents R1 score of 14.The Fall Risk Review assessment dated [DATE] documents R1 at High Risk for Fall.The Care Plan dated 12/08/22 documents R1 is at HIGH RISK for Falls as evidenced by the following risk factors and potential contributing Diagnosis: Decreased Strength and Endurance, Diabetes Mellitus, has episodes of Incontinence of Bladder & Bowel, Impaired Gait and Balance, Seizure Disorder, CHF, cardiac distress, COPD, asthma, Crohn's disease, G tube, neuropathy, Anxiety Disorder, Tachycardia, Major Depressive Disorder. Use of psychotropics. Enteral feeding. Interventions in place include 11/27/23- Floor Landing Mats when resident is in bed.Facility Policy on Falls Occurrence- revised 8/2024.Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for all prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents dignity and self-worthTo rehabilitate residents to their fullest potential of function. The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provide appropriate supervision to each resident as identified through the following process.Identification of hazards and risksEvaluationImplementationMonitoringAnalysisResponsible Party.Fall risk evaluation: A fall evaluation is used to identify individuals who have predicting factors for fall this evaluation is completed upon admission, quarterly, annually and with significant change in condition, resident evaluated as at risk for falls will be identified and ritualized fall precautions developed for each resident's preventative measures shall be taken to decrease the number of falls whenever possible.Purpose:To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately.To achieve each residence maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth.To rehabilitate residents to their fullest potential of function. individualized interventions for each resident. If the evaluation finds the resident at risk, implement resident's specific interventions/ precautions.Fall Prevention is achieved through an IDT approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Facility staff across all departments together with resident representatives and residents provide results for information with individualized care and approaches.

Based on interview and record review, the facility failed to follow their Staffing Policy by not having the appropriate staff available to meet the needs of the residents resulting in a resident (R1) fall. This failure affected one (R1) of three residents reviewed staffing.Findings include:On 4/14/26 at 12:19PM, V9 (Certified Nurse Aide) said the facility was short staffed on 3/31/26 because the facility always has three certified nurse aides for the second floor and that day there were only two certified nurse aides on the floor. V9 said the nurse for R1 was not on the floor when fall occurred, returned after 911 paramedics arrived at facility. On 4/15/26 at 11:30AM, V2 (Director of Nursing) said due to last minute call off, they were short staff on 3/31/26 only had 2 certified nurse aids on the floor, but they were scheduled to have three certified nurse aids. On 4/15/26 at 1:25PM, V11 (Agency Nurse), said the nurse for R1 was not on the floor when fall occurred. V11 said that day on 3/31/26 the second floor only had two certified nurse aides and V11 was the nurse on the opposite side of the unit. V11 said she called 911 for R1 and provided first aid. Facility Policy on Posting Direct Daily Staffing Numbers- Revised 8/2008Policy Statement I'm property will post on a daily basis for each ship the number of nursing personnel responsible providing direct care to residents. Policy interpretation and implementation At the beginning of each shift the facility shall post the nurse staffing that is as required by state and federal regulations. The information should be clear and readable format the information should be posted in a prominent place accessible to residents and visitors.Directly responsible for resident care means that individuals are responsible for resident's total care or some aspect of the residents care including but not limited to assisting with activities of daily living performing (ADLs), gastric intestinal feeds, giving medications, supervising care given by CNA's, and performing nursing assessment to admit residents or notify physicians of changes of conditions.Information shall be recorded on the form provided by the facilities administrator for each shift the information recorded on the form shall include:Name of the facilitythe date for which information is postedthe resident senses at the beginning of the shift for which the information is posted24 hour shift schedule operated by the facility the shift for which the information is postedthe type (RN, LPN, LVN, or CNA) And category licensed or non-licensed of nursing staff working during that shiftthe actual time worked during that shift for each category and the type of nursing stafftotal number of licensed and non-licensed nursing staff working for the posted shift. Computing hours of direct care staff working split shifts count only the total number of hours the individual is actually scheduled to work for the shift information being posted. (Example: You are posting data for the day shift. CNA reports to work and is scheduled to work for hours on the day shift and four hours on the evening shift. In computing the number of hours worked for that shift count only the four-hour schedule for the day shift. The remaining 4 hours would be counted toward the total on the evening shift.) The form may be typed or handwritten. If completed by typewriter or word processor, the recorded information shall be in a minimum font size of 12 points. Should the information be handwritten, it must be legible printed in black ink and must be written so that staffing data can be easily seen and read by residents, staff, visitors or others who are interested in our facility's daily staffing information. Review shifts forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location once a form is removed it shall be forwarded to the director of nursing services office and filed as a permanent record. Records of staffing information for each shift will be kept for a minimum of 18 months or as required by state law (whichever is greater). Staffing information during the reported time period shall be made available to residents, family members, and the public within 24 hours of a written or verbal request. The fee for the requested information shall not exceed the cost of copying and clerical time to retrieve the information. Inquiries concerning our direct care staffing information shall be referred to the director of nursing services or to the administrator.

Based on observation, interview, and record review the facility failed to ensure facility's daily nurse staffing information form posted at the front desk. This failure has the potential to affect 102 residents receiving care in the facility. Findings include:On 4/15/26 at 1:00PM, V10 (Receptionist) said the daily staff post last updated on 2/17/26, and stated it should be updated daily, said the person responsible for updating but has not been here.On 4/15/26 at 1:17PM, V2 (Director of Nursing) said that daily staff posting hours should be posted daily by staffing coordinator. V2 made aware the last daily staff posting was on 2/17/26. On 4/15/26 at 2:00 PM, V1 (Administrator) said the facility schedules staff based on the minimum required hours allowed, and it should reflect on the facility posting for daily staffing numbers. V1 said the daily staff posting hours should be updated daily and posted in front area, said he is aware the daily staff posting has not been updated since 2/17/26. V1 said there has been miscommunication on who is to update it since change of staff position of scheduler and new scheduler was unaware. Facility Policy on Posting Direct Daily Staffing Numbers- Revised 8/2008Policy Statement I'm property will post on a daily basis for each ship the number of nursing personnel responsible providing direct care to residents. Policy interpretation and implementation At the beginning of each shift the facility shall post the nurse staffing that is as required by state and federal regulations. The information should be clear and readable format the information should be posted in a prominent place accessible to residents and visitors.Directly responsible for resident care means that individuals are responsible for resident's total care or some aspect of the residents care including but not limited to assisting with activities of daily living performing (ADLs), gastric intestinal feeds, giving medications, supervising care given by CNA's, and performing nursing assessment to admit residents or notify physicians of changes of conditions. Information shall be recorded on the form provided by the facilities administrator for each shift the information recorded on the form shall include:Name of the facilitythe date for which information is postedthe resident senses at the beginning of the shift for which the information is posted24 hour shift schedule operated by the facility the shift for which the information is postedthe type (RN, LPN, LVN, or CNA) And category licensed or non-licensed of nursing staff working during that shiftthe actual time worked during that shift for each category and the type of nursing stafftotal number of licensed and non-licensed nursing staff working for the posted shift. Computing hours of direct care staff working split shifts count only the total number of hours the individual is actually scheduled to work for the shift information being posted. (Example: You are posting data for the day shift. CNA reports to work and is scheduled to work for hours on the day shift and four hours on the evening shift. In computing the number of hours worked for that shift count only the four-hour schedule for the day shift. The remaining 4 hours would be counted toward the total on the evening shift.) The form may be typed or handwritten. If completed by typewriter or word processor, the recorded information shall be in a minimum font size of 12 points. Should the information be handwritten, it must be legible printed in black ink and must be written so that staffing data can be easily seen and read by residents, staff, visitors or others who are interested in our facility's daily staffing information. Review shifts forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location once a form is removed it shall be forwarded to the director of nursing services office and filed as a permanent record. Records of staffing information for each shift will be kept for a minimum of 18 months or as required by state law (whichever is greater). Staffing information during the reported time period shall be made available to residents, family members, and the public within 24 hours of a written or verbal request. The fee for the requested information shall not exceed the cost of copying and clerical time to retrieve the information. Inquiries concerning our direct care staffing information shall be referred to the director of nursing services or to the administrator.

Based on observation, interview and record review the facility failed to ensure medications were administered as ordered by the physician for one of three residents (R3) reviewed for medication administration. Findings include:On 4/14/2026 at 12:40pm V12 (Nurse) observed administering medication. The electronic medication administration record on 4/14/2026 at 09:00 for R3's medications were not signed as administered.On 4/14/2026 at 12:44pm V12 and this writer observed R3 09:00am medications were not signed. V12 said, I was running late this morning I did not have a chance to sign out (R3's) medications. I know I should sign as I administer.On 4/15/2026 at 10:00am V2 (Director of Nursing-DON) said, I expect the nurses to sign out all medications as they are administered.A resident information document indicates R3 is alert and oriented two to three with forgetfulness, bed bound and dependent on staff. A diagnosis of dysphagia, cerebral infarction, dementia, hypertension, major depressive disorder. An order summary report dated 4/15/2026 for cholecalciferol 1000 units two tabs daily, clonidine 0.3mg every twelve hours, gabapentin 300mg three times a day, heparin 5000 units every twelve hours, hydralazine 10mg every eight hours hold if systolic blood pressure below 110mmHG, Keppra 100mg two times a day, a care plan intervention to administer medications as ordered and monitor for any side effects.Facility Policy: Medication Administration PolicyEffective date: NonePolicy: It is the policy of this facility to authorize licensed nursing personnel and Qualified Medication Aides to prepare and administer drugs and biologicals.Policy Specifications: To establish authorization for personnel in the administration of drugs and biologicals.Responsibility: Director of Nursing, Licensed Nursing Staff Personnel and Qualified Medication Aides.Standards:1.Drugs will be administered in accordance with orders of licensed medical practitioners in this state.17. Medications shall be recorded on the medication record promptly after each administration by the individual who administered drug.

Based on observation, interviews and record review the facility failed to implement medication self-administration policy affecting 1 of 3 (R1) residents reviewed for medication administration.Findings Include:On 3/5/2026 at 11:00AM during observation, two insulin pens (Lantus and Lispro) and Acetaminophen 325mg bottle were on top of R1's bedside table. Insulin pens and Acetaminophen bottle were not labeled. R1 said staff are aware of the medications at bedside. During the interview R1 said she's not able to self-administer insulin since she returned from hospitalization on 2/25/2026 because her hands are weak, but she was self-administering insulin and checking blood sugar before. R1 stated she's self-administering Acetaminophen/Tylenol now and facility is aware of it. On 3/5/2026 at 11:20 AM, V5 (Registered Nurse) said medications should not be left at bedside. If residents can self-administer, there should be an order and assessment. Orders reviewed with V5 and no order for self-administration for any medications was noted.On 3/5/2026 at 11:23 AM, V3 (Assistant Director of Nursing) said if resident can self-administer there should be an order, assessment and care plan.Review of R1's admission record date of 1/30/2025. Diagnosis information includes type 2 diabetes mellitus without complications. Order summary report read order date 12/9/2025 Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for Pain Do not take more than 3 gms of Acetaminophen in 24 hours from all sources. HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject 8 units subcutaneously before meals for Prophylaxis. Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 units subcutaneously at bedtime for Prophylaxis. During record review with V2 and V3 on 3/5/2026 at 12:00 PM there was no self-administration of medication assessment completed for R1. All medications did not indicate an order for self-administration. Care Plan Report, date initiated 11/1/2024 R1 is using insulin injection related to diagnosis Diabetes Mellitus. Interventions, dated 11/1/2024, modify the care plan based on patient progress and needs. Policy and ProcedureTitle: Self - Administration & Medication Storage Policy, Effective date February 2014Policy: To provide guidelines for self-administration of drugs/biologicals and their storage in the resident's room.Policy Specifications:1. Residents who request to self-administer drugs will be assessed at the time of admission or thereafter, to determine if practice is safe, based on the results of Self-Administration of Medication form.2. The assessment results will be communicated with the attending physician and an order obtained to self-administer.6. Follow-up observations of the resident self-administering medications should be performed to determine continued competency quarterly or with a significant change in condition.

Based on observation, interviews and record review the facility failed to ensure medications were safely stored, affecting 1 of 3 (R1) residents reviewed for medication storage.Findings Include:On 3/5/2026 at 11:00AM during observation, two insulin pens (Lantus and Lispro) and Acetaminophen 325mg were on top of the bedside table. Insulin pens and Acetaminophen bottle were not labeled. Insulin pens and bottles did not have an identification such as resident name, date opened and discard date. R1 said staff are aware of the medications at bedside.On 3/5/2026 at 11:20 AM, V5 (Registered Nurse) said medications should not be left at bedside. Medications should be labeled with name, date open and discard date.On 3/5/2026 at 11:23 AM, V3 (Assistant Director of Nursing) said medications should not be stored at bedside. Medications should include clear labeling. Review of R1's admission record date of 1/30/2025. Diagnosis information includes type 2 diabetes mellitus without complications. Order summary report read order date 12/9/2025 Acetaminophen Oral Tablet 325 MG (Acetaminophen), Give 2 tablet by mouth every 6 hours as needed for Pain Do not take more than 3 gms of Acetaminophen in 24 hours from all sources. HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject 8 units subcutaneously before meals for Prophylaxis. Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 units subcutaneously at bedtime for Prophylaxis. Care Plan Report, date initiated 11/1/2024 R1 is using insulin injection related to diagnosis Diabetes Mellitus. Policy and ProcedureTitle: Self - Administration & Medication Storage Policy, Effective date February 2014Policy: To provide guidelines for self-administration of drugs/biologicals and their storage in the resident's room.Policy Specifications:8. When stored in the resident's room, all medications, both legend and over-the-counter, will be stored in a locked storage unit.10. All medications/biological stored in the resident's room should be written on the Medication Administration Record (MAR) as may keep at bedside.

Based on observation, interview, and policy review, the facility failed to ensure staff donned required personal protective equipment (PPE) prior to entering rooms of residents on Enhanced Barrier Precaution (EBP) transmission-based protocol for four (R52, R100, R47, R54) of four residents reviewed for infection control is a sample of 42. This failure had the potential to expose residents and staff to the transmission of infectious agents.R52 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R52 has multiple diagnoses including but not limited to the following: encounter for attention to gastrostomy, tracheostomy status, dependence on respirator [ventilator] status. R52 is on Enhanced Barrier Precautions (EBP) transmission-based protocol R/T Trach, Vent, G-tube, Urinary catheter, Hx CRAB.R100 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R100 has multiple diagnoses including but not limited to the following: acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, dependence on respirator [ventilator] status, pneumonia due to klebsiella pneumoniae, tracheostomy status, gastrostomy status. R100 is on Enhanced Barrier Precautions (EBP) R/T Trach, Vent, G-tube, and Urinary catheter.R47 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R47 has multiple diagnoses including but not limited to the following: encounter for surgical aftercare following surgery on the digestive system, type 2 diabetes mellitus with unspecified complications. R47 is on Enhanced Barrier Precautions (EBP) transmission-based protocol R/T Wounds, and Urinary catheter.R54 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R54 has multiple diagnoses including but not limited to the following: tracheostomy status, gastrostomy status, cognitive communication deficit. R54 is on EBP: Enhanced Barrier Precautions r/t Trach, G-tube, Urinary catheter, and Wounds. Known history/recurrent MDRO CA, KPC, Acintobacter CRO; ESBL, CRE, Proteus Mirabilis, E Coli Sites: Urine, bone, wound, skin, rectal; Hx C-Diff Duration: Indefinite.On 12/15/2025 at 11:02AM while observing wound care for R47 with V13 (Wound Nurse/RN) surveyor observed V14 (Certified Nursing Assistant/CNA) entered the room to reposition and assist R54 without wearing the proper Personal Protective Equipment (PPE) for residents that are on Enhanced Barrier Precaution (EBP) transmission-base protocols. V14 (CNA) was only wearing gloves and a mask, she didn't put on a gown as required PPE for those that are on EBP transmission-based protocols. EBP signage and PPE were located at the front door of the room and V14(CNA) entered without donning a gown before having direct contact with the R54 during patient care. On 12/15/2025 at 11:20AM after wound care was complete for R47, surveyor observed V14 (Certified Nursing Assistant/CNA) enter the room without donning a gown. V14 (CNA) only put on gloves and mask to help reposition and assist R47 in bed. V14 (CNA) provided clean linens and covered R47 with a blanket while he was in bed. V14 (CNA) removed gloves and performed hand hygiene before leaving the room.On 12/15/2025 at 11:42AM surveyor observed V14 (Certified Nursing Assistant/CNA) enter R100's room without wearing the proper PPE, V14 (CNA) didn't put on a gown before entering. V14 only put on gloves and a mask before providing patient care. EBP signage was posted at the doorway and PPE bin had supplies. V14 (CNA) didn't use a gown as required for residents on Enhanced Barrier Protocols that include donning gloves, mask, and gowns while in direct contact with the resident and resident's area.On 12/15/2025 at 11:50AM surveyor observed V14 (CNA) enter R52's room without wearing the proper PPE, V14 (CNA) didn't put on a gown that was available in the bin at the entry way. V14 (Certified Nursing Assistant) proceeded to provide patient care for R52 who's on EBP precautions for vent, trach, g-tube and urinary catheter.On 12/15/2025 at 12:00PM V22 (Wound Director) said for residents that are on Enhanced Barrier Precautions (EBP) protocol staff is supposed to wear gowns, gloves, and masks when providing patient care.On 12/15/2025 at 12:20PM V17 (Respiratory Therapist) said anytime you touch a resident on EBP protocol you must wear gown, gloves, and mask.On 12/15/2025 at 12:25PM surveyor observed V14 (CNA) changed R100's linens without wearing proper PPE before entering the resident's room. R100 is on Enhanced Barrier Precautions (EBP) related to Trach, Vent, G-tube, and Urinary catheter.On 12/15/2025 at 12:30PM V14 (Certified Nursing Assistant/CNA) said when providing patient care for residents on EBP protocol you should wear gowns, gloves, and mask for protection. V14 (CNA) said it's recommended for family members when visiting to protect themselves and the resident.On 12/15/2025 at 12:35PM V12 (Licensed Practical Nurse/LPN) said residents that have g-tubes, urinary catheters, wounds, and trachs are on EBP protocols. When providing patient care you have to wear gown, gloves, and mask.On 12/16/2025 at 1:00PM V8 (Infection Preventionist) said anytime staff is providing direct care, suctioning trachs, g-tube feedings, changing linens they should be performing proper hand hygiene and wearing PPE that includes, gowns, gloves, masks. V8 said if the resident has MRSA, she expects staff to wash their hands with soap and water before and after patient contact.On 12/17/2025 at 10:45AM V3(Director of Nursing/DON) said she expects staff to gown-up, wear gloves and masks when doing patient care for residents on Enhanced Barrier Precaution (EBP) protocols. V3(DON) said any touching or direct care of g-tubes, changing diapers, trach, vent, wounds staff must put on PPE. Facility Policy titled Enhanced Barrier Precautions, revised 03/21/2024 states Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Facility Policy titled Infection Prevention and Control Program, revised 1/24/24 Guidelines: 2. Standard, transmission-based and enhanced barrier precautions to be followed to prevent the spread of infections. A. Selection and Use of PPE. B. Use personal protective equipment (PPE) including gloves and gowns. Wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment. Donning PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens.

Based on observations, interviews, and record review, the facility failed to follow maintenance work orders policy by not providing a home-like environment by not implementing an effective remedy, within the expected timeframe, to fix a broken toilet. This failure affected 1 (R1) of 3 residents reviewed for Furnishings / Equipment Not maintained.On 11/25/2025 at 10:19 AM R1 stated he notified housekeeping department, maintenance, social worker, and the administrator on October 6, 2025 that R1's toilet broke and if flushed leaks in his room. R1 stated he reported the malfunctioned toilet to the housekeeping department, maintenance director, social worker, and the administrator. R1 stated it has still not been resolved.On 11/25/2025 state agency observed a broken toilet (at the base of a manual flush valve), with no handrails attached. The toilet bowl had more than half full of yellow urine and was filthy. A transparent garbage bag halfway covering the toilet bowel. R1 stated he tried covering the toilet bowl because of the odor.On 11/25/2025 V1 (Assistant administrator), V2 (Director of Nursing/ DON), V3 (Housekeeping Director), V4 (Licensed practical Nurse/ LPN), V5 (Maintenance Director), V6 (Social Service Director), were interviewed and stated they are aware of the allegation regarding a broken toilet. V6 stated he was made aware regarding R1's broken toilet on Saturday November 22, 2025. V6 stated he placed a work order and notified maintenance regarding the broken toilet. V6 stated that he was the one who spoke to R1 regarding the room change because the R1's toilet was broken and not functioning. V6 stated R1 refused to do a room change and was educated, however R1 refused. V4 stated she has known about the broken toilet for about 2 weeks and R1 uses the bathroom across his bedroom down the hall. V1 and V5 stated there was a miscommunication regarding ordering a toilet for R1's room. V5 understood that plant operator that works for the company had ordered the toilet R1's room. V5 and V6 stated the toilet was not ordered. Both V1 and V6 stated the toilet should have been fixed immediately. V6 stated the toilet will be fixed today, 11/25/2025.Facility Policy and Procedure: Maintenance Work Orders Revised.Purpose- The purpose of this policy is to establish a clear and consistent process for reporting documenting prioritizing and resolving maintenance related issues within the facility to ensure a safe functional and compliant environment for residents' staff and visitorsScope- this policy applies to all maintenance staff facility managers department heads and any employee who identifies or reports a maintenance concern.Policy- all maintenance issues must be reported promptly document wanted accurately and addressed in a timely manner according to the priority level regulatory requirements and resident safety considerationsProcedure- Reporting a problem. Any staff member who identifies a maintenance issue must report it immediately using the facilities approved TELS Work Order System. Maintenance staff responsibility: 1. the maintenance director (or designee) must check new work orders at the start of each shift and throughout the day and be able to identify and prioritize urgent issues. 3. Any issues that cannot be resolved with the expected time frame must be escalated to the administrator. If repairs may affect resident or their routines nursing leadership must be informed offer a room change if needed compliance failure to follow this policy may result in corrective action as timely maintenance is essential for regulatory compliance and resident safety.

Based on interviews and record reviews, the facility failed to follow fall policy related to prevention of falls and implementation of resident-centered fall interventions on a resident with cognitive impairment. This failure affected one (R1) of five residents reviewed for accidents and supervision and resulted in R1 falling while walking without staff assistance and sustaining a right intertrochanteric hip fracture with associated intramuscular hemorrhage.Findings include:R1 is a [AGE] year-old, male, originally admitted in the facility on 08/20/25 with diagnoses of End Stage Renal Disease; Unsteadiness on Feet; Other Abnormalities of Gait and Mobility; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris.According to R1's census report, R1 was admitted in the facility on 08/20/25 and was discharged on 08/22/25. On 09/10/25, he came back in the facility and was considered new admission.MDS (Minimum Data Set) dated 09/19/25 documented R1 has memory problem and his cognitive skills for daily decision making is severely impaired. His functional abilities recorded that he needs supervision or touching assistance when walking 10 feet; and partial/moderate assistance when walking 50 feet with two turns. MDS also indicated that he uses a manual wheelchair.Fall risk assessment dated [DATE] categorized R1 as high risk with a score of 15.R1's admit/readmit evaluation dated 09/11/25 documented:E. Neurological: Comments - confusionM. Mobility/Safety:a. walk in room: self-performance - supervisionb. walk in corridor: self-performance - activity did not occurg. wheelchairi. gait disturbance/unsteady gait Facility's incident report dated 09/19/25 recorded: R1 had an unwitnessed fall in the hallway. R1 was observed laying on the floor on his back with his walker on the side of him. Staff did full body assessment and R1 was complaining of pain. Pain medication was offered and given. Family and on call doctor were notified and order was given to send R1 out for further evaluation. Upon checking on R1's hospital status nurse on duty spoke with emergency room nurse and was informed that R1 was being admitted for a right hip fracture.R1's hospital records dated 09/19/25 documented: Xray of hip 2 views right and pelvis: Final result - Impression: Acute comminuted displaced and angulated right intertrochanteric fracture. CT (Computed Tomography) chest abdomen pelvis without contrast: Findings: Right intertrochanteric hip fracture with associated intramuscular hemorrhage. R1 was diagnosed with closed trochanteric fracture of right femur with nonunion and acute traumatic injury of cervical spine.On 09/24/25 at 2:18 PM, V10 (Certified Nurse Assistant, CNA) stated, On 09/19/25 at 1:30 AM, I was by the nurses' station and just heard a sound like something dropped on the floor. Immediately, I stood up and went to the direction of the sound and saw him (R1) on the floor by his room. I called nurse immediately, who was at the other side of the hallway, on the east side. Nurse came immediately. R1 said he wants to walk around. He complained of pain on his hip, right side. The time he fell, he was walking out from his room. I didn't see if he was using his walker at that time. I don't remember. I didn't hear any alarm. When I did my rounds around 12ish he was sleeping on bed. That time it happened; I was the only staff on that side (west wing) where R1 was. That time it was only me and the nurse worked on the west wing. Normally, he (R1) ambulates with a walker. there's no assistance needed because he can do it by himself. He can walk around by himself. He doesn't need assistance to walk around. He has no chair or bed alarm, not that I know of.On 09/24/25 at 2:53 PM, V11 (Licensed Practical Nurse, LPN) said, That time of incident on 09/19/25, I was on 1 East, because one nurse left at 1 AM and I was the only nurse on the first floor. I had two CNAs - one in west and one in east. CNA was sitting at the nurses' station. I heard CNA called me, I went there, and I saw R1 on the floor. I did assessment. I asked him (R1) and said he was walking. I asked him about pain and showed me his right hip. I gave him PRN (when needed) pain pill. I called physician he was sent out as ordered. V11 said, He is alert, oriented to self, time and place, able to verbalize needs. he never uses call light; always sitting in his room. His room is somehow close to nurse station. At night, sometimes, he was awake and will call nurse, nurse. He usually sits in bed and will call nurse, nurse. When we go to his room, he doesn't say anything. If you tell him to sleep, he will lie in bed. I don't know if he is a fall risk, it was the second time I took care of him. I've never seen him walking with a walker, only time he had was when he had the fall.R1's room was observed across nurses' station (1West). R1's door is on the side across nurses' station.On 09/25/25 at 10:25, V12 (Registered Nurse, RN) stated, R1 is very much confused; he talks nonsense. Not able to use call light. He is very much a fall risk patient. His room was just across the station. We always monitor and check on him at least every two hours. CNAs do their rounds also. RNs and CNAs do monitor at least every two hours. I always tell my CNAs to monitor him. I do my rounds then CNAs, so more or less he is monitored and checked every hour. He gets up, he has a rollator. He is able to use rollator with supervision from staff. He uses his rollator with reminders but if not, he won't use it. His legs are weak and has unsteady gait. He needs monitoring/supervision frequently and make sure he uses the rollator when he walks.On 09/25/25 at 10:52AM, V14 (CNA)verbalized, R1 is alert but confused. Able to verbalize needs. He is not able to use call light, he uses a rollator. He is supposed to use a wheelchair. We always redirect him. He always wanted to use the rollator. He is a fall risk. We have to monitor and check on him pretty often, at least every 2 hours and when we do rounds, we check on him. He has no alarms. bed should be lowered. He has a behavior of getting up and walk, needs redirection. He needs to be reminded to use the wheelchair not rollator.On 09/25/25 at 11:14 AM, V5 (LPN/Restorative Coordinator replied, On 09/19/25 at 1:30 AM, he got up from bed, attempted to self-transfer. Did not tell nurse where he was going. The CNA heard him fall, the CNA said she was doing patient care in another patient's room. When the CNA heard it, she went to the room and found him lying on his right side, the walker was next to him. The nurse came and assessed him, he was in pain to his right hip. The nurse called the doctor and R1 was sent out to the hospital. Cause of the fall - R1 was getting up and due to unsteady gait, he fell. Staff should have done rounding/monitoring at the time to ask if he needs something. Rounding/monitoring should be every hour like nurse simultaneous with CNA doing rounds; he might need to go to the bathroom at the time because it was around 1:30 AM but no one was around, cognitively he forgot to use the call light, and he did not know his limits and walked. He gets up when he wants to and walk. He uses a walker with staff assistance. R1 definitely has confusion. Somebody has to monitor and do an hour rounding on him. R1's care plans documented the following:1. Requires restorative walking program due to his limitation in walking related to weakness (dated 09/12/25):Interventions:Discuss ambulation program with resident and responsible party.Provide staff assist with ambulation at level resident requires (e.g. set up, oversight, encouragement, cueing, physical assistance).Remind resident to not ambulate without assistance.2. Resident is high risk for falls (dated 09/11/25):Interventions:Anticipate and meet the res needs.Be sure the resident (R1) call light is within reach and encourage the resident (R1) to use it for assistance as needed. The resident (R1) needs prompt response to all requests for assistance.Educate the resident (R1)/family/caregivers about safety reminders and what to do if a fall occurs.Follow facility fall protocol.The resident (R1) uses (specify: chair/bed) electronic alarm. Ensure the device is in place as needed. R1's care plan interventions focused on his (R1) education, reminders and use of call light when assistance is needed. However, R1 is confused and forgetful. R1's Progress notes dated 09/11/25 documented in part but not limited to the following: R1 was observed up in chair, in no acute distress, eating breakfast, denies pain currently, alert and oriented to self, with noted confusion, requiring redirection per staff. On 09/25/25 at 1:19 PM, V2 (Director of Nursing) stated, He is a fall risk. He came from the hospital because of a fall. He is alert, in and out, able to hold a conversation with you. He can tell you his needs and wants but detailed conversation and remembering things, not really. He needs to be redirected. He had a fall early in the morning, like at 1:30 AM, he got up and walked. His legs gave out when he was walking using the walker. It was unwitnessed fall, so he could not be redirected.Per admit evaluation note dated 09/11/25, R1 uses a wheelchair due to gait disturbance and unsteady gait. Per care plan, R1 uses electronic alarm, but was not implemented.On 09/25/25 at 10:46 AM, V13 (Nurse Practitioner) stated, R1 is confused with place and time, he has dementia, able to verbalize needs. He sits in the wheelchair. I have not seen him walk. He is a fall risk. Rounds/monitoring should be done; making sure bed is locked; wheelchair locked; wearing non-skid socks; and follow the facility fall protocol. Facility's policy titled, Falls Guideline, dated 8/2024 documented in part but not limited to the following:Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth.The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process:I. Identification of hazards and risksII. EvaluationIII. ImplementationIV. MonitoringV. AnalysisFall risk evaluation: a fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Residents evaluated as at risk for falls will be identified and individualized fall precautions developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible.Purpose:1. To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately.3. To prevent or reduce injuries related to falls.6. Individualize interventions for each resident.Evaluation may include: Residents with recent surgery or new admission; fall history; cognitive status1. If the evaluation finds the resident at risk, implement resident specific interventions/precautions.7. All residents identified as at risk for falls will be reviewed for individualized interventions.Fall Prevention is achieved through an IDT (interdisciplinary team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Facility staff across all departments together with resident representatives and residents provide resourceful information with individualizing care and approaches.Understanding contributing and predicting factors that present will assist with determining individualized care approaches.Systems approach - Tips for Compliance:Involve interdisciplinary team (IDT) on: Individualized assessment for safety; identification of hazards; Development and implementation of interventions to reduce accidents.

Based on observations, interviews, and record review, the facility failed to notify resident's representative of discharge planning, orders, and arrangements for post-discharge care for one resident (R1) out of three residents reviewed for representative notifications. Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] to 5/22/2025 with diagnoses including but not limited to: anemia, chronic obstructive respiratory disease, heart failure, cocaine abuse, and anxiety disorder. On the (MDS) Minimal data Set assessment of 5/17/2025 Section C the BIMS (Brief Interviewed Mental Status) score was 14/15 and indicates cognitive intact. On MDS of 4/4/2025 GG Section Functional Abilities indicates R1 can wheel 150 feet: Once seated in a wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space independently. R1 can walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with setup or clean-up assistance - helper sets up or cleans up; resident completes the activity. Helper assists only prior to or following the activity. On 6/20/2025 at 11:52 PM, V3 (State Guardian) said, I sent one associate to see R1 on 6/9/2025 to the facility and R1 was discharged two weeks ago. I did not receive any update on discharge or any information about where the resident would be discharged . I spoke with V1 (Administrator) and V4 (Social Service Director) from the facility and confirmed that R1 was discharged . The facility sent me a form filled out by the physician to revoke the guardianship and the facility did not provide any court documentation that R1's guardianship was revoked. I went to the facility in January of 2025 for the first quarter assessments and visit. R1 has been under guardianship since May 9, 2022. On 6/20/2025 at 2:16 PM V4 (Social Service Director) said, I assisted R1 with discharge planning. I did not notify V3 (State Guardian) of the discharge planning for R1 before discharge. I messed up and I have to be honest with you. I should have notified the guardian, but I did not. Discharge planning is the primary responsibility of the social services, when there is no social service in the building, nursing is responsible and will call Power of Attorney/guardian or whoever the resident will appoint to assist with discharge. On 06/20/2025 at 12:27 PM V5(Vice President of Operations) said the facility does not have court documentation of the revoked guardianship for R1. I expect the staff to notify the resident's representative of discharge planning, orders, and location before the discharge. On 6/20/2025 at 4:30 PM V2 (Director of Nursing) said, I expect staff to call resident's representative/guardian to inform of discharge planning, orders, and discharge location. I do not see any records of V4 notifying the guarding under the resident's electronic notes. On 6/20/2025 at 4:30 PM V2 (Director of Nursing) provided a policy titled, Transfer and Discharge Guideline reviewed dated 10/2024. Which reads in part (but not limited to), Policy: Orientation for transfer/discharge a. The facility will provide the resident with sufficient orientation to the upcoming discharge to ensure the discharge is safe and orderly. The orientation will provide the resident or representative in a form and manner that can be understood. Notifications: Notify family/responsible party, physician, and applicable agencies (e.g., ombudsman case manager) as needed.

Based on interviews and record review, the facility failed to identify and report an allegation of sexual abuse to the facility's abuse prevention coordinator and further to regulatory state agency for one of four (R1) residents reviewed for abuse in the sample of four. Findings include: R1 is a [AGE] year-old female admitted to the facility with diagnosis including but not limited to End Stage Renal Disease; Cerebral Infarction Due to Unspecified Occlusion Or Stenosis Of Left Posterior Cerebral Artery; Depression; Borderline Personality Disorder; Suicidal Ideations; Bipolar Disorder; Torsade De Pointes; Pulmonary Hypertension; Cocaine Abuse; and Major Depressive Disorder. On 06/03/2025 at 12:12 PM R1 said, I was sitting in the hallway, in my wheelchair and I had a stuffed animal (the lion) in my lap. R2 came up to me, complemented my stuffed animal, and asked if he could touch it. I lifted the stuffed animal for R2 to see, but R2 reached out towards my private part and touched my private part instead. I reported it and talked about it every day. I notified the police to file for restraining order. The police came out about 3 weeks ago. They gave me report number, but I don't know what happened to it. I gave it to V6 (Activity Assistant). V5 (Social Service Director) confronted me in front of police officers, and asked me what time and day it happened, knowing I wouldn't know what time and day it happened. The police told me they dropped the case because no one has seen what happened. Nobody actually seen it, because nobody was around. On 06/03/2025 at 1:34 PM V6 (Activity Aid) said, R1 participates in activities but it's based on her mood. I'm familiar with R1 though. R1 never mentioned anything about R2 groping her. R1 never gave me any police report number. I don't know of R1 calling police recently. On 06/03/2025 at 2:00 PM V1 (Administrator/Abuse Prevention Coordinator) said, I never heard of the incident alleged by R1. I see R1 almost daily, she comes to my office at least weekly, but she never mentioned anything to me. Never mentioned any resident was inappropriate towards R1. If there is an abuse allegation, resident safety is our priority, then reporting and investigation. If the perpetrator is an employee, the employee would have to be suspended, and we would then complete interviews with staff and residents. On 06/03/2025 at 3:08 PM V8 (Licensed Clinical Social Worker) said, I met with R1 on 05/30/2025 to terminate services due to new corporation terminating my contract. I was seeing her for about a year and half. R1 told me, during most recent session (05/30/2025), something that occurred with another resident, allegedly, he touched her inappropriately. R1 told me police was here to investigate it. R1 said V1 (Administrator/Abuse Prevention Coordinator), and other staff knows about it. I trusted that everyone already knew. In hindsight, I realized that I should have checked if R1, in fact, reported it to other staff. I felt that if R1 said that the police were here to investigate, I couldn't have report it to anyone else. I believed and trusted R1. On 06/03/2025 at 3:15 PM V1 (Administrator/Abuse Prevention Coordinator) said, V8 (LCSW) should have reported the incident to me, but she didn't. I just found out about the incident today, from you. I will report it to the regulatory agency and initiate the alleged abuse investigation. Progress note dated 05/30/2025 10:11 AM written by V8 (LCSW) reads in part, Met with (R1) in hallway. (R1) expressed her frustration with confines of SNF environment. (R1) mentioned she was interviewed by detectives regarding an incident that happened with another resident. (V8) provided validation of feelings and a safe space to express her emotions. The facility Abuse Prevention (no date) reads in part, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence.

Based on observation, interview, and record review the facility failed to ensure ongoing assessment, monitoring is implemented to identify new skin impairment to resident who is at risk and to notify physician for appropriate wound treatment. The facility failed to follow wound care treatment as ordered by physician. The facility failed to update wound care plan for newly identified wound and notify the family member. The facility failed to follow manufacturer recommendation in using low air loss mattress. This deficiency affects all four (R2, R3, R4, R5) residents reviewed for Pressure ulcer/Wound Prevention and Treatment Management. Findings include: 1. On 4/8/25 at 9:48AM, V9 family member complaint of facility providing improper wound care to R2. On 4/8/25 at 10:12AM, Reviewed R2's medical records with V5 Wound Care Nurse (WCN) and V4 Infection Preventionist (IP). R2 was admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus with hyperglycemia, Unstageable Pressure ulcer of right buttock, Severe Morbid obesity due to excess calories, Peripheral vascular disease, Chronic obstructive pulmonary disease. Braden scale/skin assessment dated [DATE] indicated R2 is at high risk for skin impairment. Wound care physician wound assessment dated [DATE] indicated R2 acquired new identified skin impairment on Right hip, Left buttocks and Sacral. Right hip DTI pressure ulcer measures 5cmx5cmx0.1cm 80% maroon, 20% open dermis, light serosanguinous drainage. Left buttock skin tear measures 3cmx2cmx0.1cm, 100% dermis. Sacral diaper dermatitis (MASD), 100% patchy redness and excoriation. Physician order sheet indicated: Sacral cleanse with normal saline, apply zinc oxide or vit A&D ointment every shift and as needed ordered 11/5/24. R hip cleanse with normal saline, apply Medi honey, Adaptic cover with a foam or bordered gauze dressing ordered 11/6/24. Left buttocks cleanse with normal saline, apply xeroform, cover with a bordered gauze dressing ordered 11/5/24. R2's comprehensive care plan indicated R2 has alteration in skin integrity and is at risk for additional skin breakdown related to comorbidities, decreased mobility, diabetes unavoidability due to condition. Care plan was not updated, and no new intervention was formulated when R2 had 2 newly acquired skin impairment on 11/5/24 during wound rounds with physician. No documentation was found V9 Family member was notified of change in R2's skin condition. Informed V5 WCN of concern identified. V5 said V10 Wound care coordinator (WCC) usually notify the family member of any skin changes and updates the wound care plan. On 4/8/25 at 10:48AM, Informed V2 DON (Director of Nursing) of above concerns. V2 said R2's wound care plan should be updated and with new interventions for newly acquired skin impairments/pressure ulcers. V9 family member should also notify of new identified skin impairments and wound treatment management. On 4/8/25 at 12:46PM, Informed V6 Care Plan Coordinator (CPC) of above concerns. V6 CPC said she initiated wound care plan upon resident admission but V11 WCC updates the care plan and does MDS/Resident assessment wound coding. V6 said V11 should update R2's wound care plan and notify and update V9 Family member of changes in skin conditions. On 4/8/25 at 1:15PM, Informed V10 Wound Care Coordinator of above concerns. V10 said he should update R2's care plan and formulates new interventions for the new identified skin impairments on 11/5/24 during rounds with wound care physician. V10 said he did not notify V9 Family member of R2's acquired new skin impairments because R2 is alert and oriented x3. V10 said he should notify R2's family member for any changes in R2's medical condition including new acquired skin impairments and update with new wound treatment management. On 4/8/25 at 3:00PM, Informed V1 administrator of above concerns. 2. On 4/8/25 at 1:31PM, Observed R3 lying in bed with low air loss mattress. R3 was connected to oxygen via nasal cannula at 2 LPM (liters per minute). R3 is alert and oriented x 3, able to express and verbalize needs to staff. V5 and V12 repositioned R3 to her left side lying position. V5 removed bordered gauze dressing on sacral area with minimal serosanguinous drainage. V5 cleansed with NSS (Normal saline solution). V5 said R3 has stage 4 sacral pressure ulcer with clean wound 100% reddish pink tissue granulation. V5 applied hydrogel then apply Permacol/collagen and covered with foam dressing. Informed V5 of observation made during wound dressing bordered gauze dressing removed from R3 prior to wound care and he applied foam dressing. V5 was also informed no soft gel like sheet was observed when he removed the bordered gauze dressing. (Gauze dressing is absorbent and used for covering and protecting wounds while foam dressing creates moist environment, absorb moderate to heavy exudate, and provide cushioning, particularly for wounds with bony prominences). Permacol/collagen dressing absorb wound exudate and convert into soft gel like sheet which helps maintain a moist wound environment conducive for healing). V5 said R3 should have foam dressing as ordered instead of gauze dressing. R3 was admitted on [DATE] with diagnosis listed, in part, but not limited to Stage 4 Sacral pressure ulcer, Diaper dermatitis, Type 2 Diabetes Mellitus, Severe morbid obesity, End stage renal disease, Acute respiratory failure. Admission Braden scale/skin assessment indicated at R3 is at risk for skin impairment. Physician order sheet indicated Sacrum cleanse with NSS, apply wound gel and cover with collagen sheet, secure with bordered foam dressing. On 4/9/25 at 9:37AM, Informed V2 DON and V4 IP of above concern. V2 DON said they should be following physician order in providing wound treatment to resident. 3. On 4/8/25 at 1:50PM, Observed R4 lying in bed with low air loss mattress. R4 is alert and oriented x 3, able to express and verbalize needs to staff. He has right upper PICC line connected to IVPB (Intravenous piggy bag) antibiotic. He has right heel dressing connected to wound vac machine. He has right heel boot. V5 said R4 is recently admitted from hospital with IVPB antibiotics due to infected vascular wound on right heel. Observed V12 CNA entered the room without proper PPE for EBP, she did not wear gown. V5 WCN and V12 repositioned R4 to his left side lying position. V5 removed sacral bordered gauze dressing soaked with heavy greenish brown wound drainage. V5 cleansed all 3 wounds with NSS. V5 said R4 has stage 4 on the following locations: Right ischium and sacral area has 90% granulation tissue and 10% of slough formation. Left ischium has 80% tissue granulation and 20% slough formation. V5 apply the following to all 3 wounds: Medi honey, then calcium alginate and covered with foam dressing. Informed V5 of observation made during wound care bordered gauze dressing was removed from all wound dressing prior to wound care, and he applied foam dressing. Informed V5 that V12 did not wear proper PPE during wound care. V5 said R4 should have gauze dressing as ordered instead of foam dressing. V5 said V12 should wear gown in addition to gloves and mask. R4 was admitted on [DATE] with diagnosis listed in part but not limited to Acute osteomyelitis, Stage 4 sacral pressure ulcer, Paraplegia, Acute embolism, and thrombosis of deep vein of lower extremities, Atrial fibrillation, Congestive heart failure. Admission Braden scale/skin assessment dated [DATE] indicated at risk for skin impairment. Active physician order sheet indicated: Left ischium cleanse with NSS, pat dry, apply medical grade honey, calcium alginate and cover with bordered gauze dressing every day and PRN. Right ischium cleanse with NSS, pat dry, apply medical grade honey, calcium alginate and cover with bordered gauze dressing every day and PRN. Sacrum cleanse with NSS, pat dry, apply medical grade honey, calcium alginate and cover with bordered gauze dressing every day and PRN. Low air loss mattress. On 4/9/25 at 9:37AM, Informed V2 DON and V4 IP of above concern. V2 DON said they should be following physician order in providing wound treatment to resident. 4. R5 was admitted on [DATE] with diagnosis listed, in part, but not limited to Idiopathic peripheral autonomic neuropathy, Type 2 Diabetes Mellitus, Methicillin resistant staphylococcus infection, Hypertension with chronic kidney disease with heart failure, Chronic venous insufficiency, Dependence on renal dialysis. Braden scale/skin assessment dated [DATE] indicated at risk for skin impairment. Active physician order sheet indicated: Right lower abdomen cleanse with NS, apply skin prep cover with hydrocolloid every MWF and as needed for skin tear. Scrotum cleanse with NS, apply collagen and calcium alginate leave open to air every other day and PRN. Metro cream external cream 0.75% apply to sacral topically every day shift and PRN for MASD cleanse with NS, apply metro cream, Vit A & D ointment and Zinc oxide leave open to air. Nystatin powder 100,000 unit/gm apply to scrotum topically two times a day for Candida scrotum. Zinc oxide ointment apply to affected area topically two time as day and PRN. Wound care plan indicated he is at risk for alteration in skin integrity related to incontinence of bladder and bowel, impaired mobility status, decreased sensory perception, comorbidities, failure to thrive, PVD, End stage disease process. Interventions: Skin will be checked during routine care on a daily basis and during the weekly/biweekly bath or shower schedule. Any skin integrity tissue concerns will be conveyed to the charge nurse for further evaluation and or treatment changes/new interventions and the MD will be called PRN. Provide low air loss mattress. On 4/8/25 at 2:07PM, Observed R5 lying in bed with low air loss (LAL) mattress. R5 had flat sheet and folded thick cloth bath blanket in quarters over the mattress. Observed Nystatin topical power bottle 100,000 units per gram at bedside, labeled indicated apply to scrotal area twice a day. R5 wears disposable brief. Showed observation to V5 WCN and V12 CNA/Wound Tech. Both said R5 should only be on flat sheet over the LAL mattress. R5 said he did not request to have folded bath blanket over the mattress. R5 is alert and oriented x 3, able to express and verbalize needs to staff. R5 has morbid obese abdomen. R5 said his abdominal folds hurts, left hip and sacral area. R5 said they apply zinc oxide to his sacral area. R5 said they apply nystatin powder to his abdominal folds. R5 said he did not receive wound treatment yesterday. V12 said nystatin power is left at bedside for the CNA to apply. V5 said nystatin powder should not be left at bedside and CNA cannot apply it. V5 said treatment was not done because R5 was in dialysis yesterday. V5 said R5 has MASD on sacral area and healed right side abdominal skin tear. V12 repositioned R5 to his right side. Observed excoriation on sacral area with bleeding. Blood stained observed on disposable brief and folded bath blanket. Observed excoriation on left side of the abdominal folds and open wound on left hip. V5 said the excoriation on left side of abdomen and open left hip are new to him. V5 said R5 has metro cream, zinc oxide and Vit A & D ointment to his sacral area. Observed V5 prepare wound treatment for R5. Observed metro cream prepared obtained from another resident's medication. Informed V5 of observation made. V5 searched the treatment cart but could not find R5's metro cream medication. V5 said it's probably in another treatment cart. V5 left the treatment cart with open drawer and unlocked. V5 returned and said he could not find R5's metro cream medication. Informed V5 he left his treatment cart opened and unlocked. V5 said, treatment cart should be kept locked when not in sight. V5 took single use packet of zinc oxide and Vit A & D ointment from the cart. V5 apply zinc oxide to sacral area without cleansing with NSS. Called attention of V5 he applied the treatment without cleaning. V5 apologized and cleansed the sacral wound with NSS, apply zinc oxide and Vit A & D. V5 said R5 did not have metro cream medication. On 4/8/25 at 2:15PM, V5 said left excoriation of left abdominal fold and open wound on left hip are new. Surveyor requested to assess the entire abdominal folds. R5 has obese abdomen. V12 lifted the abdominal folds and observed accumulation of dried powered in the abdominal folds with foul odor. V12 cleansed abdominal folds with wipes. Observed excoriation in the entire abdominal folds with bleeding. R5 said he has had these excoriations for almost 2 weeks, and it hurts. R5 said V11 WCN and CNAs applied nystatin powder to his abdominal folds. V5 obtained measurement of 48cm x 3cm x 0.1cm. V5 applied calcium alginate and covered with bordered gauze dressing. V12 repositioned R5 to his right side. V5 measured left hip open wound and obtained 1cm x 1.5 x0.1cm, 100% red tissue granulation with minimal bleeding. V12 repositioned R5 to his back. Observed red, swollen, and excoriated scrotum with minimal bleeding. R5 has indwelling catheter with greenish brown sediments with blood visible to the tubing connected to urinary drainage bag. V5 cleansed with NSS, apply collagen, calcium alginate and leave it open to air. On 4/8/25 at 2:49PM, V13 LPN said he is the assigned nurse for R5. V13 said the treatment nurses do the wound treatment for R5. V13 is not aware of new skin impairment on R5's abdominal folds excoriations and left hip open wound. V13 said V14 CNA is the assigned CNA for R5 and did not report any new skin impairments to V13. On 4/8/25 at 3:00PM, Informed V1 of above concerns identified. On 4/8/25 at 4:46PM, V14 CNA said she has taken care of R5. V14 said she just returned to work from vacation yesterday. V14 said she applied zinc oxide to R5's sacral area and nystatin powder to abdominal folds. V14 said he observed R5's excoriation on abdominal folds 2 weeks ago with V11 WCN. V14 said she did not inform the floor nurse of abdominal excoriation because V11 is aware of it. V14 said she is aware any resident's new skin impairment should be reported to the nurse. On 4/9/25 at 9:37AM, Informed V2 DON and V4 IP of above concerns identified they failed to fail to ensure ongoing assessment, monitoring are implemented to identify new skin impairment to resident who is at risk and to notify physician for appropriate wound treatment The facility failed to follow wound care treatment as ordered by physician. The facility failed to update wound care plan for newly identified wound and notify the family member. The facility failed to follow manufacturer recommendation in using low air loss mattress. V2 DON said they should implement their policy in wound/skin assessment, prevention, treatment management. On 4/9/25 at 11:25AM, V11 WCN said he provided wound care to R5 on 4/6/25. V11 observed redness on abdominal folds not excoriation and applied zinc oxide ointment. V11 denied applying nystatin powder. V11 said he did not document his observation on abdominal folds. Reviewed R5's physician order for wound/skin treatment and facility's policy in wound care. On 4/9/25 at 1:30PM, Informed V1 Administrator of above concerns. Facility's policy on Wound Care reviewed 8/1/24 indicated: Policy statement: To provide wound care treatments/services based on standards of care under the direction of a physician. 1. Risk assessment and prevention: b. Skin checks will be performed on a routine basis and PRN (As needed) 2. Wound assessment and documented tool a. Assess when a wound I identified, weekly and or as needed. 4. Continued/ongoing treatment a. The nurse will provide wound care per <D/NP for orders/treatment. c. Wound cleansing may be performed to removed foreign debris and surfaces contaminants from the wound. Wound may be cleansed prior to the administration of topical treatments as per MD/NP orders. Facility's policy on Skin management: Specialty mattress Guidelines for the use of specialty mattresses Low air loss: Stage 3, stage 4, Unstageable, DTI to the buttock, multiple stage 2, very high risk with multiple co-morbidities or residents who need this type of mattress for comfort. Procedure: 1. As per manufacturer guideline, no more than 1 piece of linen will be placed between the mattress and the resident. Facility's policy on Care plan policy reviewed 5/21/24 indicated: Policy statement: To meet the resident's physical, psychosocial and functional needs, facility will develop and implement a comprehensive, person-centered care plan for each resident includes measurable objectives and target goals. Procedure: 10. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to verify and obtain one resident's (R1) state guardian information. This failure resulted in the facility failing to notify the correct guardian and obtaining consent from resident's family for one of three residents reviewed for social services. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, tracheostomy, dysphagia and substance abuse. R1's face sheet dated 1/14/25 documents under contacts: V4 (R1's family) as emergency contact one. V8 (state guardian) listed as third contact. R1's admission paperwork dated 11/19/24 documents: V8 as legal guardian with different phone number listed when compared to R1's face sheet. On 1/21/25 at 11:56AM, V3 (R1's state guardian) said they have not been notified of any concerns, consents, hospitalization for R1 since admission to the facility in November. On 1/23/25 at 12:35PM, V3 said although a person is assigned to a resident all agents can act on the behalf of the resident. V3 said if the facility was having difficulty in contacting the assigned agent, the facility should have contacted the main office to speak to management or another agent for any concerns. On 1/22/25 at 1:07pm, V6 (Social service) said upon admission they will verify resident information with hospital records, resident and/or family. V6 said she left messages for V8 (state guardian) with no return calls. V6 said social service is responsible for obtaining guardian paperwork at time of admission. V6 said they usually will get paperwork at initial care plan meeting within a week of admission. V6 said she does not recall reaching out to the main number at state guardian's office. V6 said R1's sister was being notified for all information pertaining to R1. On 1/22/25 at 1:48PM, V7 (social service director) said, Within 72 hours of admission, staff meet with resident and reach out to family or representative. If a resident has a guardian, we make sure the contact information is in the medical record, we will reach out to the guardian and schedule meeting with them within week of admission. Staff are supposed to reach out the obtain guardian paperwork upon admission. V7 said he was aware of staff not being able to contact V8 (former state guardian) but said he did not call anyone else to ask about R1's guardian. R1's consent for psychotropic medication dated 12/9/24 documents: V4(R1's family) gave phone consent. R1's progress note dated 12/9/24 documents: consent given by V4(R1's family) through phone call for Lorazepam Tablet 0.5 MG every 8 hours as needed. General update given to the V4. R1's progress note dated 1/6/25 documents: This writer spoke with V4 (R1's family) in regard to transfer to another facility. V4 (R1's family) verbalized understanding of transfer/discharge process. Would appreciate any communication. R1's progress note dated 1/4/25 documents: V4 (R1's family) notified with room change and sputum culture partial result. R1's progress note dated 12/22/24 documents: resident received back from the local hospital. R1 was seen and examined at bedside by Nurse Practitioner with new order hydroxyzine 25 mg every 6 hours. V4 (R1's family) called and updated will all new orders and consented hydroxyzine to be given. Facility social service responsibilities undated documents: maintain standard of documentation in the resident's records, including initial assessment note and as needed; Coordinate with outside agencies such as case managers, insurance agencies and the ombudsman and state and public guardian for the continuity of care. Facility policy on Adult Guardianship in Illinois undated documents: The facility will reach out upon admission to guardian, including the identified representative. The guardian contact information shall be identified in the clinical record along with documents proving guardianship. Facility policy titled Resident change in condition reviewed 2/2/24 documents: Regardless of the residents current mental, medical or physical condition a nurse or provider will inform the resident and residents representative/guardian of any changes in his/her condition, any incident or accident, including changes in medical care or nursing treatments.

Based on observation, interview, and record review, the facility failed to ensure an enteral feeding was administered as ordered for three (R5, R10, R12) of six residents reviewed for enteral feeding in the sample of 14. This failure resulted in R10 sustaining insidious weight loss of seven pounds in one month. Findings include: 1. On 12/13/24 at 10:28 AM, R10 was in bed sleeping with an enteral feeding connected and running at 60 ml/hr. On 12/13/24 at 11:50 AM, R10 was in bed with an enteral feeding connected and running at 60 ml/hr. On 12/13/24 at 12:50 PM, V5 Registered Nurse reviewed R10's orders and said R10's enteral feeding should be Glucerna 1.5 running at 65 ml/hr. V5, with this surveyor, observed R10's enteral feeding running at 60 ml/hr. V5 said this rate is wrong and changed the rate to 65 ml/hr. V5 said R10 is NPO (nothing by mouth) and is tube fed only. R10's Physician Orders dated 6/13/24 shows, NPO diet and an order dated 6/24/24 for Enteral Feed Order one time a day for nutrition Glucerna 1.5 @65 ml/hr. x 22 hours. R10's Dietary Progress Note dated 11/12/24 shows, Current body weight 160 #. Tube feeding meeting 100% estimated needs and appears adequate for needs as evidenced by weight maintenance. Therapeutic tube feed formulary for blood sugar control along with insulin. Well, hydrated per October labs. Weight stable. R10's Weights and Vital summary shows on 11/5/24 R10's weight was 160 pounds and on 12/3/24 R10's weight was 153 pounds (a decrease in 7 pounds in approx. 1 month.) On 12/13/24 at 12:44 PM, V11 Nurse Practitioner said resident's enteral feeding should be run according to the physician orders which are based on the dietician's recommendations. V11 said the rate provides the necessary nutrition to prevent weight loss and the formula provides the correct electrolytes needed by the resident based on their medical conditions. 2. On 12/13/24 at 10:40 AM, R12 was in bed sleeping with her enteral feeding Glucerna 1.5 connected and running at 70 ml/hr. On 12/13/24 at 11:55 AM, R12 was in bed with family at the bedside. R12's enteral feeding Glucerna 1.5 was connected and running. R12's Physicians Orders dated 11/26/24 shows, Enteral Feed Order: every shift Glucerna 1.2 at 80 ml/hr. x 22 hours (on at 7 AM, off at 5 AM). R12's Physician Order dated 11/19/24 shows NPO diet. On 12/13/24 at 12:32 PM, V10 Registered Nurse said R12's enteral feeding is supposed to be Glucerna 1.2 at 80 ml/hr. V10, with this surveyor, observed R12's feeding that was running. V12 said the feeding was the wrong formula and it was running at the wrong rate. V12 changed R12's enteral feeding to the correct formula and the correct rate. V10 said the night nurse started the feeding at 2:00 AM. On 12/13/24 at 12:39 PM, V2 Director of Nursing said enteral feedings are to be administered according to the physician order to provide the proper nutrition and the formula is specific to the resident's diagnoses. 34117 3. On 12/13/24 at 10:07 AM, R5 was observed lying in bed, his enteral feeding Osmolite 1.5 was infusing at 75ml (milliliter) /hr. (hour). At 12:11 PM, R5 was lying in bed, his enteral feeding remained infusing at 75 ml/hr. R5 was eating his noon meal. He was served two hot dogs and mashed potatoes for the noon meal. He had consumed about 90 % of his meal. R5 said he is not sure when his tube feeding gets disconnected, he is getting the tube feeding because he had poor intake. On 12/13/24 at 12:18 PM, V13 (RN) said enteral feedings orders should be followed according to the prescribed order. She said R5's intake was poor and was receiving the enteral feeding to supplement his intake. V13 said R5's enteral feeding should be off at 5:00 AM and on at 9:00 PM. Night shift staff should have stopped his feeding. She said she saw R5's feeding was infusing and did not know it was supposed to be off. Infusing to much could put the resident at risk for fluid overload. R5's Physician Order Sheets (P.O.S.) dated through December 2024 shows he is [AGE] year-old male with diagnoses including COPD, heart disease, congestive heart failure, asthma, Crohn's, and hypertension. The P.O.S. shows orders for enteral feed order Osmolite 1.5 at 75 ml/hr. x 8 hours. Off at 5:00 AM and ON at 9:00 PM. The facility's Tube Feeding Policy reviewed date 2024 states, Nasogastric, gastrostomy and jejunostomy tube are used when an alternate method of nutrition is needed .all tube feeding orders will include the formula, rate, time period, delivery method and flush . feeding pump: turn on pump, set prescribed rate and start feeding .

Based on observation, interview, and record review the facility failed to follow physician order in providing wound treatment. The facility failed to implement wound prevention management. The facility also failed to follow manufacturer recommendation in using low air loss mattress for resident with multiple stage 4 pressure ulcers. This deficiency affects all five (R1, R4, R5, R6 and R7) residents reviewed for Wound care management. Findings include: On 11/12/24 at 11:28AM, Observed R1 lying in bed with tracheostomy connected to oxygen. He has gastrostomy feeding and indwelling catheter. He has low air loss mattress (LAL). V5 WCN (Wound care nurse) was preparing wound care to R1 assisted by V7 Wound Tech and V8 CNA (Certified Nurse Assistant). Observed folded bath blanket in quarters and flat sheet over the LAL mattress. R1 wearing disposable brief. V5 said, R1 should only have flat sheet over the mattress. V8 CNA said, she did not put it, it was from the night shift. V6 LPN said, he did not notice the multilayers of linen when he administered R1's medication this morning. Observed R1 does not have bilateral heel protectors. V5 said, R1 should have bilateral heel while on bed as preventive measures. V8 said, she did not put the bilateral heel protectors because the BP cuff is placed on R1's right ankle and the pulse oximeter is placed on right great toe. V5 WCN provided wound care to R1. V5 cleansed all wound (left hip, left ischium, Sacrum, and right ischium) with Dakins solution and applied wet to dry Dakins dressing. V5 said, R1 has multiple stage 4 pressure ulcers namely: Left hip with 60% non-granulating tissue and 40% slough; Left ischium with 80% granulating tissue and 20% non-granulating; Sacrum with 70% non-granulating and 30% slough; Right ischium with 60% slough and 40% non-granulating. At 11:52AM, V5 WCN removed dressing on back of the head. V5 said, R1 has stage 3 pressure ulcer at the back of his head with 40% non-granulating and 60% slough. V5 cleansed with Dakins solution, applied calcium alginate, and covered with bordered gauze dressing. R1 was readmitted on [DATE] with diagnosis listed in part but not limited to Spastic quadriplegic Cerebral palsy, Acute and chronic respiratory failure, Type 2 diabetes Mellitus with other skin ulcer, Stage 4 pressure ulcer on sacral region, left hip, right buttock, left buttock and stage 3 back of head, Tracheostomy, Gastrostomy. Admission and most recent Braden scale skin assessment indicated that he is at very high risk for developing skin impairment. Active physician order indicates Stage 3 Posterior back of head cleanse with normal saline pat dry, apply skin prep then Adaptic and calcium alginate and cover with a foam or bordered gauze dressing every day and as needed. Stage 4 left ischium cleanse with 1/4 strength Dakins solution, apply moist saline gauze cover with bordered gauze every day shift and as needed. May apply Metrocream for contamination from feces. Stage 4 right ischium cleanse with 1/4 strength Dakins solution, apply moist saline gauze cover with bordered gauze every day shift and as needed. Stage 4 sacrum cleanse with 1/4 strength Dakins solution, apply moist saline gauze cover with bordered gauze every day shift and as needed. May apply Metrocream for contamination from feces. Comprehensive care plan indicates that he has alteration in skin integrity and is at risk for additional skin breakdown related to comorbidities, decreased mobility, decreased nutrition, decreased sensory perception, incontinent bladder and bowel, unavoidability due to condition. Interventions: Off load heels with heel protectors or pillow and per physician orders. Provide low air loss mattress. He requires dependent assist of 1-2 staff members in regard to his functional and cognitive impairments. On 11/13/24 at 10:38AM, V14 Wound Care Nurse Practitioner said he expects that facility will follow physician's order in performing wound care, will implements the wound care prevention and treatment management such as using of LAL mattress and heel protectors. V14 said, LAL mattress manufacturer recommendation of using 1 flat sheet over the mattress. On 11/14/24 at 10:50AM, Informed V2 ADON and V3 Infection Coordinator of the above concerns identified: 1. failed to follow manufacturer recommendation in using low air loss mattress for all 5 residents (R1, R4, R5, R6 and R7) with multiple stage 4 pressure ulcers. 2.V5 WCN failed to follow physician order in providing wound treatment for R1. V5 used Dakins solution for cleansing and applying wet to dry dressing to R1's left hip, left ischium, sacrum, and right ischium. However, physician order was to apply moist saline gauze after cleansing with Dakins solution. 3. Failed to apply bilateral heel protectors as indicated in care plan for pressure ulcer prevention. Both V2 and V3 said, they should follow physician's order in performing wound care, they should implement the wound care prevention and treatment management such as using of LAL mattress and heel protectors. Both said, LAL mattress manufacturer recommendation of using 1 flat sheet over the mattress. R4 On 11/12/24 at 11:57AM, Observed R4 lying in bed with LAL mattress. V5 WCN checked LAL mattress covering and observed folded bath blanket in quarters and flat sheet over the mattress. R4 is wearing disposable brief. V5 said, R4 should only have 1 flat sheet over the LAL mattress. R4 was readmitted on [DATE] with diagnosis listed in part but not limited to Metabolic encephalopathy, Chronic respiratory failure, Type 2 Diabetes Mellitus, Cerebrovascular disease, Limitation of activities due to disability, Dependence on respiratory (ventilator) status, Severe protein calorie malnutrition. Admission and most recent Braden scale skin assessment indicates that she is at high risk for skin impairment. Active physician order indicates Metrocream external cream 0.75% (metronidazole topical) apply to sacrum topically every day shift and as needed for Stage 4 pressure injury cleanse with 1/2 strength Dakins solution, apply Metrocream, Adaptic cover with border gauze or foam dressing. Left anterior lower leg, left foot 5th toe, left heel, left lateral ankle, left lateral lower leg, right 2nd toe, right 5th toe, right ankle lateral/outer, right distal lateral foot, right lateral foot, right great toe hallux, right heel, right medial ankle, right medial foot cleanse with normal saline (NS), pat dry, paint with betadine and cover with 4x4 or ABD pad wrap with kerlix and secure with tape every day shift every Mon, Wed, Fri and as needed. Left ischial tuberosity cleanse with 1/2 strength Dakins solution, pat dry, apply Metrocream, Adaptic cover with bordered gauze dressing every day shift and as needed for stage 4 pressure injury. Right ischial tuberosity cleanse with 1/2 strength Dakins solution, pat dry, apply calcium alginate cover with bordered gauze dressing every day shift and as needed for stage 4 pressure injury. Comprehensive care plan indicates she has alteration in skin integrity and at risk for additional skin breakdown related to comorbidities, decreased mobility, decreased nutrition, decreased sensory perception, diabetes, incontinent bladder, and bowel. Intervention: Low air loss mattress. She requires dependent assist of 1-2 staff members in regard to her functional mobility and ADLs related to physical and cognitive impairments. R6 On 11/12/24 at 12:00PM, Observed R6 lying in bed with LAL mattress. V5 WCN checked LAL mattress covering and observed folded linen in quarters and 2 disposable bed pads over the mattress. R6 is wearing disposable brief. V5 said, R6 should only have 1 flat sheet over the LAL mattress. R6 was admitted on [DATE] with diagnosis listed in part but not limited to Hydrocephalus, Acute and chronic respiratory failure with hypercapnia, Human immunodeficiency virus disease, intracerebral hemorrhage, Stage 4 pressure ulcer of sacral region, contracture of muscle right and left upper arm. Admission and most recent Braden scale skin assessment indicates that she is at high risk for skin impairment. Active physician order indicates Left elbow cleanse with NS, apply Medihoney cover with a bordered gauze or foam dressing every day shift and as needed for cellulitis. Left and right ischium, right trochanter, and sacrum cleanse with NS, apply collagen sheet /powder or Adaptic and calcium alginate cover with a bordered gauze or foam dressing every day shift and as needed for stage 4 pressure injury. Low air loss mattress. Comprehensive care plan indicates he has alteration in skin integrity and is at risk for additional skin breakdown related to disease process, impaired mobility, and incontinence. He requires dependent assist 1-2 staff members in regard to his functional mobility and ADLs related to physical and cognitive impairments. R5 11/12/24 at 12:04PM, Observed R5 lying in bed with LAL mattress. V5 WCN checked LAL mattress covering and observed folded linen in quarters and cloth bed pads over the mattress. R6 is wearing disposable brief. V5 said, R5 should only have 1 flat sheet over the LAL mattress. R5 was admitted on [DATE] with diagnosis listed in part but not limited to Chronic respiratory failure with hypoxia and hypercapnia, Type 2 Diabetes Mellitus, Persistent vegetable state, Stage 4 pressure ulcer of sacral region, tracheostomy, gastrostomy. Admission and most recent Braden scale skin assessment indicates that she is at high risk for skin impairment. Stage 4 pressure injury on Sacrum cleanse with NS, pat dry, apply Medihoney, Adaptic, calcium alginate cover with foam dressing or similar every day shift and as needed. May apply Metrocream external .75% (Metronidazole)topically as needed for contamination from feces. Comprehensive care plan indicates he has alteration in skin integrity upon admission to sacrum stage 4 and is at risk for additional skin breakdown related to chronic disease process, impaired mobility, and bowel movement. Intervention: Provide pressure reducing/relieving mattress. He requires dependent assist 1-2 staff members in regard to his functional mobility and ADLs related to physical and cognitive impairments. R7 On 11/12/24 at 12:07PM, Observed R7 lying in bed with LAL mattress. V5 WCN checked LAL mattress covering and observed folded linen in quarters and cloth bed pad over the mattress. R6 is wearing disposable brief. V5 said, R6 should only have 1 flat sheet over the LAL mattress. R7 was admitted on [DATE] with diagnosis listed in part but not limited to Anoxic brain damage, Acute respiratory failure with hypoxia, Type 2 Diabetes mellitus, Cerebral infarction, End stage renal disease, Tracheostomy. Admission and most recent Braden scale skin assessment indicates that she is at high risk for skin impairment. Active physician order indicates Metrocream external 0.75% (Metronidazole) apply to sacrum to both buttocks topical every day shift and as needed for stage 3 pressure injury cleanse with NS, apply Metrocream and calcium alginate cover with bordered gauze or foam dressing. Comprehensive care plan indicates she has alteration in skin integrity and at risk for additional skin breakdown related to comorbidities, decreased mobility, decreased nutrition, decreased sensory perception, incontinent bladder, and bowel, unavoidability due to condition. Intervention: Low air loss mattress. She requires dependent assist of 1-2 staff members related to physical and cognitive impairments. Facility's policy on Wound care reviewed 8/1/2024 indicates: Policy statement: To provide wound care treatments/services based on standards of care under the direction of a physician. 1. Risk assessment and prevention a. implement interventions to prevent development of pressure injuries 2. Wound assessment and documentation tool d. Re-assess need for interdisciplinary services and appropriate DME (Durable medical equipment) -air mattress, heel protectors, positioning devices/wedges, etc. Facility's policy on Skin management: Specialty mattress review date 5/2023 indicates: Guidelines for the use of specialty mattresses: The following are guidelines for the use of specialty mattress, however, the facility wound care nurses, DON, and physician will continue to use their professional judgement to determine the type of mattresses most appropriate for the individual resident. Low Air Loss: Stage 3, stage 4, unstageable, DTI to the buttocks, multiple stage 2, very high risk with multiple co-morbidities or residents who need this type of mattress for comfort. Procedure: 1. As per manufacturer guideline, no more than 1 piece of linen will be placed between the mattress and the resident Facility's policy on Physician orders reviewed 2/28/24 indicates: Guidelines: 4. The RN/LPN will follow physician/practitioner's order as written per the resident's POS (Physician order sheet).

Based on interview and record review the facility failed to protect the resident from unwelcome physical touch of another resident to her shoulder. This deficiency affects one (R3) of three residents reviewed for Abuse prevention Program. Findings include: On 11/12/24 at 12:20PM, Observed R2 sitting on bed in his room. He is alert and oriented, able to express himself. He denied complaint allegation of R3. He refused to talk about the allegation. On 11/12/24 at 12:32PM, Observed R3 receiving dialysis treatment monitored by V12 Dialysis Nurse in the dialysis room. R3 was sleepy and refused to be interviewed. On 11/12/24 at 1:38PM, V1 Administrator denied complaint allegation of R3 that R2 touched R3's left breast in the elevator. V1 said, their final investigation of facility reported incident revealed that on 10/25/24 after lunch time, both R2 and R3 were together in the elevator. Both are able to use and operate the elevator for transport, no other person was in the elevator when the incident happened. Both were facing the elevator door. When the elevator opened on the first floor. R3 did not moved. R2 tapped both R3's shoulder and signaling to R3 that he wanted to get out the elevator. R3 got out of the elevator first then R2 got out the elevator next. Later during therapy, R3 mentioned that she was touched by R2 inappropriately in the elevator. R3 denied any pain or physical discomfort. Skin assessment was done with no skin alteration. R3 verbalized feeling safe at the facility. Staff and resident were interviewed. Both residents were sent to the hospital for evaluation and returned to the facility a few hours later with no new orders. R2 is in 2nd floor and R3 is in 3rd floor. Both residents are monitored for safety. Police report completed and filed. It was determined that R2 and R3 were together in the elevator. Misdemeanor complaint was filed by [NAME] County Sheriff's police against R2 under case No. SH-24-00396164 for Battery/Physical contact with the court date on [DATE]. Review R3's initial and final incident report -unwelcome touch to IDPH dated 10/25/24 and 10/30/24. Review [NAME] County Sheriff's police report dated 10/25/24 against R2 for Misdemeanor complaint of Battery/Physical contact. On 11/13/24 at 9:30AM, V3 Infection Coordinator said R3 was sent to the hospital for evaluation due to change of clinical condition. On 11/13/24 at 10:00AM, Informed V1 Administrator of concern identified of failure to protect R3 from R2's unwelcome touched to her shoulder in the elevator. On 11/14/24 at 9:28AM, V3 Infection Coordinator said that R3 was admitted with diagnosis of Hypoglycemia and Pneumonia. R3 is admitted to the facility on [DATE] with diagnosis listed in part but not limited to Toxic encephalopathy, Chronic respiratory failure with hypoxia, End stage renal disease, Generalized anxiety disorder. Active physician order indicates she is on Buspirone HCL 5mg 1 tablet by mouth two time a day for anxiety related to adjustment disorder with mixed emotion and depressed mood. Mirtazapine 15mg 1 tablet by mouth at bedtime for depression. Olanzapine 5mg 1 tablet by mouth at bedtime for bipolar disorder. Comprehensive care plan indicates that she is at risk for abuse (physical, mental, sexual, verbal, financial involuntary seclusion, neglect, exploitation, and misappropriation of property). She has impaired cognitive function or impaired thought processes related to disease processes of anoxic brain injury, cognitive communication disorder, adjustment disorder, depression and dysphagia, impaired decision making, neurological symptoms. She has a behavior problem related to younger age and being at nursing home. She was caught involved with another resident. She disclosed allegations of inappropriate physical contact by another resident. R2 is readmitted on [DATE] with diagnosis listed in part but not limited to Metabolic encephalopathy, Acute and chronic respiratory failure with hypercapnia, Type 2 Diabetes Mellitus, Bipolar disorder, Cognitive communication deficit, Schizophrenia, Opioid dependence with withdrawal. Comprehensive care indicates that he is an identified offender, He has history of criminal behavior. He has demonstrated stability during the admission screening process, does not appear to present an unusual risk and is therefore considered appropriate for admission. According to the available history he was convicted of possession of illegal substances and multiple thefts. Behavior care plan indicates that he is sexually preoccupied and focused on female staff. He is exposing himself while sitting in wheelchair by the entrance to his room. He has potential to demonstrate physical behaviors related to poor impulse control as evidenced by grabbing by hand of female staff. He has mood problem related to disease process of schizophrenia and bipolar disorder. He uses psychotropic medications. He is at risk for abuse (physical, mental, sexual, verbal, financial, involuntary seclusion, neglect, exploitation, and misappropriation of property). Facility's policy on Abuse prevention indicates: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. 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. The facility has a no tolerance philosophy, persons found to have engaged in such conduct will be terminated.

Based on observation, interview and record review, the facility failed to implement fall precaution interventions for two (R3, R4) residents identified as a fall risk in a sample of three residents reviewed. Findings include: 1. On 10/27/2024 at 10:32AM, R3's bed observed to not be in the lowest position. R3 observed in a supine position with head of bed elevated at 45 degrees. R3's bed observed in a high position that reaches surveyor's mid upper thigh measuring approximately 2 feet, 8 inches in height. R3's floor mats were also observed leaning against a wall underneath R3's window in R3's room. R3 observed with a tracheostomy in place. R3 is verbally able to make his needs known. R3 stated he does not remember the last time he fell . On 10/27/2024 at 10:53AM, V2 (Licensed Practical Nurse/LPN) stated she is the nurse responsible for caring for R3. V2 observed R3's floor mats were not in place and R3's bed was not in the lowest position. V2 stated R3 is at high risk for falls and is supposed to have floor mats on both sides of the bed while in bed. V2 stated R3's bed should also be kept in the lowest position. V2 was observed operating R3's bed and lowering R3's bed to the lowest position. R3's bed is now in a position that reaches the middle of surveyor's calf muscles measuring approximately 1 foot, 1 inch in height. V2 was observed taking R3's floor mats from against the wall underneath the window and placing them on the floor on the right and left sides of R3's bed. V2 stated if R3's fall precaution interventions are not implemented, R3 could potentially fall out of bed and hurt himself while in the facility. 2. On 10/27/2024 at 11:20AM, observed R4 in a supine position with head of bed elevated at 30 degrees. R4's floor mats were observed leaning against the radiator and a wall underneath R4's window in R4's room. R4 stated he does not remember the last time he fell . On 10/27/2024 at 11:23AM, V3 (Certified Nursing Assistant/CNA) stated she is responsible for caring for R4. V3 observed R4's floor mats are not in place. V3 stated R4 is at high risk for falls and is supposed to have floor mats on both sides of the bed while in bed. V3 stated she recently was inside of R4's room changing R4's incontinence briefs. V3 stated she must have forgot to replace R4's floors mats after she was done changing him. V3 observed taking R4's floor mats from against the wall underneath the window and the radiator and placing them on the floor on the right and left sides of R4's bed. V3 stated she should not have forgotten to replace R4's floor mats and need to pay more attention to that next time. V3 stated if R4's fall precaution interventions are not implemented, R4 could potentially fall out of bed and hurt himself while in the facility. On 10/27/2024 at 2:27PM V5 (Restorative Nurse/Fall Coordinator) stated R3 and R4 are at high risk for falls. V5 stated R3 and R4's fall precaution interventions are to have floor mats in place and the bed in lowest position. V5 stated if fall precaution interventions are not implemented, R3 and R4 could potentially fall and injure themselves in the facility. V5 stated the purpose of implementing fall precaution interventions is to maintain resident safety and to prevent any injuries from occurring. R3's fall risk assessment dated [DATE] documents R3 is at high risk for falls with a fall risk score of 15. R3's care plan dated 09/23/2024 documents R3 is at high risk for falls with interventions to include floor mats. R4's fall risk assessment dated [DATE] documents R4 is at high risk for falls with a fall risk score of 14. R4's care plan dated 09/17/2024 documents R4 is at high risk for falls with interventions to include bed in the lowest position and floor mats while in bed. Facility policy dated 02/13/2024 titled, Fall Prevention and Management documents in part, Policy statement: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Fall interventions: a. Fall Precautions will be implemented for residents as appropriate.

Based on observation, interview and record review, the facility failed to monitor and prevent a high risk cognitively impaired resident from sustaining a preventable fall, failed to provide fall preventative devices, failed to develop/implement a plan of care for residents at high risk for falls, and failed to educate staff on identifying and protecting residents from accidental falls. This failure affects 1 (R57) of 1 residents reviewed for falls in the sample of 28. R57 was admitted to the hospital with a left comminuted (multiple bone breaks) femur fracture with surgical intervention as a result of this failure. Findings include: R57 is a cognitively impaired resident with diagnoses including but not limited to End Stage Renal Disease, Major Depressive Disorder, Dependence on Renal Dialysis, Other Abnormalities of Gait and Mobility, Lack of Coordination, Long Term (Current) Use of Anticoagulants, Reduced Mobility, and Weakness. R57's MDS Minimum Data Set (Comprehensive Assessment) dated 05/24/24 documents a brief interview for mental status (BIMS) score of 4 out of 15. A score of 0-7 indicates severe cognitive impairment. All 3 consecutive MDS assessments dated 05/24/24, 02/27/24, and 12/06/23 maintain R57's cognitive decision making to be severely impaired with the latest MDS assessment showing a significant change post-fall incident. Four consecutive fall risk assessments dated 12/1/2023, 4/15/2024, 5/20/2024, and 7/17/20204 all assess R57 at High Risk for Falls. On 9/23/24 at 11:15 AM, R57 was observed in bed asleep. One fall mat on the floor next to the right side of the bed. No other fall precautions were in place. On 09/25/24 at 10:51 AM, interview with V16 Maintenance Technician regarding R57's fall on 07/17/2024. V16 said, I got a work order for the room. I knocked on the door and asked if I could come in. I was there for bed B by the bathroom because the TV wasn't working. When I saw R57 she was in bed A she was sitting in the middle of the bed facing the door. I came and went in the middle of both beds. I started to set up the TV remote for bed B. I heard a loud thud noise like something dropped. I turned my face and saw (R57) on the floor. I said just a minute to R57, and I went to the nurse's station. V8 RN was in the hall, and I said somebody in the room was on the floor. She went into the room first. I didn't go back into the room. As soon as I knew what happened V1 Administrator and V5 Restorative Nurse came and talked to me. They said I had to make a report and I wrote it down. This surveyor showed V16 Maintenance the written statement provided by V1 Administrator and asked if he saw her fall. V16 said, That's mine. I didn't see her fall; I saw the privacy curtain move after she fell . On 09/25/24 at 11 :24 AM, V8 RN inquired of R57's fall incident on 07/17/2024. V8 said, V16 Maintenance came to me I was in the hallway passing medication. He told me someone had fallen in the room. I went into the room and R57 was on the floor by the side of the bed. I told V16 Maintenance to call for help to get her off the floor. While I was assessing her, I asked her if she had pain. I checked her extremities and skin. She said she had pain on both thighs. She said the pain was about 3 out of 10. She was able to move her extremities at her baseline, able to move everything. I asked if she hit her head on the floor and she said no. I asked her how she fell . She said she was trying to get out of the bed. She didn't say where she was going. The other staff came in and helped me get her off the floor. V21 CNA, another restorative person, V18 RN, and I lifted R57 and put her back in bed. R57 didn't show any pain. R57 has confusion sometimes. They helped me put her back in bed and we turned her, and I checked her skin if she had any bruises. I asked her to move her arms and legs and she was able to move as much as she can. Surveyor asked to clarify how she assessed and interviewed R57 given her severe cognitive impairment, V8 said, I didn't ask her to show me where her pain was. I just checked her skin and asked her to move. I talked to V16 Maintenance, and he said he didn't actually see her fall, he just heard her fall. I called the V20 NP Nurse Practitioner on the phone about the pain she had, and she ordered an x-ray. V20 NP Nurse Practitioner was in the building. She said to give her Tylenol. We have a protocol for 72 hour neurological checks and follow up fall monitoring. I gave her Tylenol after the incident because she had an order. I went back in thirty minutes, and she wasn't having pain. R57 speaks English and I understood her clearly. She didn't have any changes to her condition. I called for an x-ray for her hips and pelvis, left femur and left elbow. I didn't say anything about R57's left side, it's just what the V20 NP ordered. I ordered the x-ray stat (immediately). They didn't say when they'd come. I work 7AM to 7PM. They didn't do the x-ray before I left so I gave report to the oncoming nurse. I said the x-ray hadn't been done yet. I didn't tell anyone else that the x-ray wasn't done yet. V8 was asked if she completed the fall event form for R57 and why certain areas were left blank. V8 said, Yes, I did it. Was R57 ambulatory? Why was the ambulatory status and extremities section left blank? V8 was asked, did you check her range of motion and position of her extremities? V8 RN said, No, she wasn't. She was a one person assist to a wheelchair. She could bear her weight and transfer to a wheelchair. I accidently left it blank; she didn't have any deformities. V8 was asked, was R57 a fall risk? How would you know if she was a fall risk? If so, what interventions were previously in place? V8 said, I'm not sure if she was. It would have been in her profile. This was the first time I worked with her. There's a folder on the unit with the fall risks. I'm not sure I checked. I could have checked her care plan, but I didn't. A nursing note written by V8 RN reads in part, On 7/17/24 at 11:30 AM, a staff member from maintenance notified NOD (nurse on duty) that resident was on the floor. Upon arrival in resident's room, NOD noted resident sitting on the side of the bed. Resident stated I was trying to sit on the side of the bed and lost my balance while trying to get up. Head to toe assessment done, no injury noted, able to move all extremities at baseline, VS (vital signs) taken and recorded, resident with complaint of pain on both thighs, Tylenol 650 mg PRN (as needed) administered. Resident denies hitting head at this time. V20 NP Nurse Practitioner notified with order for Xray of bilateral hip and pelvis, left femur, and left elbow order confirmed and carried out. Notified POA (Power of Attorney) via voicemail as cell phone wasn't picked up. Ongoing Neurological check and 72 hour post monitoring initiated. R57's progress notes reflect the x-ray was not performed by the portable x-ray company until 07/18/24. On 09/25/24 at 12:29 PM, V21 CNA Certified Nurse Assistant said, R57 is alert and knows where she is and what she wants. I was in her room after she was done with her restorative. I warmed up her milk and set up her tray while she was in bed. She was eating and I went back to the nurse's station. V16 Maintenance came and told me someone was on the floor. When I went to the room V8 RN, another nurse and V16 Maintenance were in the room. R57 was sitting on the floor next to the bed. I asked her what happened. She's not confused. R57 said I thought I could walk by myself. V8 RN assessed her and R57 said she was fine and didn't hurt herself. The nurses and I helped lift her up and we put her sling underneath her. We hooked it up to the mechanical lift and placed her on the bed. She didn't show any pain. The nurses checked her body, we repositioned her. She was wearing a house dress. They didn't take her dress off, they just lifted it up. I just checked on her after that, she didn't say anything hurt. V21 CNA said, R57 wasn't a fall risk because she never tried to get up. If she was a fall risk, we'd have a low bed and use little mattresses on the floor both sides of the bed. She only had the low bed. How would you find out if R57 was a fall risk? V21 CNA said, The restorative nurse educates the nurses and aides. On 09/25/24 at 1:00 PM, two surveyors visited R57 and observed the resident laying in the bed. There was one fall mat beside the resident's bed and another that was folded up and leaning in the corner of the room not being utilized. A call light was wrapped multiple times around R57's side rail and with the call light button tucked under R57's pillow away from R57's reach. V8 (RN) was asked to affirm what the surveyor's observed. V8 said, The call light is under her so she can't reach it. She needs repositioning. She has a mat on the floor and the other is in the corner. It's supposed to be on the other side on the floor. There's a sign hanging on the wall, but I don't know what it means. V8 was asked if she has had any training on fall risk precautions and fall risk residents? V8 said, It was last month with V5 Restorative Nurse. The CNA or nurse should make sure the fall precautions are in place. I'll tell her CNA to put the other mat down and to give her the call light. V8 RN attempted to speak to R57 asking, How are you feeling? Do you know where you are? R57 did not respond. V8 said, She wasn't able to answer. V8 was asked if this a change in her mental status? V8 said, Yes, she usually answers. On 09/25/24 at 01:27 PM, interview with V18 RN regarding R57's fall incident from 07/17/24. V18 RN said, I didn't witness her fall, I was on the other end. One of the CNA's came and got me. I got to the room, and they were asking for help to transfer back to bed. She was sitting on the floor next to the bed on the right side. I helped them. They had a mechanical lift pad or sheet underneath her, and just helped them get her in the bed. We repositioned her and I left. R57 shook her head no when asked if in pain. On 09/25/24 at 01:33 PM, V5 Restorative Director was interviewed regarding R57's fall incident on 07/17/24. V5 said, I was aware she fell on Wednesday the 17th; V8 RN reported it to me. I wasn't there during the assessment. I saw her after when she was in bed just to look at her to see what interventions we could place. R57 was sleeping, she wasn't able to answer me. I talked to her between Thursday and Friday. I asked R57 before she went out and she told me she was sitting on the side of the bed and was trying to get up, that's what she said. She had x-rays ordered on Wednesday; we got the results on Thursday night close to midnight. It said signs of old fracture healed in the results. On Friday the nurse had the report in hand, and I called the V20 NP Nurse Practitioner. When I told her she said to send R57 out to the hospital. I called the family, her POA, and told him we received the x-rays, and he was grateful. When she went to the hospital I called to see if they were admitting her. I did the interdisciplinary note. She was a high fall risk. She scored a 10 or higher on all her fall risk assessments done upon admission, quarterly, and annual. V5 said, We do 50% or more of the effort so we put a gait belt on her and a walker and follow with a wheelchair for resting periods. V5 was asked, what interventions were in place when she fell ? V5 said, I would have to check, we didn't have the landing mats at that time. We only place interventions when there's a fall. This was her first fall with me. If anyone scores high, we don't place any interventions until they fall. She didn't have any interventions at that time. The only thing was to keep her bed in a low position. We do purposeful rounds, the four P's everyone does them. Position, check a resident. Potty, if they're soiled, clean them. Possessions, place items and call light within reach, before leaving ask if there's anything they need. I can't remember the last P. R57's fall was due to lack of coordination and weakness. V5 said, Yes, she was able to use it (call light). She was alert and oriented x 1 (person) to 2 (place) with bouts of confusion, but she's able to verbalize needs and follow simple instructions. V5 was asked, what are her current fall interventions? V5 said, She has landing mats bilaterally and while in bed. Regarding knowing if resident is a high fall risk, V5 said, We started training staff to use a cared file system, it's on the residents profile. It's new about a month ago. It would say high fall risk and if they have fallen it's shows what interventions are there. V5 said, Between me, nurses, CNAs, and RNAs (restorative nurse assistant). Once a resident falls and has interventions in place we tell them the interventions. I started the training of the card file on Tuesday the 24th. I have fall binders in the nurse's station, one per floor. At that time, this was the other way to know if they were a fall risk. They could also check the care plan. The card file system is in the electronic chart record. On 09/26/24 at 12:34 PM, interview with V20 NP Nurse Practitioner regarding R57's fall on 07/17/24. V20 NP said, Nursing staff called me on 7/17 the day of the fall, I'm not sure if I was in house. R57 is in bed most of the day, a dialysis patient. She is forgetful but could voice her needs and use her call light. Alert and oriented x 2 (to person and place) maybe. She was in the bed. She wasn't in any pain or distress. She said she was attempting to sit at the edge of the bed and slid off is what was told to me by the nurse. Nursing said staff found her sitting on the floor. My note is from 7/18/24. I did a full assessment. She was complaining of pain with movement of the left leg but appeared to be comfortable. She wasn't in any distress. There was no deformity from my clinical judgement. Sometimes a fracture can't be seen. She was in some pain. I ordered x-rays bilateral hip and pelvis, left femur and elbow. In this situation I ordered them stat, so it should be done as soon as possible. I ordered blood work to make sure nothing was underlying. After I saw the x-ray from (the x-ray company), I ordered R57 to be sent to the hospital for further evaluation. The x-ray doesn't say it's acute, it says healed or healing pubic fracture and Osteopenia. Due to this and her having a fall I ordered her to be sent for further evaluation. V20 was asked, were you informed the x-ray wasn't completed until 07/18/24? V20 NP said, I don't remember when the x-ray was done. I usually ask when I come in the next day. If not, I ask them to call the x-ray company. I don't remember if the nurse told me when it was done. It's been more difficult with this company. It's a common thing that a nurse should report that. When the x-ray company comes, they don't even tell the nurses when they are there and when it (the x-ray) was done. It's expected to be done as soon as possible the same day. R57 has an order for Tylenol 650mg by mouth every 6 hours as needed. I can't remember if V8 RN told me about how well she tolerated it. The nurses usually document the pain assessment and let me know if any additional orders are needed. Review of R57's POS (Physician Order Sheet) states in part she was prescribed Heparin 5,000 units/ml (milliliter) injectable solution. Inject 1ml (milliliter) into the skin every 12 hours. Heparin is in a class of anticoagulant medications used to prevent and treat blood clots. It works by decreasing the clotting ability of the blood (blood thinner). Falls can cause bone fractures which can be more serious for patients taking blood thinners due to the risk of severe bleeding. R57's 05/20/2024 care plan indicates R57 is at risk for falls related to vomiting, generalized weakness and multiple chronic disease conditions. Dx: HTN (Hypertension), COPD (Chronic Obstructive Pulmonary Disease), CKD-4 (chronic kidney disease), Anemia diagnosis of End Stage Renal Disease, COPD, Anemia, muscle weakness, difficulty walking, reduced mobility. Interventions: educate resident to use call light for assistance. Encourage resident to ask staff to help her put her sweater on. Keep furniture in locked position. Keep needed items, water, etc. in reach. Maintain a clear pathway, free of obstacles. Avoid repositioning furniture. Provide visual prompts to ask for help. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes as possible. Educate resident/family/caregivers/interdisciplinary team as to causes. Educate R57/family/caregivers about safety reminders and what to do if a fall occurs. R57 Needs activities that minimize the potential for falls while providing diversion and distraction. Encourage R57 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that R57 is wearing appropriate footwear when mobilizing in wheelchair. R57 is on Anticoagulant therapy (Heparin injection) for clot prevention. R57 is at risk for bleeding and complications. Interventions: Daily skin inspection. Report abnormalities to the nurse. R57/family/caregiver teaching to include the following: take/give medication at the same time each day, use soft toothbrush, use electric razor, avoid activities that could result in injury, take precautions to avoid falls, signs/symptoms of bleeding, avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, brussels sprouts, milk, and cheese. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD (medical doctor) PRN (as needed) signs/ symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review medication list for adverse interactions. R57'S 05/24/24 MDS Minimum Data Set (Comprehensive Assessment) Section GG Mobility states in part C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. The portable x-ray company's date of service for R57 states in part 07/18/2024 x-ray of the pelvis and bilateral hips, five views. Impression: 1. Impacted left subcapital femoral neck fracture deformity, of unknown age. 2. Healed or healing left inferior pubic ramus fracture. The portable x-ray company's date of service for R57 states in part 07/18/2024 x-ray of the left femur, AP (anterior to posterior) and lateral. Impression: 1. Subcapital left femoral neck fracture deformity, of unknown age. 2. Osteopenia. R57 was hospitalized on [DATE] through 07/31/2024 with a diagnosis of closed fracture of the left hip. The physical exam for musculoskeletal indicates left hip restriction of range of motion due to pain. The 07/19/2024 hospital (CT) Computed Tomography Scan of the pelvis without contrast indicates final result 1. Comminuted (a bone breaks into more than two pieces), mild to moderately displaced left sacral ala fracture, extending to the left sacroiliac joint. Additional comminuted. mildly displaced fracture of the left posterior superior iliac spine, also extending to the sacroiliac joint. Suspected mild left sacroiliac joint diastases. 2. Comminuted, mildly displaced fractures of both superior and inferior pubic rami. Additional mildly displaced fractures of both acetabular and anterior columns. 3. Mildly displaced and impacted fracture of the left femoral neck, possibly Basi-cervical. 4. Focal angulation of the right femoral head-neck cortex may represent a nondisplaced fracture. The assessment and plan indicate left hip fracture: patient has been evaluated by orthopedics plan for surgical intervention today. The preoperative diagnosis states in part 1. Left displaced femoral neck fracture. On 07/23/24 R57 had Left Hip Arthroplasty (a surgery to restore the function of a joint. The joint is replaced, remodeled, or realigned.) The 02/13/24 Fall Prevention and Management Policy states in part: Policy Statement: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Procedures: Fall Risk Screening a. Residents and patients will be screened to determine fall risk. b. Fall risk screening will be used on admission, readmission to the facility, following a fall, following a change in status, and quarterly. c. High risk residents will receive interventions as appropriate to risk factors. Fall Interventions a. Fall precautions will be implemented for residents as appropriate. b. The IDT (interdisciplinary team) will discuss interventions that may be added to the resident's care plan. c. Fall interventions may include, but not be limited to: assess the need for an assistive device for mobility and locomotion. Meaningful activities are encouraged. Keep hearing aids, glasses, dentures with the resident. Pharmacy may review medications for any potential side effects/drug interactions. Physical/Occupational evaluation as appropriate. Assess needs for toileting or incontinence care. Restorative may evaluate programs such as ambulation, transfers, and bed mobility. Room change near the nurses station if available. Development of Plan of Care a. An interim or basic care plan will be initiated for all new admissions or readmissions. b. A comprehensive falls care plan will be developed. c. A review of the current care plan will be conducted after the fall with the IDT.

Based on observation, interview and record review the facility failed to recognize, evaluate and manage pain for a 1 (R57) resident with severe cognitive impairment of 3 residents reviewed for pain management in the sample of 28 residents. This failure affected R57 receiving inadequate pain medication after an unwitnessed fall, and failure to thoroughly assess and monitor for further pain for over 48 hours until being emergently sent to the hospital for treatment of a femur fracture requiring surgical intervention. Findings include: R57 is a cognitively impaired resident with diagnoses including but not limited to End Stage Renal Disease, Major Depressive Disorder, Dependence on Renal Dialysis, Other Abnormalities of Gait and Mobility, Lack of Coordination, Long Term (Current) Use of Anticoagulants, Reduced Mobility, and Weakness On 09/25/24 at 02:25 PM, Surveyor inquired with V1 Administrator about R57's fall incident and report to IDPH Illinois Department of Public Health. V1 said, R57 fell during the daytime, and she complained of pain. X-ray was ordered, technician came the next day, and the results came at midnight. She fell on a Wednesday and the results came between Thursday night and Friday morning. Based on the results of the x-ray relayed to the V20 NP R57 was transferred to the hospital. I found out from V5 Restorative Nurse on Monday or Tuesday that R57 was going to have surgery for a hip fracture. R57 was sent to the hospital for further evaluation. It was a recommended procedure for R57 to have surgery. This is a fall with a serious injury. The hospital conducted its own evaluation and confirmed the fracture, that's why she had the surgery. A nursing note written by V8 RN reads in part, On 7/17/24 at 11:30 AM, a staff member from maintenance notified NOD (nurse on duty) that resident was on the floor. Upon arrival in resident's room, NOD noted resident sitting on the side of the bed. Resident stated, I was trying to sit on the side of the bed and lost my balance while trying to get up. Head to toe assessment done, no injury noted, able to move all extremities at baseline, VS (vital signs) taken and recorded, resident with complaint of pain on both thighs, Tylenol 650 mg PRN (as needed) administered. Resident denies hitting head at this time. V20 NP Nurse Practitioner notified with order for Xray of bilateral hip and pelvis, left femur, and left elbow order confirmed and carried out. Ongoing Neurological check and 72 hour post monitoring initiated. R57's progress notes reflect the x-ray was not performed by the portable x-ray company until 07/18/24 a day after R57 sustained a mechanical fall. There were also no pain assessments conducted or pain medications during the time period based on the medical records provided to surveyor. R57's MDS Minimum Data Set (Comprehensive Assessment) dated 05/24/24 documents a brief interview for mental status score of 4 out of 15. A score of 0-7 indicates severe cognitive impairment. Surveyor asked to clarify how she (V8-RN) assessed and interviewed R57 given her severe cognitive impairment. V8 said, I didn't ask her to show me where her pain was. I just checked her skin and asked her to move. I talked to V16 (maintenance man), and he said he didn't actually see her fall, he just heard her fall. I called the V20 NP Nurse Practitioner on the phone about the pain she had, and she ordered an x-ray. V20 NP Nurse Practitioner was in the building. She said just to give her Tylenol. We have a protocol for 72 hour neurological checks and follow up fall monitoring. I gave her Tylenol after the incident because she had an order. I went back in thirty minutes, and she wasn't having pain. R57 speaks English and I understood her clearly. She didn't have any changes to her condition. I called for an x-ray for her hips and pelvis, left femur and left elbow. I didn't say anything about R57's left side, it's just what the V20 NP ordered. I ordered the x-ray stat (immediately). They didn't say when they'd come. I work 7 AM to 7 PM. They didn't do the x-ray before I left so I gave report to the oncoming nurse. I said the x-ray hadn't been done yet. I didn't tell anyone else that the x-ray wasn't done yet. Surveyor asked if she provided any other pain medications other than the one dose of Tylenol, V8 indicated that she provided only one time. The July MAR (Medication Administration Record) showed on July 17th, 2024 on the day of the fall incident, R57 was administered two tablets of regular strength Tylenol for mild pain by V8 (RN). This same nurse assessed a severely cognitively impaired resident with a pain level of 3 for mild pain after an unwitnessed mechanical fall to the floor sustained by R57. There were no additional pain medications administered to R57 from the 1 dose throughout her discharge to the hospital on July 19, 2024. Further review of the July medication administration records showed no other pain assessments were conducted for the entire month of July 2024. On 7/17/24, there is one pain evaluation written by V8 post fall incident with incomplete information and assessment of R57's pain and interventions for the pain. V8 left blank on the pain assessment form the sight, onset of pain or duration of the residents pain. R57's quality of pain was an ache. Numerous blanks of the assessment including any non-verbal indicators of pain or pain exacerbating factors for a resident with severe cognitive impairment. There were no non-pharmacological interventions provided. V8 indicated that Tylenol 650 mg should have been provided every 4 hours and as needed but left blank whether the resident had any side effects from the pain medication or if there were any signs of sedation, nausea, constipation, indigestion or diarrhea or whether the resident was receiving any medications to alleviate side effects which again was left blank. On 09/26/24 at 12:34 PM, V20 NP Nurse Practitioner V20 NP said, Nursing staff called me on 7/17 the day of the fall, I'm not sure if I was in house. R57 is in bed most of the day, a dialysis patient. She is forgetful but could voice her needs and use her call light. Alert and oriented x 2 (to person and place) maybe. She was in the bed. Per V8, she wasn't in any pain or distress. The nurse said that the resident was attempting to sit at the edge of the bed and slid off is what was told to me by the nurse. Nursing said staff found her sitting on the floor. My note is from 7/18/24. I did a full assessment. She was complaining of pain with movement of the left leg but appeared to be comfortable. She wasn't in any distress. There was no deformity from my clinical judgement. Sometimes a fracture can't be seen. She was in some pain. I ordered x-rays bilateral hip and pelvis, left femur and elbow. In this situation I ordered them stat, so it should be done as soon as possible. I ordered blood work to make sure nothing was underlying. After I saw the x-ray from (the x-ray company), I ordered R57 to be sent to the hospital for further evaluation. The x-ray doesn't say it's acute, it says healed or healing pubic fracture and Osteopenia. Due to this and her having a fall I ordered her to be sent for further evaluation. V20 NP said, I don't remember when the x-ray was done. I usually ask when I come in the next day. If not, I ask them to call the x-ray company. I don't remember if the nurse told me when it was done. It's been more difficult with this company. It's a common thing that a nurse should report that. When the x-ray company comes, they don't even tell the nurses when they are there and when it (the x-ray) was done. It's expected to be done as soon as possible the same day. R57 has an order for Tylenol 650 mg by mouth every 6 hours as needed. I can't remember if V8 RN told me about how well she tolerated it. The nurses usually document the pain assessment and let me know if any additional orders are needed. Facility's policy dated 1/01/2021 titled Pain Management reads in part, The facility will provide adequate pain assessment and management to that residents attain or maintain the highest practicable physical mental, and psychosocial well-being. Procedure: Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status (after a fall, etc.). Behavior signs and symptoms that may suggest the presence of pain include: change in gait, loss of function, decline in activity, resisting care, bracing, guarding or rubbing, fidgeting, facial expressions of grimacing, frowning, fear, grinding of teeth; change in behavior: depressed mood, decreased participation in usual activities of daily living, loss of appetite, sleeping poorly, sighing, groaning, crying, breathing heavily. Assessment and evaluation: Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident. Review of the resident's diagnosis or conditions that may be causing or contributing to pain. Identifying key characteristics of the pain, obtaining descriptors of the pain, determining factors that make the pain better or worse, identifying recent exacerbations of pain, impact of pain on quality of life. Current prescribed pain medications, dosage and frequency. Non-pharmacological pain management interventions include adjusting room temperature, smoothing linens, turning and repositioning to a comfortable position.

Based on observations, interviews, and record reviews, the facility failed to medically manage a brittle Type 1 diabetic by failing to follow physician orders in administering insulin orders and obtaining blood glucose levels; failed to administer anti-seizure medications for a resident with a history of seizure disorders; and failed to have a care plan in place for a resident with history of seizure disorders. This failure applies to 1 resident R1 of 3 residents reviewed for quality of care and resulted in the emergent transfer to the ER (emergency room ) to receive immediate critical care for treatment and prevention of imminent life-threatening deterioration of dehydration, endocrine crisis, and metabolic crisis. Findings include: R1 is [AGE] years old admitted to the facility on [DATE] with diagnoses include but are not limited to Toxic Encephalopathy, Type 1 Diabetes Mellitus, Seizures, Chronic Respiratory Failure with Hypoxia, Tracheostomy, End Stage Renal Disease, Dependence on Renal Dialysis. On 07/30/24 at 11:28 AM, R1 appeared alert and oriented to person and place. R1 was observed sitting near the nurse's station in her wheelchair. Inspection of R1's room showed snacks of diabetic cookies and sunflower seeds on her over bed table. Surveyor asked R1 about her care on 6/9/24. R1 said, I went to the hospital. R1 was unable to recall the reason for her hospitalization . On 07/31/2024 at 11:20 AM, R1's room was observed again and with V13 LPN Licensed Practical Nurse inside the room. There was a 1/2 package of diabetic cookies and 12 ounce bottle of zero sugar electrolyte drink with 1/2 amount remaining on the bedside table. No other food items were found. R1 appeared to be compliant with her nutrition. On 07/31/24 at 11: 23 AM, V10 CNA Certified Nurse Assistant was asked of R1's snacks in her room. V10 said, R1 has some diabetic wafer cookies and sunflower seeds. She usually drinks coffee or water. That's all. On 07/31/24 at 2:14 PM, Interviewed V12 LPN regarding R1's June 8, 2024, 6 AM dose of Insulin Glargine 100 units/ml (milliliters); inject 3 units subcutaneously (applied under the skin) one time a day for high sugar. V12 said, I believe I checked her blood sugar, but I can't remember since it's not documented. I have no idea. A review of R1's medication administration record dated June 8, 2024 showed insulin was not administered as ordered. The physician order states 6 AM dose of Insulin Glargine 100 units/ml (milliliters); inject 3 units subcutaneously (applied under the skin) one time a day for high sugar. This was not administered. V12 was asked of R1's seizure and blood glucose level of 255 from June 9, 2024, prior to being hospitalized . V12 said, I was the assigned nurse, I worked overnight. I was leaving at 7AM. I entered the blood sugar number at the time I documented it. I was busy calling the family and doctor, but I took it when it was scheduled at 6AM. I gave the insulin by the order at 6AM. [R1] was walking around the room when I came to do her blood sugar. I was there before I started my medication pass. She was alert. [V14 CNA] went to change her because she was incontinent. Between 6 and 7AM, [V14] called me in the room. When I came in [R1] was in the chair and she was shaking; it wasn't her normal. I called my co nurse and she called the doctor and got orders to call 911. I was taking her vitals. I took care of her the whole time. I stepped out the room when EMS (Emergency Medical Service) got here; not sure if they checked her blood sugar. She was still having seizures when they got here. V12 was asked if R1 had anything to eat during the night. V12 said, During the night, R1 came out a few times so I sat her at the desk with me. She had a snack, juice and a graham cracker or a peanut butter and jelly sandwich. I can't remember which one. It was around 3 to 4 AM. I don't think she had anything else. On 07/31/24 at 3:02 PM, V16 LPN was asked about administering R1's June 7, 2024, 8 PM Dilantin medication. V16 said, I know we have it on hand. I don't know if it was since it wasn't documented, it may be an error. She doesn't refuse medicine from me. I'm good with her. I'm not sure what happened. Review of R1's June 7, 2024, at 14:50 military time (2:50 PM) physician order and medication administration record indicates Dilantin Oral Suspension 125mg/5ml (milligrams/milliliters) (Phenytoin). Give 10ml by mouth every 12 hours for seizures. The medication is not documented as being administered as per physician order for the 8 PM dose. R1's 6/7/24 lab report states in part: Dilantin 4.0 ug/ml (microgram/milliliter) L (low). Reference range 10.0 - 20.0. On 07/31/24 at 3:09 PM, V17 LPN was asked about administering R1's Insulin Lispro Injection 100 units/ml (milliliters); inject 4 units intramuscularly with meals for high sugar. V17 said, I gave the insulin, maybe I forgot to click it. I always give my insulin with the food. Her blood sugar was fine. There is no documentation of V17 LPN administering R1's 4 units of Lispro insulin on 6/7/24 at 1700 (5PM) in the electronic medication administration record. There is no documentation of R1's blood glucose checked at 1700 (5PM) on the blood sugar summary. On 08/1/24 at 10:16 AM, V15 Nurse Practitioner was asked about R1's elevated blood sugar of 573 and abnormal Dilantin lab result of 4.0. V15 was also asked what interventions were done when the facility relayed the negative lab results. V15 said, R1 was a new resident to me. The nurses called me on 6/7/24 because her blood sugar was 573 and her Dilantin level abnormal at 4.0. Surveyor asked if the current order was sufficient to manage her seizures and whether the Valproic Acid was the same medication, V15 NP said, I increased the Valproic Acid to 10ml BID (twice daily). I just changed it in my notes. It's not the same medication. It was just a typo; it was for Phenytoin. We can increase at certain times usually 4 weeks, but she went to the hospital. Surveyor asked how the facility managed R1 being a brittle diabetic and any interventions or orders given because of the recent labs and what orders. V15 said, For the blood sugar, she's fragile diabetic type 1. Her blood sugar goes into the 20's and has been hospitalized multiple times for that. I told the nurse to give her insulin per her MAR (medication administration record). I don't see it in my notes. She [R1] had sliding scale Lispro and that's what I asked the nurse to give. It was my first time seeing her and she has a history or hypoglycemia. She's very non-compliant about her food. They check her blood sugars three times a day with meals and at night. When I did her rounds, we try to help her with her meals. We have a dietician on board with her as well. I did talk to the doctor the day before. I'm not sure how she did overnight if she ate some sugary snacks for her blood sugar to be 1600 when she went to the hospital. There are concerns with R1 not being administered blood glucose monitoring and insulin for meals as prescribed. Surveyor asked what the expectations were for R1's care, V15 NP said, The nurses have to make sure to check the blood sugar as ordered and make sure she eats, and give the insulin as ordered. If the blood sugar is more the 400, they have to notify us. Surveyor asked if there was a concern with R1 not being administered Dilantin 10ml by mouth as prescribed for 6/7/24, V15 NP said, Seizure medication should be given on timely manner. They have a window of 1 hour before and after to give it. A Review of R1's 6/7/24 09:10 AM progress note by V15 NP Nurse Practitioner states in part: HPI (History of Present Illness). Seen today for BS (medical abbreviation for blood sugar) 573. Abnormal Dilantin level. Lab/Imaging results: Dilantin (Phenytoin) 4.0. Assessment/Plan: #BS 573. Increase Valproic Acid to 10ml (milliliters) BID (medical abbreviation for twice a day). Review of R1's 06/01/2024 to 06/30/2024 physician order summary does not list Valproic Acid being an active order for her. On 08/01/24 at 11:35 AM, interview with V2 DON Director of Nursing regarding R1's blood glucose monitoring not performed and documented and insulin and Dilantin medication not administered as prescribed. Additionally, R1 was not administered blood glucose monitoring and insulin for meals as prescribed. V2 DON said, The nurses should be following the physician's orders. It should be documented on the MAR (medication administration record). Surveyor asked about R1's Dilantin 10ml by mouth not given as prescribed for 6/7/24. V2 DON said, The nurse should administer the medication as ordered and make sure to document it on the MAR. Surveyor asked about R1 not having any care plan for her seizure disorder, V2 said, She should have a care plan in place for her seizure disorder, so staff know what the precautions are, and what care to provide and what makes her at risk for a seizures. Review of records showed no documented plan of care for R1's seizure diagnosis as listed per MDS (Minimum Data Set/Comprehensive Assessment) dated 06/10/2024 Section I Active Diagnoses. Further review showed R1 was not provided an order for blood glucose monitoring until 06/07/2024. R1's 06/01/2024 to 06/30/2024 physician order summary states in part- check blood glucose before each meal and at bedtime related to Type 1 Diabetes Mellitus start date 06/07/2024. A care plan dated 06/06/24 states in part- R1 is at risk for elevated blood sugar and complications. R1 is on insulin injection (see POS Physician Order Sheet/MAR Medication Administration Record). Goal- R1 will have no complications related to diabetes through the review date. Interventions- Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Educate R1/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs/symptoms) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Monitor compliance with diet and document any problems. R1 has nutritional problem or potential nutritional problem r/t diagnosis of respiratory failure, DM (Diabetes Mellitus) 2, ESRD End Stage Renal Disease, CKD Chronic Kidney Disease, moderate protein calorie malnutrition. On clear liquids, SLP (speech language pathology) to follow. BMI (body mass index) 24.2 is WNL (within normal limit). Skin intact. 6/7/24: Diet change to Lib. renal, regular texture, thin liquids, Nepro once daily. Interventions- Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide and serve supplements as ordered. Provide, serve diet as ordered. Monitor intake and record every meal. RD Registered Dietitian to evaluate and make diet change recommendations PRN (as needed). Weigh at same time of day and record: weekly weight x weeks or per facility protocols. R1's 06/09/2024 hospitalization documentation reads in part- [AGE] year-old female trach vent at baseline presents with seizure from nursing home she does have a history of seizure disorder her Dilantin level is very low given a dose of Fosphenytoin (anti-seizure medication). Patient also with severe hyperglycemia (high blood sugar) likely causing hyperosmolar hyperglycemic disorder, her bicarb and anion gap are actually normal not an official DKA (diabetic ketoacidosis), but hyperosmolar state may have contributed to her seizure no further seizure activity in the emergency room . Given severe hyperglycemia and severe dehydration patient started on insulin drip and multiple lactated ringer boluses (intravenous fluids). Patient admit to ICU (intensive care unit) covered with broad-spectrum IV (intravenous) antibiotics. Patient also with elevated lactic acid and metabolic acidosis noted on VBG (venous blood gas) likely multifactorial from severe dehydration as well as acute seizure IV fluids. Ordered patient lactic acid improved from 4.3 to 2.6 she did get 30 cc/kg (cubic centimeter/kilogram) bolus. Multiple liters for severe dehydration doubt septic shock. I do not have a source at this time chest x-ray was negative. Clinical Impression ED Diagnosis 1. Hyperglycemia 2. Seizure (CMD) 3. Metabolic acidosis Admit 6/9/2024 8:26 AM R1's 06/09/24 hospital lab results state in part Glucose 0720 AM 1,669 (H) High. Reference Range 70-99 mg/dl (milligrams/deciliter). Dilantin 1.1 (L) Low. Reference Range 10.0 - 20.0 mcg/mL (micrograms/milliliter). R1 remained hospitalized from 06/09/2024 until 06/22/2024. The 2/28/24 Physician Orders policy states in part- General: Medications are administered upon orders of the primary care physician/ practitioner. Consulting physicians, podiatrists, dentists, and optometrist may write orders, and these orders will be verified by the primary care physician/ practitioner. Responsible Party: RN (Registered Nurse), LPN (Licensed Practical Nurse). Guideline: 4. The RN/LPN will follow the physician/ practitioner orders as written per the resident's POS (Physician Order Sheet). The March 2023 Drug Administration General Guidelines states in part- Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known. The licensed nurse is aware of an indication for the resident receiving medication, usual dose, parameters, and routes, contraindications, allergies, precautions, and side effects. Procedure: 2. Medications are administered in accordance with written orders of the attending physician. 7. Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administration on the resident's MAR (medication administration record) at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses are were administered and all administered doses were documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications. 9. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature in the space provided on the MAR or on a master signature sheet. The 2/28/24 Care Plan policy states in part- Policy statement: To meet the resident's physical, psychosocial, and functional needs facility will develop and implement a comprehensive, person centered care plan for each resident that includes measurable objectives and target goals. Procedure: 1. A care plan is initiated at the time of admission for each resident. 2. An interdisciplinary care plan is completed according to federal regulations and the RAI (Resident Assessment Instrument) process.

Based on interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by staff. This failure applied to one of one (R1) resident reviewed for sexual abuse and resulted in R1 being sexually abused by a facility CNA (Certified Nurse Aide). The Immediate Jeopardy began on 2/4/24 when R1 was sexually abused by a male facility CNA. V1 (Administrator) and V4 (Regional Director of Operations) were notified of the Immediate Jeopardy on 2/20/24 at 2:20PM. The surveyor confirmed by interview and record review, that the Immediate Jeopardy was removed on 2/21/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1 is a [AGE] year old female, initially admitted to the facility on [DATE] with medical history that includes: anoxic brain damage, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, history of sudden cardiac arrest, fusion of the cervical spine region, need for assistance with personal care, post-traumatic stress disorder, muscle weakness, Schizoaffective disorder, depression, anxiety, and aphonia (loss of ability to speak related to disease). Review of R1's medical record included review of the following documentation: MDS (Minimum Data Set) assessment dated [DATE], documents R1's BIMS (Brief Interview for Mental Status) score as a 15 - indicating that cognition is intact. Physician Order Summary (active orders as of 2/19/24) documents the following physician orders: - Monitor for side effects of anti-depressive and antianxiety medication (Order Date 1/17/24) - Only female staff to work with resident, work in pairs every shift (Order Date 2/14/24) - Alprazolam tablet 0.5mg Give 1 tablet by mouth three times a day for Anxiety (Order Date 5/25/23) - Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 1 tablet by mouth at bedtime for Depression related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9) (Order Date 10/11/23) - Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth in the morning for depression total of 25mg (Order Date 10/06/23) It is to be noted that other than above medications for anxiety and depression, R1 has no current orders for any other psychotropic or psychiatric medications. Review of behavior tracking for the past month for R1, does not document any events of inappropriate behavior (i.e., hallucinations, inappropriate behavior, yelling/screaming, etc.). Reviewed R1's nursing progress nurse - nothing noted in progress notes that indicates R1 has been exhibiting any signs and symptoms of psychosis or inappropriate behaviors. Resident electronic medical record has flag that reads: Special Instructions: FEMALE STAFF ONLY, CARE IN PAIRS. Enhanced Barrier Precaution: History of MDRO, KPC; Site; GB Bile; Duration: Indefinite. //HIGH FALL RISK//. Care plan for abuse trauma mistreatment PSWB mood was initiated on 2/8/24 and includes intervention of having two caregivers address her needs and observe the entire situation. Have supervisory personnel observe care delivery, as possible and in accordance with privacy and dignity considerations. Social Service Trauma Screening dated 1/19/24 documents, (Question #5) R1 has no psychiatric history and/or present mental health diagnosis, including psychotic symptoms (e.g., delusional thinking, hallucinations) and possible misinterpretation of events and the intentions of others; (Question #8) R1 has no history or presence of dysfunctional behavior (e.g., provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking, criminal history and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. Total score on Trauma Screening was a 2; per scale, a 2 is less than minimal symptomology. Hospital record for visit on 2/8/24 does not indicate that there are any physical injuries but hospital documents R1 agreed to SANE (Sexual Assault Nurse Examiner) assessment and was prescribed antibiotics prophylactically. Facility provided documentation of incident and investigation regarding allegation R1 made of sexual abuse against a facility staff member, which reads: On February 8, 2024, at about 11:45am, received report that resident alleged that a few nights ago, between Friday and Monday night (2/2/2024 to 2/5/2024), a male CNA, African-American, with [NAME] hairstyle, came into her room, standing at the bedside leaning on the bed, then started kissing her face, touching her chest area, and attempted to open her legs. CNA whispered to her that they should have a relationship. Per resident, she pushed him away and he left the room. No other physical contact occurred after this. The resident is unable to remember exactly when the incident happened and unable to identify the name of the alleged perpetrator. The resident stated that the CNA was not assigned to care for her. Investigation started, nursing assessment nursing assessment conducted with no significant findings noted, police came and interviewed resident, family notified, physician called with order to transfer resident to ER. Resident initially declined to go to the hospital. After explanation and encouragement, she agreed and was picked up by paramedics and transported to the hospital. A few hours later, resident returned to facility in stable condition with new order for Doxycycline and Metronidazole PO until 2/16/2024 for prophylaxis. Family notified by resident herself. Physician informed and updated. ER visit note dated 2/8/2024 revealed no visible signs of abuse or neglect .Resident is alert and oriented x 2-3, has the demonstrated ability to use the call light, she has clear speech, she owns a cellular phone in addition to facility phone at her bedside, and she talks to her husband every day. While at the facility, resident has history of calling 911 herself when she was in distress. She did not place any call to 911 during or immediately after this alleged incident. At the time of reporting, resident denied any sexual penetration, she denied pain and no new skin alteration noted during physical assessment. Resident's vital signs remain within baseline, no changes in mental state, range of motion, or appetite, and she did not appear to be in any form of distress. Resident verbalized feeling safe at the facility. Resident chose to go back to the facility despite having the opportunity to be transferred from the hospital to another care facility. Resident expressed a desire to stay in her current room and she also verbalized to not having a preference for the gender of a caregiver. Resident seen and examined by multiple providers and continued to be assessed by clinical staff after the brief ER visit. Psychotherapist, Psychiatric NP, County Detective, and IDT team followed up with resident's allegations. Resident was re-interviewed. Resident reported significant inconsistencies in her statements. Hospital and other medical records reviewed, and husband/family interviews made. Records revealed that resident had panic attacks since she was about 8 years old. She recalled having been asked a lot of questions by the police when she was in first grade. She was sexually abused by her own father when she was young. Resident can be anxious, restless, and frustrated at times secondary to adjustment due to loss of independence, and adjustment to health decline. She has long history of anxiety which goes back to childhood due to past traumatic events and reported seeing outpatient psychiatrists in the past. Currently taking psychotropic medications. Based on the description by the resident of the perpetrator, there is no African American male CNA with [NAME] hairstyle who work at the facility during night shift. Investigation completed. Allegation of sexual abuse made by the resident is not substantiated. Facility is working closely with law enforcement regarding this case. County detectives and police are conducting a separate investigation. Resident continues to reside at the facility. Wellness checks ongoing. Care plan meeting held with resident/family and IDT in attendance. Care plans updated. Resident and family informed of the outcome of the investigation. No concerns presented. Interview with R1 on 2/16/24 at 5:07PM, R1 was noted to be alert and oriented to person, place, and time and seemingly of sound mind - statements were coherent and appropriate. R1 stated that she was told by the facility that someone from the State was coming to talk to her and that she did not have a problem talking with State surveyor. R1 stated that she alleged that a CNA sexually abused her but did not feel like she was taken seriously. R1 stated that they (facility) were just trying to cover their a**es. R1 added that the two male police officers that interviewed her initially, while still at the facility did not appear to take her seriously because they were whispering and making faces at each other. R1's eyes were visibly watering up throughout interview. R1 said she had been thru a similar incident in her 20's, where she was raped after a party. R1 said she thought she was over with this part of her life. R1 stated the CNA was not her regularly assigned CNA but that he had provided care for her before. R1 said he had tried to kiss her previously, but she shoved him away and he left her alone. R1 stated she did not report this because she thought he was just being playful since he stopped when she told him get out of here. R1 added, but on this day (of the sexual assault), he was in a mood, like a bad mood and nothing was going to stop him. R1 then changed the subject and proceeded to talk about her daughters and wanting to just go home and get out of the facility. R1 was seemingly disturbed and did not want to talk about the sexual assault allegation any longer. Surveyor advised R1 that we did not have to talk about it anymore if she was uncomfortable and the interview could be continued later. R1 was interviewed on 2/17/24 at 2:36PM, R1 was again noted to be alert and oriented to person, place, and time and seemingly of sound mind. Surveyor asked R1 to please recount the events that occurred on the night of the sexual assault that she reported. R1 stated the CNA involved, came into her room after she pressed her call light because she needed to be cleaned up after a bowel movement. After the CNA provided care, R1 stated, he just came up and was pushing on me. R1 was asked if she knew the name of the individual and she said he has an African name that she cannot pronounce but that she could identify him if she saw him. R1 added he has taken care of her in the past. He has a strong accent, and he has a [NAME]. Surveyor asked R1 to elaborate on the [NAME] hairstyle and R1 said, it's not like an 80's punk, it's the shape of the lining but it's only about an inch or two thick. R1 stated the CNA inserted his penis into her vagina. R1 said that her brain wouldn't let her talk. (It is to be noted that R1 has a medical condition - aphonia - that limits her ability to speak). R1 stated she used to have a black belt in karate and that if her legs weren't weak, she would be able to fight and defend herself. R1 said, I hate to say that he is stronger than me. I couldn't understand well what he was saying. I kept moving like a fish. I didn't have a roommate at the time. Surveyor asked R1 if there is any particular reason why she didn't report right after the incident happened. R1 stated she didn't report it because she wasn't planning to tell anyone because she felt ashamed. R1 stated, There was this white guy (CNA) working with me the next day or whenever it was. He was nice and we were talking and then the next thing I know he got the nurse and then I told her about it. It all happened so fast at that point. R1 said, I feel like the first two cops who came didn't believe me. R1 was visibly upset and started using profanity to express how angry she was at the assailant and how she would physically hurt him if she could. R1 said about the police officers that, something like this should happen to them to see how they feel about it and F*** them . R1 added she felt ashamed and didn't know what would happen if she told. What if the facility threw her out for reporting? Surveyor asked R1 if she ever told the nurse at the facility that the male CNA put his penis in her vagina. R1 said, I don't think so, I don't think I got that far because she ran out pretty quickly. They came in and were asking me questions and next I remember; I was here talking to the two cops. R1 was asked if there were any other details about the CNA involved that she could remember. R1 said that on previous occasions when he works, she has seen him wearing a black jacket, like a [NAME] light jacket or something; he doesn't wear glasses or anything like that. On 2/17/24 at 1:29PM V8 (Registered Nurse) was interviewed and confirmed that she was the nurse who took the report of sexual abuse from R1. V8 said, I've worked here since October 2022. R1 is pretty much alert and oriented times three, she is a little forgetful. She needs full care, and she makes her needs known. She has no Alzheimer's or Dementia, sometimes she has a hard time finding the words to say. I can't recall the exact date, but the CNA called me into the room because she had a bruise on her belly, but it was from the shot that she had gotten and I started asking her if anyone had been rough with her, etc. Then she asked to talk to me privately. She said that somebody tried to put it in. I said what do you mean, and she said you know what I mean. I asked her if I could tell the DON because I told her it was inappropriate and if it was okay to tell the DON because the DON is male. She never said that he put it in. I did not tell the detective anything different than what I am telling you. I have been working with her since June and she is comfortable talking to me. She said she meant to tell me and that she had seen him before. I think if you showed her a picture, she could point him out; per R1's description, he wasn't that tall, thick African accent, he's black and dark skin (not caramel). On 2/17/24 at 12:18PM V2 (Director of Nursing) was interviewed regarding R1's sexual abuse. V2 stated, V8 (Registered Nurse), came to my office and told me that R1 reported sexual abuse. So, we went together to talk to R1. R1 said that a few days ago - it happened on a day that V8 was not working - R1 said that a CNA came into her room and was standing next to her watching TV. He said they should be in a relationship. He started kissing her face and touching her chest. He was touching her left leg but her left leg was weak. She said she was able to push him off. Then he left and never came back. She said he was African American, stocky, about my height. Then I went to V1 (Administrator), and we followed the protocols. I spoke to her family. The brother was concerned. The social worker reached out to her spouse. At the time of the incident, R1 couldn't yell out because she has issues with her voice. She has no history of reporting being abused while being here in the facility. V2 was asked about R1's cognitive status and V2 said that R1 has normal cognition and coherent thought processes. Surveyor asked if V2 had any special training or experience in how to approach victims of sexual abuse. V2 said, I haven't had any special abuse training while I have been here. V2 added V6 (CNA) was the assigned CNA for R1 on the night that they had narrowed down the incident to but that R1 was adamant that it wasn't him who assaulted her. V1 (Administrator) was interviewed on 2/16/24 at 11:02AM. V1 stated the nurse (V8) had made an allegation of sexual abuse to V2 (Director of Nursing) and then V2 reported it to V1. V1 stated, 911 was called, along with the physician, and the police. The police came to the facility and a report was filed. They physician ordered for R1 to be transferred to the local hospital. V1 said, When I reviewed the hospital record, there was no evidence of sexual abuse. Police, detectives, and CSI came to the facility. R1 had said that it was a CNA on the night shift, who was not assigned to her, a black male. Per R1, the CNA had a similar build to V2 (Director of Nursing). She said it happened when V8 (Registered Nurse) was not here. Those dates were narrowed down to February 2nd - 5th but at some point, she told the police it was on Sunday. I got the punches and schedule from HR to identify who worked that Sunday and identified four black, male staff who worked that night. Based on their description, I immediately suspended V5 (CNA) and V6 (CNA). V1 added that she immediately interviewed, educated, and suspended V5 and V6. V6 had been assigned to care for R1 on that night and V5 was assigned on the second floor. V1 stated, I suspended them both on the 8th (February). I could not substantiate the allegation, so I closed the investigation. We updated R1's care plan to only have female staff and care in pairs was implemented during the investigation. I offered her a room change and she refused. On 2/16/24 from 3:57PM - 4:10PM V7 (Cook County Police Detective) was interviewed via phone. V7 stated, I reviewed the video footage and during the time frame that the victim provided. There was a subject, a CNA in her room for approximately 15 minutes and that would be during the time frame that she made the allegation. Being that there was a delay in reporting, bed linens had been changed and she had bathed. I can't say that I have a suspect in custody, or any arrests made at this time. I can say that there's two suspects but until I do a photo lineup with the victim, I won't be able to properly identify the subjects. I shared the same information with the administration of the nursing home. I met with V1 (Administrator) on the date of the incident (reporting) and wanted to try to get video footage because like I said it was delayed by four days. The recordings were put on my flash drive. The monitors for it are on the 3rd floor but the base for it is the basement - the DVR storage device was in the basement. So, we had viewed it up there and then I was able to transfer it but (V1) had to go tend to other issues, but the Maintenance Supervisor watched the video with me. He was the one helping me load it onto the flash drive. The first thing I did was collect video footage, the incident allegedly Sunday between 11am - midnight; and we identified the days V8 (Registered Nurse) off, Fri - Mon from 11-midnight. While viewing the footage I can see the subject in the hallway - one goes in the room for approx. 15 minutes and the other one was outside. I have to get a proper identity by photo lineup with the victim. Ideally, she will be able to identify someone. We need to have the proper evidence to present to the State's Attorney's office. It's just paused at this point, and it was delayed because of lack of evidence (i.e., clothing, linens - it was reported about four days later). I would say that they (V5 and V6 / CNA's) should be off pending criminal investigation. The victim (R1) is still residing there; she wanted to stay at the facility. My concern (with V5 and V6 allowed to be back at work) would be how are they interacting with her or threatening her while they are on duty. Unless she is protected. I would say my opinion is they shouldn't be working. I told V1 (Administrator) the same thing I'm telling you. On 2/16/24 at 4:52PM, V9 (Regional Plant Operations), confirmed that he was the individual helping the police detective (V7) download the video from the facility footage. V9 said, (about the video), I watched a little of it, I was more trying to get the thumb drive. I think the time frame was from about 11:30PM - 1AM but it was hard to tell the time because we were forwarding it at like 32x speed. I can't tell you how long it was in actuality, but I saw one CNA go in for some time and then two CNA's. They're nighttime staff so I didn't recognize them, or could I tell you who they are. The video stays on the hard drive for like 24 hours or three days, something like that. We pay an outside company. There are no copies. I think after a certain amount of time, they can't access it. They have to have enough memory. On 2/17/24 from 9:17AM - 9:50AM, V7 (Cook County Police Detective) was interviewed in person. V7 stated regarding R1's sexual assault, It was reported four days after it happened. So, the investigation is considered delayed because at that point there may have been more evidence. It's an ongoing investigation. First (R1) said she didn't know what day it happened but then she said it was on a day that (V8 Registered Nurse) was off, so we determined it happened sometime between Friday - Monday. V7 expressed concern over how the facility is keeping R1 safe from the CNA's (V5 and V6) and how is the facility ensuring that R1 is not being intimidated by staff. V7 was asked about facility's statement that there were inconsistencies regarding R1's story, V7 shrugged his shoulders and said, We have to treat it as if it happened until we have evidence of the contrary. On 2/19/24 at 11:28AM, V10 (Hospital Site SANE Clinical Lead) was interviewed via phone and said, I did not do the exam myself, but I am the supervisor. (At the hospital), R1's sexual assault exam finished up at like 8PM or so. V10 was asked if it is uncommon for there to be no visible or physical injuries in cases of rape, since R1's hospital record does not document any bruises or scratches, etc. V10 replied that in the setting of sexual assault, it is not uncommon for there to be no documented physical injuries. V10 said, The female genitalia, in particular, by design is able to accommodate items being inserted into it so there may not always be any physical signs. That would not be an indicator of whether something was inserted or not. We don't release the medical forensic documentation because it is evidentiary, it would need to be subpoenaed. V10 was asked if there was any reason to believe R1 was not being truthful about the events that happened and responded, I believe all of my survivors. These exams are very intrusive and traumatic for the patient. I would think that someone who is willing to subject themselves to something of this nature would do so for a reason. There are photos and samples, etc. taken. These exams are very intrusive (emphasized) - they are not easy to go thru. There's nothing in the charting that names the particular person (aggressor). V10 was asked about facility concern that R1's story was inconsistent. V10 responded, They are not at liberty to make that judgment. Everyone has a different level of comfort with law enforcement - it is possible that depending on the person's comfort level they would provide more or less information. Everyone's experience is different, and it is possible that they may say more or less with different people, it's not unusual. There is no one way that survivors will act as everyone is different and responds differently. It was very strange and inappropriate for the facility to repeatedly ask for the full forensic record when we have told them repeatedly that we cannot divulge that information. That is information that we can only provide to the patient herself. On 2/17/24 at 12:42PM, V11 (Social Services Director) was interviewed. V11 stated she first spoke to R1 about the sexual abuse and then spoke to the husband. V11 stated R1 told her there was a guy, she had turned on her call light and he answered her call light. V11 said, He tried to kiss her, and she pushed him away and told him to get out, go away and he left. I asked her to describe him, she said he was medium build, not too tall, [NAME] haircut, and of African descent. She said she had seen him before, but he was not her caregiver that night and that she hoped she wasn't making a mistake in reporting this. V11 was asked if R1 has a history of making false allegations while in the facility. V11 said, (R1) has no history of making false allegations that I am aware of. She did tell me that in her younger years someone touched her inappropriately and now the person is in jail because of it. V11 was asked about her training with sexual assault victims and stated, about five years I had training on how to interview a person, body language, tone of voice, sincerity in their voice. We look at family history, background, diagnoses. The only thing that really stood out was that her story was inconsistent. Surveyor asked V11 to go into more detail about the so-called inconsistency in R1's recollection but V11 did not provide any specific examples of what was inconsistent in R1's recollection of events. V11 added, she did speak with R1's husband and that R1's brother is currently the POA but R1 wanted to change it to be her husband. V11 was asked why R1 needs a POA and V11 clarified R1 needed a POA because when she came in, she was not alert and decisional because of her medical history. V11 said, She does have history of anoxic brain injury and history of schizoaffective disorder, but if she didn't want a POA right now, she wouldn't need one. It's her choice, she wants to have one. Surveyor asked if R1 was currently receiving any care from psychiatry or psychologist and facility provided current notes from psychology visits for January and February 2024, there is nothing in the psychology notes indicating that R1 is delusional or shows poor insight, judgement. Notes document that R1's strengths include that R1 is friendly, open minded, honest, engaged, and demonstrates awareness. Psychiatric Note, written by V12 (Mental Health Nurse Practitioner) dated 11/3/2023 documents R1 has a history of depression, panic attacks, and anxiety; has not had any psychiatric hospitalization s in the past and has seen outpatient psychiatrist in the past. R1 has reported no psychosis or hallucinations and it is documented that it appears unlikely that R1 has diagnosis of schizoaffective disorder. Attempted to contact V12 during this survey but was unable to reach V12. Interview with V6 (CNA) on 2/21/24 at 3:59PM, V6 said, I started working there in July 2023. I have worked on the first, second, or third floor. Right now, I am a floater, but I work on the third floor the most. I used to have a regular schedule, but the management of the office was not stable for like four months now. They were changing DON's and Administrators and schedulers. I used to work all weekends, Thursday thru Sunday but due to the unstable management issue, I only work night shift, 7pm to 7am. I am familiar with(R1). I don't normally work with her like that because I get rotated. I don't work on that (East) side that much. I work more on the [NAME] side of the third floor. In a two week pay period, I might work only one or two times on the third floor, east side. She (R1) is one person assist because she can turn and scoot up on her own. She is a good woman, she is nice. She is confused and our duty is to correct her. Sometimes I don't understand what she is saying. Sometimes her sheets are all wet and I have to tell her to press her call light. She does press her call light but once in a while she doesn't use it. She is able to make her needs known and will ask for the nurse if she needs her meds. She usually calls when her phone is not charging and will ask for a charger or her phone is dead. Sometimes when I go to her, she will tell me about her husband being pulled over while driving. I haven't seen any changes in her behavior. She has never reported any inappropriate behavior to me. I was shocked when they told me that she made those allegations. I don't think anyone would do such a thing to her. She is alert enough to shout out or report to the nurse. She is not slow or dull to the extent that she would not be able to report to the next person that comes into room. I have never tried to touch or kiss her inappropriately. I would never do that to any one of my residents. I would never do such a thing to a woman, let alone a bed bound woman. I would rather kill myself first. My administrator said that the person who abused her has worked here for a long time, more than two years. I don't think that I have even worked more than three days in February. Review of facility provided Timecard for V6 (CNA) shows that V6 worked the 7pm - 7am shift on February 1, 2, 3, 4, 5, and 6; on February 6, 2024, worked until 7am and then was not back on duty again until February 15, 2024, at 7pm. Interview with V5 (CNA) on 2/21/24 at 3:17PM. V5 said, I normally work 7pm - 7am. I don't remember exactly what days I worked but I usually Mon, Tue, Wed. I can't really recollect but I don't work a particular floor. I float. I don't have a permanent floor. I might be assigned to first floor one day and then third floor another day. I have experience working on all floors. I am familiar with (R1). She is alert and a bit disoriented, she is not stable mentally. She will talk about things in the past and bringing them to the present - like being confused. She is incontinent and I help her by changing her brief when she has a bowel movement. She is bed bound, to my knowledge she never gets out of bed. She is a total care. Recently she has been agitated, like she wants to go home. I think she is bored being there. She is a little bit scared. I don't know what is responsible for that. In my opinion, she is just bored of being there and wants to go home. She has been shaking like when I ask her to turn, when I am giving her care. She is like nervous. I have not been working with her, so I work with her only once in a while. I have not worked with her since about the 23rd. The last time I worked with her was on Monday night into Tuesday - the 5th (February). Before that, it had been a long time. I have not been on that side in a long time. On that night, she had called like four times. When I went into the room, she said she didn't need anything and didn't realize she had pulled the call light. The third time, she had me plug the socket back into the wall for the call light. Then the fourth time, she asked me to change her. She had a very large bowel movement; I cleaned her very well and gave her a new brief and she asked for water. I got her water and she said thank you. It was around 11-12 midnight. That was how I left her that night. She didn't call during the night. I did the normal routine of checking through the night, and she was asleep. In the morning, I asked her if she needed to be changed and she said she was dry. That was on Tuesday morning before I left. I never attempted to kiss her or touch her inappropriately. Never, never, I would never do that. I have worked as a CNA for about seven years. I have dealt with dementia patients, and I have been accused of being sexually inappropriate. I have never been found guilty or convicted of any type of abuse towards a resident. Review of facility provided Timecard for V5 (CNA) shows that V5 worked the 7pm - 7am shift on February 1, 2, 3, 4, 5, 6, 7, and 8; on February 8, 2024, worked until 7am and then was not back on duty again until February 14, 2024, at 7pm. Documentation of facility investigation, staff interviews, documents the following: 2. (V6 - CNA) interviewed 2/8/2024 3:44pm. He worked over the weekend and remembered being assigned to 3rd floor, (R1's room#). He is a floater, and he works 2nd floor and 3rd floor. Resident is incontinent and can be wet during the night. He recalled in one of the nights he worked with her that she was very wet. She allowed him to clean and change her diaper, gown/clothes, and sheets. She always says Thank you after incontinence care. One night, (R1) told him that he forgot to put powder in between her thighs, so he did put powder as preferred by the patient and then he closed the diapers. He does not have any issue with patient. - SUSPENDED PENDING INVESTIGATION 3. (V5 - CNA) called twice at 3:57 pm 2/8/2024. Returned call at 4:22pm, recalled having worked in 3rd floor, said that he did not do anything wrong. SUSPENDED PENDING INVESTIGATION 4. V13 (LPN) - called at 4:15 pm on 2/8/2024 Regular nurse scheduled in 3rd floor. (R[TRUNCATED]

Based on interviews and record review, the facility failed to have a system in place to prevent residents from potential abuse by staff after an allegation of staff to resident sexual abuse was made and while allegation was still pending investigation by law enforcement. This failure applied to one of one (R1) resident reviewed for sexual abuse investigation and has the potential to affect the 146 residents currently in the facility. The Immediate Jeopardy began on 2/14/24 when V5 (CNA) was allowed to return to work with no mitigating interventions put in place to protect residents from further abuse after V5 was identified as being a potential aggressor in an allegation of sexual abuse that is still under investigation with local law enforcement authorities. V1 (Administrator) and V4 (Regional Director of Operations) were notified of the Immediate Jeopardy on 2/20/24 at 2:20PM. The surveyor confirmed by interview and record review, that the Immediate Jeopardy was removed on 2/21/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: Upon survey entrance on 2/16/24, V1 (Administrator) provided facility census as 146 residents. R1 is a [AGE] year old female, initially admitted to the facility on [DATE] with medical history that includes: anoxic brain damage, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, history of sudden cardiac arrest, fusion of the cervical spine region, need for assistance with personal care, post-traumatic stress disorder, muscle weakness, Schizoaffective disorder, depression, anxiety, and aphonia (loss of ability to speak related to disease). Review of R1's medical record included review of the following documentation: MDS (Minimum Data Set) assessment dated [DATE], documents R1's BIMS (Brief Interview for Mental Status) score as a 15 - indicating that cognition is intact. Physician Order Summary (active orders as of 2/19/24) documents the following physician orders: - Monitor for side effects of anti-depressive and antianxiety medication (Order Date 1/17/24) - Only female staff to work with resident, work in pairs every shift (Order Date 2/14/24) - Alprazolam tablet 0.5mg Give 1 tablet by mouth three times a day for Anxiety (Order Date 5/25/23) - Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 1 tablet by mouth at bedtime for Depression related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED (F32.9) (Order Date 10/11/23) - Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth in the morning for depression total of 25mg (Order Date 10/06/23) It is to be noted that other than above medications for anxiety and depression, R1 has no current orders for any other psychotropic or psychiatric medications. Review of behavior tracking for the past month for R1, does not document any events of inappropriate behavior (i.e., hallucinations, inappropriate behavior, yelling/screaming, etc.). Reviewed R1's nursing progress nurse - nothing noted in progress notes that indicates that R1 has been exhibiting any signs and symptoms of psychosis or inappropriate behaviors. Resident electronic medical record has flag that reads: Special Instructions: FEMALE STAFF ONLY, CARE IN PAIRS. Enhanced Barrier Precaution: History of MDRO,KPC; Site; GB Bile; Duration: Indefinite. //HIGH FALL RISK//. Care plan for abuse trauma mistreatment PSWB mood was initiated on 2/8/24 and includes intervention of having two caregivers address her needs and observe the entire situation. Have supervisory personnel observe care delivery, as possible and in accordance with privacy and dignity considerations. Social Service Trauma Screening dated 1/19/24 documents (Question #5) R1 has no psychiatric history and/or present mental health diagnosis, including psychotic symptoms (e.g., delusional thinking, hallucinations) and possible misinterpretation of events and the intentions of others; (Question #8) R1 has no history or presence of dysfunctional behavior (e.g., provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking, criminal history and/or otherwise abrasive/inappropriate behavior), including roaming/wandering into peer's rooms/personal space. Total score on Trauma Screening was a 2; per scale, a 2 is less than minimal symptomology. Hospital record for visit on 2/8/24 does not indicate that there are any physical injuries but hospital documents that R1 agreed to SANE (Sexual Assault Nurse Examiner) assessment and was prescribed antibiotics prophylactically. Facility provided documentation of incident and investigation regarding allegation that R1 made of sexual abuse against a facility staff member. Per facility report, On February 8, 2024, at about 11:45am, received report that resident alleged that a few nights ago, between Friday and Monday night (2/2/2024 to 2/5/2024), a male CNA, African-American, with [NAME] hairstyle, came into her room, standing at the bedside leaning on the bed, then started kissing her face, touching her chest area, and attempted to open her legs. CNA whispered to her that they should have a relationship. Per resident, she pushed him away and he left the room. No other physical contact occurred after this. The resident is unable to remember exactly when the incident happened and unable to identify the name of the alleged perpetrator. The resident stated that the CNA was not assigned to care for her. Investigation started, nursing assessment nursing assessment conducted with no significant findings noted, police came and interviewed resident, family notified, physician called with order to transfer resident to ER. Resident initially declined to go to the hospital. After explanation and encouragement, she agreed and was picked up by paramedics and transported to the hospital. A few hours later, resident returned to facility in stable condition with new order for Doxycycline and Metronidazole PO until 2/16/2024 for prophylaxis. Family notified by resident herself. Physician informed and updated. ER visit note dated 2/8/2024 revealed no visible signs of abuse or neglect .Resident is alert and oriented x 2-3, has the demonstrated ability to use the call light, she has clear speech, she owns a cellular phone in addition to facility phone at her bedside, and she talks to her husband every day. While at the facility, resident has history of calling 911 herself when she was in distress. She did not place any call to 911 during or immediately after this alleged incident. At the time of reporting, resident denied any sexual penetration, she denied pain and no new skin alteration noted during physical assessment. Resident's vital signs remain within baseline, no changes in mental state, range of motion, or appetite, and she did not appear to be in any form of distress. Resident verbalized feeling safe at the facility. Resident chose to go back to the facility despite having the opportunity to be transferred from the hospital to another care facility. Resident expressed a desire to stay in her current room and she also verbalized to not having a preference for the gender of a caregiver. Resident seen and examined by multiple providers and continued to be assessed by clinical staff after the brief ER visit. Psychotherapist, Psychiatric NP, County Detective, and IDT team followed up with resident's allegations. Resident was re-interviewed. Resident reported significant inconsistencies in her statements. Hospital and other medical records reviewed, and husband/family interviews made. Records revealed that resident had panic attacks since she was about 8 years old. She recalled having been asked a lot of questions by the police when she was in first grade. She was sexually abused by her own father when she was young. Resident can be anxious, restless, and frustrated at times secondary to adjustment due to loss of independence, and adjustment to health decline. She has long history of anxiety which goes back to childhood due to past traumatic events and reported seeing outpatient psychiatrists in the past. Currently taking psychotropic medications. Based on the description by the resident of the perpetrator, there is no African American male CNA with [NAME] hairstyle who work at the facility during night shift. Investigation completed. Allegation of sexual abuse made by the resident is not substantiated. Facility is working closely with law enforcement regarding this case. County detectives and police are conducting a separate investigation. Resident continues to reside at the facility. Wellness checks ongoing. Care plan meeting held with resident/family and IDT in attendance. Care plans updated. Resident and family informed of the outcome of the investigation. No concerns presented. Interview with R1 on 2/16/24 at 5:07PM, R1 was noted to be alert and oriented to person, place, and time and seemingly of sound mind - statements were coherent and appropriate. R1 stated that she was told by the facility that someone from the State was coming to talk to her and that she did not have a problem talking with State surveyor. R1 stated that she alleged that a CNA sexually abused her but did not feel like she was taken seriously. R1 stated that they (facility) were just trying to cover their a**es. R1 added that the two male police officers that interviewed her initially, while still at the facility did not appear to take her seriously because they were whispering and making faces at each other. R1's eyes were visibly watering up throughout interview. R1 said she had been thru a similar incident in her 20's, where she was raped after a party. R1 said she thought she was over with this part of her life. R1 stated the CNA was not her regularly assigned CNA but that he had provided care for her before. R1 said he had tried to kiss her previously, but she shoved him away and he left her alone. R1 stated she did not report this because she thought he was just being playful since he stopped when she told him get out of here. R1 added, but on this day (of the sexual assault), he was in a mood, like a bad mood and nothing was going to stop him. R1 then changed the subject and proceeded to talk about her daughters and wanting to just go home and get out of the facility. R1 was seemingly disturbed and did not want to talk about the sexual assault allegation any longer. Surveyor advised R1 that we did not have to talk about it anymore if she was uncomfortable and the interview could be continued later. R1 was interviewed on 2/17/24 at 2:36PM, R1 was again noted to be alert and oriented to person, place, and time and seemingly of sound mind. Surveyor asked R1 to please recount the events that occurred on the night of the sexual assault that she reported. R1 stated the CNA involved, came into her room after she pressed her call light because she needed to be cleaned up after a bowel movement. After the CNA provided care, R1 stated, he just came up and was pushing on me. R1 was asked if she knew the name of the individual and she said he has an African name that she cannot pronounce but that she could identify him if she saw him. R1 added he has taken care of her in the past. He has a strong accent, and he has a [NAME]. Surveyor asked R1 to elaborate on the [NAME] hairstyle and R1 said, it's not like an 80's punk, it's the shape of the lining but it's only about an inch or two thick. R1 stated the CNA inserted his penis into her vagina. R1 said that her brain wouldn't let her talk. (It is to be noted that R1 has a medical condition - aphonia - that limits her ability to speak). R1 stated she used to have a black belt in karate and that if her legs weren't weak, she would be able to fight and defend herself. R1 said, I hate to say that he is stronger than me. I couldn't understand well what he was saying. I kept moving like a fish. I didn't have a roommate at the time. Surveyor asked R1 if there is any particular reason why she didn't report right after the incident happened. R1 stated she didn't report it because she wasn't planning to tell anyone because she felt ashamed. R1 stated, There was this white guy (CNA) working with me the next day or whenever it was. He was nice and we were talking and then the next thing I know he got the nurse and then I told her about it. It all happened so fast at that point. R1 said, I feel like the first two cops who came didn't believe me. R1 was visibly upset and started using profanity to express how angry she was at the assailant and how she would physically hurt him if she could. R1 said about the police officers that, something like this should happen to them to see how they feel about it and F*** them . R1 added she felt ashamed and didn't know what would happen if she told. What if the facility threw her out for reporting? Surveyor asked R1 if she ever told the nurse at the facility that the male CNA put his penis in her vagina. R1 said, I don't think so, I don't think I got that far because she ran out pretty quickly. They came in and were asking me questions and next I remember; I was here talking to the two cops. R1 was asked if there were any other details about the CNA involved that she could remember. R1 said that on previous occasions when he works, she has seen him wearing a black jacket, like a [NAME] light jacket or something; he doesn't wear glasses or anything like that. On 2/17/24 at 1:29PM V8 (Registered Nurse) was interviewed and confirmed that she was the nurse who took the report of sexual abuse from R1. V8 said, I've worked here since October 2022. R1 is pretty much alert and oriented times three, she is a little forgetful. She needs full care, and she makes her needs known. She has no Alzheimer's or Dementia, sometimes she has a hard time finding the words to say. I can't recall the exact date, but the CNA called me into the room because she had a bruise on her belly, but it was from the shot that she had gotten and I started asking her if anyone had been rough with her, etc. Then she asked to talk to me privately. She said that somebody tried to put it in. I said what do you mean, and she said you know what I mean. I asked her if I could tell the DON because I told her it was inappropriate and if it was okay to tell the DON because the DON is male. She never said that he put it in. I did not tell the detective anything different than what I am telling you. I have been working with her since June and she is comfortable talking to me. She said she meant to tell me and that she had seen him before. I think if you showed her a picture, she could point him out; per R1's description, he wasn't that tall, thick African accent, he's black and dark skin (not caramel). On 2/17/24 at 12:18PM V2 (Director of Nursing) was interviewed regarding R1's sexual abuse. V2 stated, V8 (Registered Nurse), came to my office and told me that R1 reported sexual abuse. So, we went together to talk to R1. R1 said that a few days ago - it happened on a day that V8 was not working - R1 said that a CNA came into her room and was standing next to her watching TV. He said they should be in a relationship. He started kissing her face and touching her chest. He was touching her left leg but her left leg was weak. She said she was able to push him off. Then he left and never came back. She said he was African American, stocky, about my height. Then I went to V1 (Administrator), and we followed the protocols. I spoke to her family. The brother was concerned. The social worker reached out to her spouse. At the time of the incident, R1 couldn't yell out because she has issues with her voice. She has no history of reporting being abused while being here in the facility. V2 was asked about R1's cognitive status and V2 said that R1 has normal cognition and coherent thought processes. Surveyor asked if V2 had any special training or experience in how to approach victims of sexual abuse. V2 said, I haven't had any special abuse training while I have been here. V2 added V6 (CNA) was the assigned CNA for R1 on the night that they had narrowed down the incident to but that R1 was adamant that it wasn't him who assaulted her. V1 (Administrator) was interviewed on 2/16/24 at 11:02AM. V1 stated the nurse (V8) had made an allegation of sexual abuse to V2 (Director of Nursing) and then V2 reported it to V1. V1 stated, 911 was called, along with the physician, and the police. The police came to the facility and a report was filed. They physician ordered for R1 to be transferred to the local hospital. V1 said, When I reviewed the hospital record, there was no evidence of sexual abuse. Police, detectives, and CSI came to the facility. R1 had said that it was a CNA on the night shift, who was not assigned to her, a black male. Per R1, the CNA had a similar build to V2 (Director of Nursing). She said it happened when V8 (Registered Nurse) was not here. Those dates were narrowed down to February 2nd - 5th but at some point, she told the police it was on Sunday. I got the punches and schedule from HR to identify who worked that Sunday and identified four black, male staff who worked that night. Based on their description, I immediately suspended V5 (CNA) and V6 (CNA). V1 added that she immediately interviewed, educated, and suspended V5 and V6. V6 had been assigned to care for R1 on that night and V5 was assigned on the second floor. V1 stated, I suspended them both on the 8th (February). I could not substantiate the allegation, so I closed the investigation. We updated R1's care plan to only have female staff and care in pairs was implemented during the investigation. I offered her a room change and she refused. On 2/16/24 from 3:57PM - 4:10PM V7 (Cook County Police Detective) was interviewed via phone. V7 stated, I reviewed the video footage and during the time frame that the victim provided. There was a subject, a CNA in her room for approximately 15 minutes and that would be during the time frame that she made the allegation. Being that there was a delay in reporting, bed linens had been changed and she had bathed. I can't say that I have a suspect in custody, or any arrests made at this time. I can say that there's two suspects but until I do a photo lineup with the victim, I won't be able to properly identify the subjects. I shared the same information with the administration of the nursing home. I met with V1 (Administrator) on the date of the incident (reporting) and wanted to try to get video footage because like I said it was delayed by four days. The recordings were put on my flash drive. The monitors for it are on the 3rd floor but the base for it is the basement - the DVR storage device was in the basement. So, we had viewed it up there and then I was able to transfer it but (V1) had to go tend to other issues, but the Maintenance Supervisor watched the video with me. He was the one helping me load it onto the flash drive. The first thing I did was collect video footage, the incident allegedly Sunday between 11am - midnight; and we identified the days V8 (Registered Nurse) off, Fri - Mon from 11-midnight. While viewing the footage I can see the subject in the hallway - one goes in the room for approx. 15 minutes and the other one was outside. I have to get a proper identity by photo lineup with the victim. Ideally, she will be able to identify someone. We need to have the proper evidence to present to the State's Attorney's office. It's just paused at this point, and it was delayed because of lack of evidence (i.e., clothing, linens - it was reported about four days later). I would say that they (V5 and V6 / CNA's) should be off pending criminal investigation. The victim (R1) is still residing there; she wanted to stay at the facility. My concern (with V5 and V6 allowed to be back at work) would be how are they interacting with her or threatening her while they are on duty. Unless she is protected. I would say my opinion is they shouldn't be working. I told V1 (Administrator) the same thing I'm telling you. On 2/16/24 at 4:52PM, V9 (Regional Plant Operations), confirmed that he was the individual helping the police detective (V7) download the video from the facility footage. V9 said, (about the video), I watched a little of it, I was more trying to get the thumb drive. I think the time frame was from about 11:30PM - 1AM but it was hard to tell the time because we were forwarding it at like 32x speed. I can't tell you how long it was in actuality, but I saw one CNA go in for some time and then two CNA's. They're nighttime staff so I didn't recognize them, or could I tell you who they are. The video stays on the hard drive for like 24 hours or three days, something like that. We pay an outside company. There are no copies. I think after a certain amount of time, they can't access it. They have to have enough memory. On 2/17/24 from 9:17AM - 9:50AM, V7 (Cook County Police Detective) was interviewed in person. V7 stated regarding R1's sexual assault, It was reported four days after it happened. So, the investigation is considered delayed because at that point there may have been more evidence. It's an ongoing investigation. First (R1) said she didn't know what day it happened but then she said it was on a day that (V8 Registered Nurse) was off, so we determined it happened sometime between Friday - Monday. V7 expressed concern over how the facility is keeping R1 safe from the CNA's (V5 and V6) and how is the facility ensuring that R1 is not being intimidated by staff. V7 was asked about facility's statement that there were inconsistencies regarding R1's story, V7 shrugged his shoulders and said, We have to treat it as if it happened until we have evidence of the contrary. On 2/19/24 at 11:28AM, V10 (Hospital Site SANE Clinical Lead) was interviewed via phone and said, I did not do the exam myself, but I am the supervisor. (At the hospital), R1's sexual assault exam finished up at like 8PM or so. V10 was asked if it is uncommon for there to be no visible or physical injuries in cases of rape, since R1's hospital record does not document any bruises or scratches, etc. V10 replied that in the setting of sexual assault, it is not uncommon for there to be no documented physical injuries. V10 said, The female genitalia, in particular, by design is able to accommodate items being inserted into it so there may not always be any physical signs. That would not be an indicator of whether something was inserted or not. We don't release the medical forensic documentation because it is evidentiary, it would need to be subpoenaed. V10 was asked if there was any reason to believe R1 was not being truthful about the events that happened and responded, I believe all of my survivors. These exams are very intrusive and traumatic for the patient. I would think that someone who is willing to subject themselves to something of this nature would do so for a reason. There are photos and samples, etc. taken. These exams are very intrusive (emphasized) - they are not easy to go thru. There's nothing in the charting that names the particular person (aggressor). V10 was asked about facility concern that R1's story was inconsistent. V10 responded, They are not at liberty to make that judgment. Everyone has a different level of comfort with law enforcement - it is possible that depending on the person's comfort level they would provide more or less information. Everyone's experience is different, and it is possible that they may say more or less with different people, it's not unusual. There is no one way that survivors will act as everyone is different and responds differently. It was very strange and inappropriate for the facility to repeatedly ask for the full forensic record when we have told them repeatedly that we cannot divulge that information. That is information that we can only provide to the patient herself. On 2/17/24 at 12:42PM, V11 (Social Services Director) was interviewed. V11 stated she first spoke to R1 about the sexual abuse and then spoke to the husband. V11 stated R1 told her there was a guy, she had turned on her call light and he answered her call light. V11 said, He tried to kiss her, and she pushed him away and told him to get out, go away and he left. I asked her to describe him, she said he was medium build, not too tall, [NAME] haircut, and of African descent. She said she had seen him before, but he was not her caregiver that night and that she hoped she wasn't making a mistake in reporting this. V11 was asked if R1 has a history of making false allegations while in the facility. V11 said, (R1) has no history of making false allegations that I am aware of. She did tell me that in her younger years someone touched her inappropriately and now the person is in jail because of it. V11 was asked about her training with sexual assault victims and stated, about five years I had training on how to interview a person, body language, tone of voice, sincerity in their voice. We look at family history, background, diagnoses. The only thing that really stood out was that her story was inconsistent. Surveyor asked V11 to go into more detail about the so-called inconsistency in R1's recollection but V11 did not provide any specific examples of what was inconsistent in R1's recollection of events. V11 added, she did speak with R1's husband and that R1's brother is currently the POA but R1 wanted to change it to be her husband. V11 was asked why R1 needs a POA and V11 clarified R1 needed a POA because when she came in, she was not alert and decisional because of her medical history. V11 said, She does have history of anoxic brain injury and history of schizoaffective disorder, but if she didn't want a POA right now, she wouldn't need one. It's her choice, she wants to have one. Surveyor asked if R1 was currently receiving any care from psychiatry or psychologist and facility provided current notes from psychology visits for January and February 2024, there is nothing in the psychology notes indicating that R1 is delusional or shows poor insight, judgement. Notes document that R1's strengths include that R1 is friendly, open minded, honest, engaged, and demonstrates awareness. Psychiatric Note, written by V12 (Mental Health Nurse Practitioner) dated 11/3/2023 documents R1 has a history of depression, panic attacks, and anxiety; has not had any psychiatric hospitalization s in the past and has seen outpatient psychiatrist in the past. R1 has reported no psychosis or hallucinations and it is documented that it appears unlikely that R1 has diagnosis of schizoaffective disorder. Attempted to contact V12 during this survey but was unable to reach V12. Interview with V6 (CNA) on 2/21/24 at 3:59PM, V6 said, I started working there in July 2023. I have worked on the first, second, or third floor. Right now, I am a floater, but I work on the third floor the most. I used to have a regular schedule, but the management of the office was not stable for like four months now. They were changing DON's and Administrators and schedulers. I used to work all weekends, Thursday thru Sunday but due to the unstable management issue, I only work night shift, 7pm to 7am. I am familiar with(R1). I don't normally work with her like that because I get rotated. I don't work on that (East) side that much. I work more on the [NAME] side of the third floor. In a two week pay period, I might work only one or two times on the third floor, east side. She (R1) is one person assist because she can turn and scoot up on her own. She is a good woman, she is nice. She is confused and our duty is to correct her. Sometimes I don't understand what she is saying. Sometimes her sheets are all wet and I have to tell her to press her call light. She does press her call light but once in a while she doesn't use it. She is able to make her needs known and will ask for the nurse if she needs her meds. She usually calls when her phone is not charging and will ask for a charger or her phone is dead. Sometimes when I go to her, she will tell me about her husband being pulled over while driving. I haven't seen any changes in her behavior. She has never reported any inappropriate behavior to me. I was shocked when they told me that she made those allegations. I don't think anyone would do such a thing to her. She is alert enough to shout out or report to the nurse. She is not slow or dull to the extent that she would not be able to report to the next person that comes into room. I have never tried to touch or kiss her inappropriately. I would never do that to any one of my residents. I would never do such a thing to a woman, let alone a bed bound woman. I would rather kill myself first. My administrator said that the person who abused her has worked here for a long time, more than two years. I don't think that I have even worked more than three days in February. Review of facility provided Timecard for V6 (CNA) shows that V6 worked the 7pm - 7am shift on February 1, 2, 3, 4, 5, and 6; on February 6, 2024, worked until 7am and then was not back on duty again until February 15, 2024, at 7pm. Interview with V5 (CNA) on 2/21/24 at 3:17PM. V5 said, I normally work 7pm - 7am. I don't remember exactly what days I worked but I usually Mon, Tue, Wed. I can't really recollect but I don't work a particular floor. I float. I don't have a permanent floor. I might be assigned to first floor one day and then third floor another day. I have experience working on all floors. I am familiar with (R1). She is alert and a bit disoriented, she is not stable mentally. She will talk about things in the past and bringing them to the present - like being confused. She is incontinent and I help her by changing her brief when she has a bowel movement. She is bed bound, to my knowledge she never gets out of bed. She is a total care. Recently she has been agitated, like she wants to go home. I think she is bored being there. She is a little bit scared. I don't know what is responsible for that. In my opinion, she is just bored of being there and wants to go home. She has been shaking like when I ask her to turn, when I am giving her care. She is like nervous. I have not been working with her, so I work with her only once in a while. I have not worked with her since about the 23rd. The last time I worked with her was on Monday night into Tuesday - the 5th (February). Before that, it had been a long time. I have not been on that side in a long time. On that night, she had called like four times. When I went into the room, she said she didn't need anything and didn't realize she had pulled the call light. The third time, she had me plug the socket back into the wall for the call light. Then the fourth time, she asked me to change her. She had a very large bowel movement; I cleaned her very well and gave her a new brief and she asked for water. I got her water and she said thank you. It was around 11-12 midnight. That was how I left her that night. She didn't call during the night. I did the normal routine of checking through the night, and she was asleep. In the morning, I asked her if she needed to be changed and she said she was dry. That was on Tuesday morning before I left. I never attempted to kiss her or touch her inappropriately. Never, never, I would never do that. I have worked as a CNA for about seven years. I have dealt with dementia patients, and I have been accused of being sexually inappropriate. I have never been found guilty or convicted of any type of abuse towards a resident. Review of facility provided Timecard for V5 (CNA) shows that V5 worked the 7pm - 7am shift on February 1, 2, 3, 4, 5, 6, 7, and 8; on February 8, 2024, worked until 7am and then was not back on duty again until February 14, 2024, at 7pm. Documentation of facility investigation, staff interviews, documents the following: 2. (V6 - CNA) interviewed 2/8/2024 3:44pm. He worked over the weekend and remembered being assigned to 3rd floor, (R1's room#). He is a floater, and he works 2nd floor and 3rd floor. Resident is incontinent and can be wet during the night. He recalled in one of the nights he worked with her that she was very wet. She allowed him to clean and change her diaper, gown/clothes, and sheets. She always says Thank you after incontinence care. One nigh[TRUNCATED]

Based on observation, interviews, and record reviews, the facility failed to implement intervention in preventing the development and worsening of pressure ulcers on a resident with physical and cognitive impairment. This failure applied to one (R36) of three residents reviewed for skin breakdown and resulted in R36's intact skin developing an unstageable pressure ulcer on the right buttock and right ischium; and Stage 3 pressure ulcer on the left ischium worsened into Unstageable. Findings include: R36 is a [AGE] year-old, male, initially admitted in the facility on 12/31/21 with diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia; Human Immunodeficiency Virus (HIV) Disease; Nontraumatic Intracerebral Hemorrhage, Unspecified; Metabolic Encephalopathy; Schizoaffective Disorder, Depressive Type; Anxiety Disorder, Unspecified; Contracture of Muscle, Right Upper Arm and Contracture of Muscle, Left Upper Arm. Per MDS (Minimum Data Set) dated 08/16/23, under Section C, R36 has long and short-term memory impairment. R36's cognitive skills for daily decision making are severely impaired. On 11/06/23 at 10:20 AM, R36 was observed in bed, asleep. He was using a low air loss mattress. R36 is nonverbal, does not respond to verbal stimuli but wakes up when repositioned. Facility's pressure ulcer list indicated that R36 has facility acquired pressure ulcers on the left ischium, right ischium, and right buttock/trochanter. On 11/07/23 at 11:30 AM, R36 was observed for wound care. The left ischium pressure ulcer had 95% (percent) granulation tissue with 2-5% slough present. The right ischium and right trochanter pressure ulcers' wound beds appeared beefy red; on negative pressure wound therapy at -125 mm Hg (millimeters mercury). R36 Physician Wound notes recorded the following, with corresponding measurements: 04/03/23: Stage 3 pressure wound of the left ischium was identified, duration of more than 1 day - 0.8cm (centimeters) x 0.5cm x 0.3cm 04/17/23: Unstageable (due to necrosis) of the left ischium - 2cm x 2cm x 0.1cm 04/24/23: Stage 3 pressure wound of the left ischium - 2.6cm x 2.5cm x 1cm 05/15/23: Stage 4 pressure wound of the left ischium - 4cm x 3.5cm x 3.5cm 05/22/23: Stage 4 pressure wound of the left ischium - 4cm x 3.3cm x 3.5cm; Unstageable DTI (deep tissue injury) of the right ischium was identified - 1cm x 1cm x not measurable cm 06/01/23: Stage 4 pressure wound of the left ischium - 4.4cm x 3.3cm x 3.5cm; Unstageable DTI of the right ischium - 1cm x 0.4cm x not measurable cm 06/05/23: Stage 4 pressure wound of the left ischium - 4.8cm x 3.9cm x 3.5cm; Stage 3 right ischium - 1cm x 1cm x 0.1cm 06/19/23: Stage 4 pressure wound pressure wound of the left ischium - 5.5cm x 4.2cm x 3.5cm; Unstageable (due to necrosis) of the right ischium - 3cm x 2.7cm x 0.1cm; Unstageable (due to necrosis) of the right buttock - 5.1cm x 4cm x 0.1cm 06/26/23: Stage 4 pressure wound of the left ischium - 5.5cm x 4.1cm x 3.5cm; Unstageable (due to necrosis) of the right ischium - 4cm x 3.8cm x 0.1cm; Unstageable (due to necrosis) of the right buttock - 5cm x 4.2cm x 0.1cm 11/03/23: Plan of Care - Preventive Measures in place, general: Avoid bony prominence under direct pressure; repositioning in the bed and wheelchair as needed, or per facility protocol, if patient cannot do it. R36's census reports indicated that there were no hospitalization s occurred from 04/14/23 to 09/01/23. On 11/07/23 at 12:35 PM, V16 (Wound Care Nurse) was asked regarding R36's pressure ulcers. V16 replied, His left ischium, right ischium and right trochanter or buttock are facility acquired pressure ulcers. He developed the wounds because of moisture and not repositioning. He has HIV and wound is compromised. On 11/08/23, random observation from 9:55 AM to 12:10 PM was conducted regarding R36's repositioning. The following were observed: From 9:55 AM to 11:31 AM, R36 was observed asleep in bed, lying on his back. The head of his bed was slightly elevated. From 11:55 AM to 12:10 PM, R36 was again observed in bed, asleep, head of bed slightly elevated, and was lying on his back. V27 (Wound Care Tech) was asked regarding repositioning. V27 stated, He (R36) needs to be repositioned every two hours. We have to position him to one side and stay in that position for two hours. Then we put pillow between his knees. It was also observed that a signage was posted on R36's bedside stating, Rock and Roll. Please turn and reposition every two hours. On 11/08/23 at 11:45 AM, V22 (Licensed Practical Nurse) and V23 (Agency Certified Nurse Assistant, CNA) both stated residents with pressure ulcers need to be turned and repositioned every one to two hours. V17 (Wound Care Coordinator) was interviewed on 11/08/23 at 12:15 PM regarding R36. V17 stated, Unfortunately, in my opinion, he is immunocompromised. He has low air loss mattress; heel protectors and he needs repositioning every two hours. V19 (Wound Physician) was also interviewed on 11/08/23 at 1:56 PM regarding R36's pressure ulcers. V19 verbalized, He has severe contractures on both legs. In preventing the development of pressure ulcers, incontinence care; use of low air loss mattress and turning and repositioning every two hours. Facility's policy titled Wound Prevention and Healing dated 06/01/2022 documented in part but not limited to the following: Policy Statement: To provide wound care treatment/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician.

Based on observation interview and record review, the facility failed to provide an individualized program for supervision to prevent recurring falls for a resident and prevent a resident who is NPO from eating and drinking by mouth (R12), failed to ensure a proper system was in place for safe and secure transfers and failed to safely transport one resident (R124) while riding on the facility bus. This failure affected two residents (R12 and R124) of seven residents reviewed for accidents. R12 have had four falls since admission, was sent to the hospital after the last fall and returned to the facility with four staples to the right top forehead. R12 has been drinking his G-tube feeding, stealing, and eating food and is currently receiving antibiotic treatment for possible aspiration on food. R124 sustained two fractures to two of the right ribs during transfer. Findings include: 1. R12 is a [AGE] year-old male admitted to the facility on [DATE], with past medical history of acute respiratory failure unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease with acute exacerbation, bipolar disorder, muscle weakness, dysphagia oropharyngeal phase, schizophrenia, difficulty walking, shortness of breath etc. 11/5/2023 at 10:40AM during random observation in the unit, R12 was observed in his bed sleeping. R12 was on an air loss mattress, trach noted to the neck but was capped and not connected to the oxygen tank. R12's bed was not low to the ground. Review of progress noted showed a fall incident on 11/7/2023 documented as follows: Sent patient to hospital for witnessed fall with superficial scrape on top of right side of head. Staff, CNA was in room [ROOM NUMBER] to 15 min ago for diaper change. RT reportedly in the room [ROOM NUMBER] min ago, changing the dressing on trach due to patient removing and throwing it on the floor. Patient is awake, alert, responsive, AXO 2-3. Resident returned to the facility with 4 staples for laceration to right forehead. Review of facility fall log showed resident had a fall on 9/17/2023 (found on the floor in his room), 9/21/2023 (found on the floor at the nursing station),10/31/2023 and 11/8/2023 as documented in progress notes. Fall risk assessment dated [DATE] scored resident as 12, indicating high risk for falls. Minimum data set (MDS) assessment dated [DATE], showed section G (functional) coded R12 as requiring extensive assistance with two-person physical assist for transfer and bed mobility and extensive assistance to total dependence with one-to-two-person physical assist for all other ADLs. Care plan initiated 9/14/2023 indicated resident is at risk for falls, interventions include educate resident to use call light, frequently remind resident to use wheelchair for locomotion/long distance transfer, instruct resident to use his wheelchair for long distance transfer, etc. 11/8/2023 at 11:38AM, V4 (RN) said R12 was non-compliant with his diet, R12 is supposed to get nothing by mouth (NPO) and R12 was eating by mouth at one time. V4 stated, R12 fell at the nursing station on the third floor while carrying some ramen noodle cups. V4 asked R12 what happened but R12 could not explain. V4 said the incident happened in the evening, close to 6PM. V4 said V4 could not recall if R12 was NPO before the incident but that R12 needed assistance with ADLs including ambulation. Progress note dated 9/11/2023, documented R12 was admitted from the hospital and was supposed to have nothing by mouth (NPO). R12 has a G-tube and on Jevity 1.2, [NAME] stoma with oxygen 2 liters via nasal canula. Review of medical record showed several documentations of resident wanting to eat food by mouth, stealing food from trays and drinking his tube feeding formula. At 2:28PM, V28 (Dietary Manager) said R12 came to the facility on NPO status. R12 expressed wanting to eat. V28 spoke to R12 and explained to R12 what could happen if R12 ate by mouth. V28 said a mechanical soft diet was initiated, R12 was not tolerating diet so ENT was consulted. R12 was placed back on NPO status. On 11/8/2023 at 2:45PM V26 (ADON) said R12 came with an open stoma, R12 was supposed to be NPO but was insisting on eating. V26 said nursing staff spoke to the attending physician and he recommended to try giving resident something by mouth. However. speech therapy recommended NPO because resident could not tolerate PO feeding and was put back on NPO. V28 added resident was changed to bolus feeding to avoid R12 from drinking his tube feeding. V26 said R12's feeding should not be left in his room to avoid R12 from drinking it and possibly aspirating on it. On 9/29/2023, V33 (LPN) documented R12 was given a scheduled bolus feeding. A box of feeding was left in the room and when staff returned for the tube feeding it was gone. R12 stated he drank it. On11/9/2023 at 10:39AM, V33 (LPN) said R12 is supposed to be NPO. V33 was told R12 eats and drinks. V33 flushed the R12's tube and gave him scheduled bolus feeding. V33 said V33 left one box in a closed drawer for the next dose. Next morning V33 came to the room to give the bolus feeding and could not find it. V33 asked R12 who stated he drank the feeding. V33 said she placed the feeding in a drawer on the other side of the room. V33 said the feeding was supposed to be in the nursing station or nursing cart but she left it in the room because she was going to give it soon. V33 stated R12 could choke or get an infection from drinking his feeding. On 10/29/2023, V34 documented R12 was observed putting back G-tube feeding bottle on the pole after drinking from it. R12 was sent out to the hospital and was treated with antibiotics for possible aspiration on food. On 11/9/2023 at 10:26AM, V34 (LPN) said she did not see R12 drinking the feeding but saw R12 hanging the bottle back on the pole. R12 was on continuous feeding. R12 returned to the facility with an antibiotic prophylactic order. V34 added R12 pulls off his trach and oxygen tubing. V34 said R12 is supposed to be monitored frequently, between the nurse and the C.N.A, R12 should be monitored every 15 to 30 minutes. On 11/9/2023 at 9:55AM, V32 (Therapy Director) said she is familiar with R12. Therapy worked with R12 initially when he was first admitted . Physical therapy evaluated him on 9/13/2023 and speech evaluated him on 9/12/2023. Speech therapy declared resident not appropriate for eating by mouth due to resident having an open stoma. Diet order was NPO and recommended for R12 to follow up with ENT. R12 went to the ENT appointment and was put back on trach due to paralysis of the vocal cord. Therapy department never cleared resident to have something by mouth. V32 said she is aware R12 was eating something by mouth at one time but was a decision made by the nursing department and the attending physician that R12 did not tolerate the PO diet and was placed back on NPO. V32 said she doesn't believe R12 had a video swallow study. R12 failed the ones he had at the hospital according to the hospital record. R12 had not had another swallow study because the scheduler stated was trying to schedule in the R12, but R12 was going in and out of the hospital. Speech would not have upgraded R12 to an oral diet for risk of aspiration. 11/9/2023 at 2:11PM, V36 (Registered Dietician) said R12 was NPO and R12 failed speech therapy evaluation for diet upgrade. R12 was always hungry and always wanting to eat by mouth which was not appropriate for him. V36 said she was made aware R12 is always trying to steal food and was drinking his G-tube feeding. V36 recommended bolus feeding on 9/25/2023 but was not sure if and when R12 was changed back to continuous feeding. V36 said they increased R12's feeding and made sure he does not have any feeding or food in his room. V36 was not aware R12 was still drinking his feeding formula after he was changed to bolus. V36 added if this behavior is being documented all staff should have been aware and made sure R12 is being monitored. Fall policy revised 10/30/2023 states, facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring a safe patient environment is maintained. Under procedure, the policy states in part, high risks residents and patients for falls will receive individualized interventions as appropriate to risk factors. Interventions b. High risks residents and patients for falls will receive individualized interventions as appropriate to risk factors, interventions may include meaningful and or scheduled rounds. 46344 2. R124 is a [AGE] year-old male who originally was admitted to the facility on [DATE] and continues to reside in the facility. Facility reported incident dated 9/27/23 states in part but not limited to the following: R124 was utilizing the facility bus to tour another facility as part of their discharge planning. While on the way back to the facility, one of the strap harnesses securing R124's wheelchair loosened and caused R124's wheelchair to tilt when the bus was making a turn. R124 called for help and V12 (Transportation Scheduler) pulled the bus over to assist. V12 observed R124 to be tilted at a 45-degree angle while still secured in the harness straps. R124 said he felt some pain by his rib cage on the side where he fell into the armrest when the wheelchair was tilted. R124 arrived back to the facility and was assessed by nursing staff. X-ray was ordered. X-ray impression result dated 10/1/23 shows acute fractures of the seventh and eighth right rib. On 11/7/23 at 10:29AM, R124 was interviewed regarding incident on 9/27/23. R124 said. (V12) was transporting me back to the facility after touring another facility to potentially transfer to. On our way back to the facility, I was in a manual wheelchair and (V12) had made a left turn which caused me to fall on my right side. Either the strap that was strapping me in was not secure or my wheelchair brakes were not locked. I had hit my ribs on the armrest of the wheelchair and hit my head off something. They did an x-ray of my ribs where they said I fractured two of my ribs. I was in pain for about two weeks after the incident. On 11/8/23 at 10:03AM, V12 was interviewed regarding the incident on 9/27/23. V12 said, I had transported (R124) to another facility to tour. On our way back that day, I made a left turn and I heard (R124) yell for help. I immediately pulled over and assessed the situation. (R124) was strapped into the seatbelt and the floor straps but was leaning at a 45-degree angle. I adjusted his chair upright and asked him if I should call 911 which he refused. He wanted to go back to the facility however he was saying he was in pain in his rib area. At the time of the incident, it had looked as if one of the harnesses on the floor had come loose. I was able to tighten it and transport him back to the facility where he was evaluated by his nurse. V12 said, We are now required to complete a vehicle check off list before and after operating the vehicle. Prior to this we did not have this checklist in place. V12 said the floor straps on the bus were replaced due to normal use and wear and tear of the straps. It is to be noted that this surveyor requested a transportation policy involving the use of the facility bus. V1 (Administrator) did provide this surveyor a policy titled Appointments and Transportation with reviewed date of 5/19/23. At 12:37PM, V1 said this policy does not have any details regarding our facility bus or the safety checklist that was implemented after the incident. V1 said this policy needs to be reviewed in our next quality assurance meeting.

Based on interviews and record reviews, the facility failed to ensure one resident's airway (R18) was free of any obstruction and failed to perform effective bag-valve to tracheostomy resuscitation during a code blue. This failure resulted in R18's airway being obstructed with suction catheter tubing in her tracheostomy preventing adequate oxygenation for at least 7 minutes until Emergency services arrived when it was removed. This affected one of three residents reviewed for death. The Immediate Jeopardy began on [DATE] when R18 was not provided effective bag-valve-mask tracheostomy resuscitation. V1 (administrator) and V2 (director of nursing) were notified of the Immediate Jeopardy on [DATE] at 10:53AM. The surveyor confirmed by record review and interview 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 interventions implemented. Findings include: R18 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction, lack of coordination, respiratory failure muscle weakness, atrial fibrillation, hyperlipidemia, anemia, insomnia, dysphagia, dependence on supplemental oxygen, aphonia, tracheostomy history of pulmonary embolism and acute embolism of right lower extremity. R18's brief interview for mental status was ,d+[DATE] which indicated cognitively intact. R18's minimum data set under functional ability dated [DATE] documents one person assists for eating, dressing and personal hygiene. R18's physician order documents R18 is a full code. R18's progress note dated [DATE] at 7:40AM documents: 19.00 (700PM): Resident received sleeping in bed with head of the bed elevated 30 degrees and bed in the lowest position. Resident has no signs of pain or distress noted. 21.00 (9:00PM): Resident was alert awake not in distress. All due medications given. Resident kept clean and comfortable.23.00 (11:00PM): continue monitoring, not in distress. Resident kept clean and comfortable Hourly rounds performed, patient not in distress. Approximately 04.45AM writer went into the room to change the tube feeding of the co-resident, she (R18) was breathing normally, not in any kind of distress and looks comfortable. 0500am Certified nursing assistant, CNA was doing ADL for the resident (R18), he went out from the room to get necessary items for the continuation of care, at 0508 resident (R189) found unresponsive, CNA called for help, immediately ran in to the room and patient found unresponsive, code blue called, CPR initiated. At 0509, 911 called immediately. Fire department arrived at 0516 am. 911 came and took over the CPR. During resuscitation 911 removed the suction catheter, from the trach site with the help of respiratory therapist from the facility. R18's fire department run sheet dated [DATE] documents: notified at 5:02AM and patient contact at 5:09AM unresponsive, cyanotic. Narrative documents: dispatched to local nursing home for cardiac arrest. R18 found lying supine in bed with nursing home staff performing cardiopulmonary resuscitation, (CPR) with Bag Valve Mask (BVM) via tracheostomy. Upon assessment crew found R18 unresponsive, pulseless, and apneic. R18 was placed on the cardiac monitor via pads with pulseless electrical activity, (PEA) noted. Crew continued CPR with pulse and rhythm check every two minutes. While using BVM to ventilate R18 via tracheostomy crew noted resistance on BVM and was unable to ventilate and deliver breaths to pt. When checking trach crew noted an obstruction inside the trach that appeared to be part of a suction tubing. With assistance of the respiratory therapist, the suction tubing was removed from inside the trach. Crew was then able to effectively deliver ventilations to R18 via BVM with oxygen at 15 and maintain throughout. Approximately 12 minutes into CPR with cardiac monitor, R18 obtained return of spontaneous circulation, (ROSC). Crew had a strong femoral pulse and organized sinus tachycardia rhythm noted. R18 was secured to stretcher and moved to Ambulance. Crew contacted local hospital; no orders given. While crew was attempting to obtain further vital signs and a 12 lead, crew noted rhythm change on the monitor and found R18 to be in cardiac arrest with PEA on the monitor. Crew re-started CPR with BVM and continued at ER. Under arrest etiology: respiratory/asphyxia. On [DATE] at 11:49AM, V50 (EMS) said he was present for the emergency call for R18. V50 said they arrived to R18's room with staff performing cardiopulmonary resuscitation and utilizing bag valve mask to R18's tracheostomy site. V50 said he took over the bag mask valve and was meeting resistance and unable to squeeze the bag valve mask. V50 said they attempted to open airway and inspected R18's tracheostomy and observed what appeared like a straw within the tracheostomy. V50 said they requested for respiratory therapist to inspect and she then removed the tracheostomy and pulled out what looked like a suction catheter tubing approximately ,d+[DATE] inches long from the resident. The tracheostomy was put back into place and V50 said they were able to utilize the bag valve without any resistance and shortly after R18 had return of spontaneous circulation. On [DATE] at 6:23PM, V54 (respiratory therapist, RT) who was identified as the respiratory therapist working with R18 on [DATE] 7:00pm through [DATE] 7:00AM, said there were no concerns with R18 prior to code blue. V54 said she responded to the code blue and removed tracheostomy collar and checked the inner cannula and provided suctioning with smaller catheter with minimal white secretions removed. V54 (RT) said she connected bag valve mask (BVM) and administered 100 % oxygen. V54 (RT) said she was able to provide ventilations with no resistance. When V54 (RT) was asked how you ensure the resident is receiving adequate oxygen, V54 said because I could squeeze the bag. V54 was asked if there is anything else you would monitor or look for to ensure resident was receiving adequate oxygenation, V54 said no. V54 was asked if she was able to see the chest rise and V54 said no. V54 said that Emergency services took over the Cardiopulmonary resuscitation. Emergency service called respiratory therapist back into the room and observed suction tubing in her tracheostomy. V54 said she removed the tubing and emergency services left with the resident to the hospital. V54 said she did not remove tracheostomy to remove tubing and pulled it out with her hand. V54 said during a code blue staff should check patients, provide 100% oxygen, check airway, suction airway. Make sure tracheostomy is not clogged, remove inner cannula and check for mucous plug suction, may put saline, apply 100% oxygen. On [DATE] at 2:44PM, V54 (RT) said she did not provide any suctioning care to R18 during her shift because R18 self-suctions. Staff leave the suction catheter unlocked and connected to the suction canister on the wall. V54 said she last saw R18 around 4:30AM sleeping in bed. Around 5:00AM, they called a code blue. V54 said she responded to the code and went to R18's room. V54 said she removed the closed suction catheter that was attached to R18's tracheostomy and did not observe any concern. R18 had secretions around her neck and V54 utilized smaller suction catheter to remove secretions. V54 (RT) said she suctioned within the inner cannula but not deeply and observed a minimal amount of white secretions. V54 said she removed the inner cannula and did not see any obstruction. V54 proceeded to administer 100 % oxygen via bag valve mask. V54 said she could easily squeeze the bag valve mask with no resistance. Emergency services arrived and took over care to R18. Emergency services called us back into the room and told there was tubing within the tracheostomy. V54 was unable to recall if emergency services had removed R18's inner cannula or if she removed the inner cannula, but she said she saw the obstruction and removed a piece of the suction catheter tubing. V54 was unable to estimate the length of the tubing, but said it appeared to be broken off the closed suction system. V54 (RT) denied seeing the tubing prior to Emergency services arrival. On [DATE] at 12:13PM, V55 (respiratory therapist, RT) said was the assigned to the other side of R18's unit and was not directly assigned to R18. V55(RT) said V54(RT) said, She (R18) was not getting oxygen and asked V55 to obtain an oxygen tank. V55 said he obtained an oxygen tank from the storage room and went back to R18's room where V54 (RT) placed R18 oxygen on tracheostomy site. V55 said emergency services arrived and took over and asked Respiratory therapist to come into the room where they showed them a broken tubing. V55 said it appeared to be part of the suction catheter tubing from the closed suctioning kit. V55 said Emergency services removed the suction catheter tubing from R18. R18's hospital record dated [DATE] documents: Patient's presentation is most consistent with cardiac arrest potentially in the setting of hypoxia after an object was left in her trach. Patient placed on the ventilator with good oxygen saturations Patient remains unresponsive to verbal and motor stimuli but pupils are slightly more reactive. Patient also noted on reevaluation to have some blood from her trach does not appear to be actively bleeding and only minimal blood suctioned from the trach. Ear nose and throat, ENT scoped patient at the bedside and noted diffuse tracheal injury but from unclear etiology, potentially frequent suctioning. Urinalysis appears infectious but of unclear clinical significance, however patient started on broad-spectrum antibiotics. CT brain showed cerebral edema consistent with diffuse hypoxic injury. She was fluid resuscitated here. Currently her physical examination shows severe neurologic impairment with fixed and dilated pupils and no gag or corneal reflexes. CT dated [DATE] at 11:32 am, document diffuse hypoxic ischemic injury. [DATE] 11:54AM Flexible tracheoscopy performed at bedside. Tube in good position without obstruction or foreign body. Tracheal mucosa diffusely excoriated with apparent trauma. Scant miniscule sanguine crusts. Patient with recent cardiac arrest with chronic tracheostomy with tracheitis in a pattern that appears consistent with suction trauma. Neurology determined that patient had extremely poor prognosis for neurological recovery. At 1200 on ,d+[DATE], patient was taken off vent/pressor support and expired at 12:31 PM. According to the American heart association, a patent airway is essential to facilitate proper ventilation and oxygenation. Although there is no high-quality evidence favoring one technique over another for establishment and maintenance of a patient's airway, rescuers should be aware of the advantages and disadvantages and maintain proficiency in the skills required to establish an adequate airway. Patients should be monitored constantly to verify airway patency and adequate ventilation and oxygenation. V54 (respiratory therapist) basic life support from the American heart association with an issue date of [DATE] and renew by ,d+[DATE]. V54 (respiratory therapist) basic life support from the American heart association with an issue date of [DATE] and renew by ,d+[DATE]. On [DATE] an onsite visit was conducted to verify the facilities implementation of the following removal plan: Corrective action which was accomplished for those resident (s) affected by the deficient practice. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected. 1. All scheduled nursing staff received coaching and in-services from the DON, ADON, and shift nursing supervisors on BLS standards of practice including identifying signs of airway obstruction, clearing airway obstruction, and airway assessment. Initiated [DATE], completed as of [DATE], & is ongoing. 2. Facility reviewed the following guidelines. Completed [DATE]. Basic Life Support- CPR Rapid Response and Code Blue policy CAB- Circulation, Airway, breathing protocols noted in Mock Code Blue Competencies Emergency Services 3. Nursing in-services conducted on all shifts by DON, ADON, & shift nursing supervisors. Copy of policies provided to the staff. Initiated on [DATE], completed as of [DATE], and is ongoing. The following topics were discussed: Basic Life Support- CPR Rapid Response and Code Blue policy Assessment and quickly determine the need for Emergency Services. Change in condition and monitoring of residents until emergency services takes over, including CAB protocols 4. Post test was created and will be completed by all clinical staff scheduled to work on all shifts. All nursing staff are required to complete in-service & post-test prior to returning to work. This was initiated on [DATE]. 5. A mock code blue drill will be conducted on all shifts by Nursing Managers and clinical staff. This was initiated on [DATE] and continued periodically on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], & ,d+[DATE]. Results of mock code blue drill are to be reviewed as part of the next monthly QAPI meeting to determine frequency thereafter. Mock Code Blue Competency and Code documentation attached. 6. CPR certifications were reviewed for all scheduled nursing staff on [DATE]. All scheduled staff are verified to have current CPR certification. All scheduled nursing staff are required to have current certification to return to work. Quality Assurance plans to monitor facility performance to make sure that the corrective actions are achieved and permanent. 1. QA tool was developed and utilized by nursing managers to check for compliance when applicable for 30 days. Director of Nursing and/or designee will be responsible to bring audits to the Quality Assurance Committee for review and recommendations. 2. A QAPI meeting was conducted on [DATE] attended by the Facility Department Managers to discuss F678- CPR and Removal Plan. Medical Director was informed of the meeting on [DATE] and the information discussed. 3. This will be completed with oversight of the administrator.

Based on interviews and record reviews, the facility failed to notify the physician of an acute change in condition on [DATE] and failed to immediately activate 911 for an acute change in condition. R7 was exhibiting lethargy, blue discoloration to fingertips, slow speech, glazed eyes, and a critically low sodium level. This affected one of three resident (R7) reviewed for change of condition, and emergency management response. This failure resulted in R7 being left unmonitored with a declining clinical status for over 14 minutes. R7 was found unresponsive without pulse/respiration by the local EMS team who initiated lifesaving interventions to include CPR. However, R7 expired. The immediate jeopardy began on [DATE] when R7 experienced an acute change in condition and the facility failed to monitor and failed to immediately activate 911. V1(administrator) and V2 (director of nursing) were notified of the Immediate Jeopardy on [DATE] at 2:44pm. The surveyor confirmed by record review and interview 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 interventions implemented. Findings include: On [DATE] at 3:55pm, V17 CNA (certified nurse aide) stated V17 was off 4 days prior to [DATE]. V17 stated when V17 came in on [DATE], R7 did not want to eat and was sleepy. V17 stated R7 refused breakfast and lunch. V17 stated V17 told V34 (nurse) R7 did not look good at about 10:00am and again at 1:00pm. V17 stated V17 tried to feed R7, but he refused. V17 stated when she returned from break at 3:00pm, V17 checked on R7. V17 stated R7 was pointing to his nose. V17 asked R7 if he wanted his oxygen and R7 nodded yes. V17 stated V34 was busy in another resident's room, and she told V34 to check on R7. V17 stated V34 exited the room and went to R7's room and assessed R7. V17 stated V17 left R7's room to assist another resident. V17 stated V17 went back to R7's afterwards and R7 had eyes open, leaning towards the right side in bed. V17 stated R7 asked for the head of bed to be raised a little higher. V17 stated R7 stated R7 was feeling cold, so V17 covered him with blanket. V17 stated she touched his skin and R7 was cold. V17 stated V17 did not notice any other staff in R7's room. V17 stated she did not return to R7's room to check on R7. On [DATE] at 9:55am, V9 (social services) and V8 (social services director) stated social services documents on a care plan conference form which is uploaded to the resident's electronic medical record. V8 and V9 stated the care conference on [DATE] was with R7's family via telephone. V9 stated on the evening of [DATE], at about 5:30pm, V21 (wound care coordinator) approached both V8 and V9 and mentioned a decline in R7. V8 and V9 planned a care conference meeting with R7's family on [DATE]. V8 and V9 stated V21 stated R7 had discoloration in fingers, appetite poor, slow speech, glazed eyes, and lazy vision. V8 stated V8 contacted R7's family and explained to family R7's medical condition. R7's family asked what to do next and V8 and V9 mentioned hospice care. V8 and V9 stated R7's family stated hospice was not an option and family wanted R7 to remain a full code. On [DATE] at 10:05am, V21 (wound care coordinator) stated on [DATE] V21 saw R7 in the afternoon for wound care treatment. V21 stated R7 was lethargic. V21 stated R7 informed V21 he didn't feel like eating, he was not 'feeling great today'. V21 stated R7 was alert and oriented. V21 stated V21 explained the importance of eating for wound healing. V21 stated R7's skin was pale, fingertips were discolored, and skin felt cooler to touch. On [DATE] at 1:30pm, V26 (nurse) stated V26 received a telephone call from the outside laboratory company on [DATE] in the afternoon. V26 was informed of R7's critically low sodium level. V26 stated V26 called V40 (attending physician) with laboratory test results and received order for sodium tablet orally immediately and then twice a day. V26 stated R7's family was present in R7's room and V26 informed family of R7's condition. V26 stated R7's family informed V26 R7 is not eating as much as before. V26 stated V26 explained R7's decline to the family, V8 (social services), and V2 DON. When questioned to clarify R7's decline, V26 responded R7 was not eating much. When questioned if V26 asked R7 about R7's change in appetite, V26 did not respond. When questioned regarding R7's potassium level dated [DATE] having an asterisk instead of a number value, V26 responded V26 was not aware there was no potassium level resulted. V26 stated R7's vital signs were stable. V26 stated V26 asked V21 (wound care coordinator) and V2 DON to assess R7. When questioned reason V26 asked other nurses to assess R7's medical status, V26 responded R7 wasn't eating much. When questioned reason V26 discussed changing R7's full code status to DNR (do not resuscitate) with R7's family if R7 was stable, V26 did not respond. Review of V26's progress note, dated ,d+[DATE] at 5:18pm, noted: all laboratory results informed to V40 with orders. Per V40, he referred V42 (renal physician) to see R7. R7's family member informed about R7's condition. R7's family member said R7 is not feeling well or eating today. V21 and V8 informed and updated R7's condition and talked about DNR (do not resuscitate) plan, but R7's family does not want DNR. On [DATE] at 11:12am, V40 (attending physician) stated V26 (nurse) called V40 with R7's laboratory results. V40 stated V26 informed V40 R7's potassium level was 5.3 (normal 3XXX,d+[DATE].0) and sodium level was 119 (normal range is ,d+[DATE]). V40 denied being made aware R7's potassium was not resulted. V40 stated V40 consulted with V42 (renal physician) regarding sodium 119 and potassium 5.3. V40 stated V42 wanted CMP repeated on [DATE]. V40 stated V40 spoke with V26 and ordered CMP for the following day. V40 denied being made aware of R7's change in condition - generalized weakness, slow speech, glazed eyes, lazy eyes, blue discoloration to fingertips, cool swollen hands, and poor appetite. V40 stated if V40 had been informed of R7's condition or the potassium level not reported, V40 would have sent R7 to the hospital on [DATE] for further evaluation. V40 stated V40 can only work with the information the nurse provides. Review of R7's POS (physician order sheet), dated [DATE], does not note V26 entered orders for the renal physician consult or CMP test for the morning of [DATE]. On [DATE] at 2:00pm, V2 DON (director of nursing) stated R7's family called the facility on [DATE] and requested an update on R7. V2 stated V2 informed R7's family R7 was okay. V2 stated during this phone conversation, R7's family expressed concerns of R7's poor appetite. V2 stated V2 did not receive any report from staff R7 was not eating well recently. V2 stated R7's family stated R7 has had a poor appetite for a while. V2 stated R7's family member didn't specify when R7's appetite changed. V2 stated R7's family thought maybe R7 was depressed and needed to see psychiatry. V2 stated V2 planned to put R7 on psychiatry's list to be seen. When questioned if V2 did put R7 on list, V2 responded the psychiatrist only comes to this facility on Fridays. V2 stated V2 spoke with R7 on [DATE] at 6:00pm after R7's family left. V2 stated V2 asked R7 how he felt, R7 informed V2 he was okay and everything was good. V2 stated V2 assessed R7 at time. V2 stated R7's hand was pale due to edema (swelling), head of bed was elevated 40 degrees, R7 was alert and oriented x 3. V2 stated R7's skin was dry, R7 felt warm but his left hand felt cool. When questioned if V2 compared the temperature in both hands, V2 responded V2 only felt R7's left hand, both hands were swollen. V2 stated R7 was readmitted to this facility [DATE] with generalized edema. The NP's (nurse practitioner) progress note, dated [DATE], was reviewed with V2. The NP noted R7 with trace edema to right lower extremity. When questioned if R7's bilateral hand swelling would be a change in condition and if the physician should have been notified, V2 responded this could be considered a change in R7's condition based on the documentation. When questioned if V2 contacted the outside laboratory company regarding R7's potassium level reported on [DATE] having an asterisk instead of a number value, V2 responded she did not notice the potassium level was not resulted. V2 stated V2 was aware R7's sodium level was critically low at 119 (normal range is ,d+[DATE]). V2 stated V26 (nurse) notified V40 (attending physician) of the lab results and R7's medical condition. V26's progress note, dated [DATE] at 5:18pm, reviewed with V2. V26's documentation notes all labs informed to V40. There is no documentation noting V40 was informed of R7's current medical condition. V2 acknowledged if it's not documented, it wasn't done. V2 stated V26 should have documented R7's condition in detail and informed V40. V2 stated V26 took R7's vital signs ,d+[DATE] times and R7's vital signs were stable. V2 was informed R7's vital signs were documented on [DATE] at 10:45am. V2 acknowledged V26 should have documented all vital sign results obtained. On [DATE] at 2:08pm, V34 (nurse) stated V34 was assigned to provide care for R7 on [DATE]. V34 stated R7 wasn't as interactive with V34 as he had been earlier in September. V34 stated R7 recently had an above the knee amputation and thought R7 was depressed. V34 stated V34 asked R7 if R7 was okay because V17 CNA informed V34 R7 had not eaten breakfast or lunch day. V34 stated R7 informed V34 R7 was not hungry. V34 stated V34 took a break from 2:00pm until 2:45pm. Upon returning to nursing unit, V34 stated V34 went to R7's room. V34 stated R7 informed V34 he was fine, but R7 was not his usual self. V34 stated just before dinner, at 4:00pm, V34 instructed V17 to round on the residents. V34 stated V17 came and informed V34 R7 was not looking well. V34 stated V34 went to R7's room to assess R7. V34 stated R7 had oxygen at 3 liters via nasal cannula; V34 increased R7's oxygen to 4 liters and exited R7's room and went to the nurses' station. V34 stated V34 notified V2 DON R7 was not looking well. V34 stated V34 also contacted V40 (attending physician), but V40 did not respond. V34 stated V2 informed V34 if he thought R7 did not look well, V34 should send R7 to the hospital via EMS (emergency medical services) 911. V34 stated V34 called EMS 911. V34 stated V34 was printing the paperwork for EMS and hospital when another resident was complaining of increased pain. V34 stated V34 was in the other resident's room when EMS paramedics arrived at R7's bedside. V34 stated V34 exited room and observed the paramedics working on R7. V34 stated V2 came onto nursing unit ,d+[DATE] minutes after EMS arrived. V34 stated V34 did not receive any information regarding R7 from the off going nurse at morning. V34 stated V34 reads the residents' progress notes at the beginning of V34's shift, at 7:00am, but on ,d+[DATE] V34 did not read R7's notes until after this event. V34 stated V34 did not review R7's laboratory test results from ,d+[DATE]. On [DATE] at 12:40 pm, V34 (nurse) was asked to clarify 'not looking well'. V34 stated when V34 asked R7 if R7 was okay, R7 stated he was fine, but it was in a low voice and R7 was speaking slowly. V34 stated R7 did not respond per usual. V34 stated R7 was receiving oxygen at 3 liters per nasal cannula and oxygen saturation level was 94%. V34 increased oxygen to 4 liters and oxygen saturation level increased to 96%. V34 stated V2 came onto the nursing unit at 4:40pm. V34 stated V2 called EMS 911. V34 stated V17 CNA informed him another resident was complaining of pain. V34 stated he left R7's room and went to assess the other resident. V34 stated he went into R7's room just as paramedics were arriving; the paramedics immediately started performing CPR on R7. V34 stated R7's skin coloring was normal and warm and R7 did not exhibit any signs of labored breathing. On [DATE] at 2:00pm, V34 stated he texted V2 DON at 4:38pm R7 didn't look right. V34 stated V2 came onto nursing unit. V34 stated he informed V2 of R7's vital signs. V34 stated V2 left R7's room to call 911. V34 stated no staff was at R7's bedside continuously monitoring R7 until EMS crew arrived at R7's bedside. V34's progress note, dated [DATE], notes at 4:40PM - R7 seen with altered mental status, appears lethargic. Vital signs - blood pressure ,d+[DATE]; heart rate 94; respirations 16 per minute; oxygen saturation level 91% on room air; blood sugar level 172. Oxygen per nasal cannula administered at 3 liters. At 4:50PM- 911 called. On [DATE] at 11:23am, V45 (EMS paramedic) stated this facility called EMS at 4:54pm for an unresponsive resident. Upon arrival at R7's bedside, it was determined R7 was in cardiac arrest. V45 stated R7's skin appeared grey/cyanotic. V45 stated there were no staff present in R7's room when EMS arrived. V45 stated EMS connected R7 to a heart monitor and began CPR. V45 stated V45 was met outside of R7's room by a nurse. V45 stated she wasn't R7's nurse and was not able to provide any information to V45. V45 stated eventually V34 (R7's nurse) appeared and was able to provide some information to V45 regarding R7. R7's EMS (emergency medical services) 911 run sheet, dated [DATE], notes 911 dispatch was notified at 4:54pm for an unresponsive resident. EMS crew were at R7's bedside at 4:59pm. The EMS crew found R7 in cardiac arrest. Per nursing home staff, R7 had last been seen normal approximately 30 minutes prior to calling emergency services. R7 was placed on a monitor which confirmed asystole (no heartbeat). Crew began chest compressions which would continue throughout the remainder of the resuscitative efforts and bagging via non-rebreather mask. A total of 5 epinephrine doses were given throughout efforts, with R7 maintaining asystole the entire time. The local hospital was contacted to end resuscitative efforts. Time of death 5:26pm. On [DATE] at 10:25am, V41 (outside laboratory representative) stated all critical test results are called to the nurse. V41 stated the technician marked the potassium level with an asterisk because the results were questionable. V41 stated the potassium level test is a very sensitive test and a high level resulted on ,d+[DATE] and it needed to be repeated to verify the results. V41 stated V26 was notified on [DATE] at 2:24pm by the technician of the critical low sodium level. V41 stated it is up to the nurse to decide if the potassium level should be re-drawn or not when there is an asterisk instead of a number value. On [DATE] at 3:28pm, V46 (diagnostic imaging company representative) stated R7's chest x-ray result was faxed to this facility on [DATE] at 6:34pm. V46 stated these results were also faxed to this facility today, [DATE], at 1:00pm. On [DATE] at 3:30pm, V2 DON stated the outside diagnostic imaging company will fax results or upload results directly into this facility's computer system. V2 stated the nurse should communicate any pending laboratory and x-ray results on the 24-hour shift report. V2 stated all the nurses should follow-up with pending results and notify the physician of the results when known. R7's chest x-ray results, dated [DATE], notes study limited by R7's suboptimal inspiration. Faint retrocardiac infiltrate could represent a small focus of pneumonitis. Correlate clinically. Follow-up chest radiographs recommended after medical management. There is no documentation found in R7's medical record noting R7's chest x-ray results were reviewed by the nurse and relayed to V40 (attending physician). R7's CMP (comprehensive metabolic panel), dated [DATE], notes R7's sodium level was critically low at 119 (normal range is ,d+[DATE]). It also notes an asterisk for R7's potassium level. R7's meal intake for [DATE] notes on ,d+[DATE], R7 consumed ,d+[DATE]% of each meal. There is no documentation noting R7 consumed any meals on ,d+[DATE] and ,d+[DATE]. R7's POS (physician order sheet), dated [DATE], notes V44 (infectious disease physician) ordered a chest x-ray. R7's progress notes: On ,d+[DATE] at 9:17pm, V2 DON noted: returned R7's family member's phone call tonight, R7's family concerned about R7's weakness, mental status, and poor appetite. Reviewed R7's labs, last potassium 5.3, sodium 128, blood pressure ,d+[DATE], temperature 97.6, respirations 19/minute, pulse 80 beats per minute, oxygen saturation level 97%. Blood culture and chest x-ray results still pending. Called V44 for new orders. V44 ordered CBC and CMP in am, ,d+[DATE]. On ,d+[DATE], V9 (social services) noted V21 (wound care coordinator) reported change in wound status and noticed a decline in care: discoloration in fingers/wound, slowed speech, glazed eyes, and lazy vision. V8 (social services director) called R7's family member for family meeting at 10:30AM on [DATE]. This facility's resident change in condition policy, reviewed [DATE], notes when there is a change in condition, the nurse will perform an assessment, provide immediate nursing interventions, continue to monitor, and follow current order to manage symptoms/emergent situations. On [DATE] an onsite visit was conducted to verify the facilities implementation of the following removal plan: Corrective action which was accomplished for those resident (s) affected by the deficient practice. The measures the facility will take or systems the facility will alter to ensure the problem will be corrected. 1. V2 and V34 received 1:1 coaching and in-services from Corporate Regional RN Nurse Consultant on notification of attending physician of acute changes, assessment and monitoring of residents until emergency takes place and code policy. This was completed on [DATE]. 2. Facility implemented the following guidelines. Completed [DATE]. Rapid Response policy Emergency Services policy 3. Facility reviewed the following guidelines. Completed [DATE]. Notification of attending physician of acute changes Rapid Response policy Code Blue policy Change in condition policy; assessment and monitoring of residents until emergency services takes over. Emergency Services policy 4. Nursing in-services conducted by DON, ADON, and day & night shift Supervisors for all shifts initiated [DATE]. Copy of the policies provided to the staff. Completed as of [DATE] & is ongoing. The following topics were discussed: Change in condition and notification of MD of acute changes in timely manner. Rapid Response and Code Blue policy Change in condition and monitoring of residents until emergency services take over. Assessment and quickly determine the need for Emergency Services. 5. Post test was created and will be completed by nurses scheduled to work on all shifts. This was initiated on [DATE] & is ongoing. All staff are REQUIRED to complete in-service & post-test prior to returning to work. 6. A mock code blue drill will be conducted on all shifts by Nursing Managers and clinical staff. This was initiated on [DATE] 23 and continued periodically on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], & ,d+[DATE]. Results of mock code blue drill are to be reviewed as part of the next monthly QAPI meeting to determine frequency thereafter. Mock Code Blue Competency and Code documentation attached. Quality Assurance plans to monitor facility performance to make sure the corrective actions are achieved and permanent. 1. QA tool was developed and utilized by nursing managers to check for compliance daily for the next 3 weeks. Director of Nursing and/or designee will be responsible to bring audits to the Quality Assurance Committee for review and recommendations. 2. A QAPI meeting was conducted on [DATE] attended by the Facility Department Managers to discuss F684- Quality of care and Removal Plan. Medical Director was informed of the meeting on [DATE] and the information discussed. 3. This will be completed with oversight of the administrator.

Based on interviews and record reviews, the facility failed to monitor/supervise a resident requiring assistance in the shower room and failed to ensure effective fall prevention interventions were in place to prevent fall incidents. This affected 2 of 4 residents (R19, R2) reviewed for falls and fall prevention. This failure resulted in R19 being in the shower room, unmonitored, experiencing an unwitnessed fall sustaining a cervical spine fracture requiring immediate surgery. This failure also resulted in R2 having four falls in three weeks. Findings include: On 10/6/23 at 12:24pm, V30 (Nurse) said she was passing medications and overheard R19 reporting to staff at the nursing station that R19 fell in the shower room and bumped her head. V30 was unable to identify staff by name (agency, female, African American) R19 was talking to at time. V30 said R19 said R19 hit her head. Physical assessment completed no visible injuries but when V30 touched the right side of R19's forehead, R19 had pain. R19 had left or right hip was painful also. V30 stated she told R19 to stay in the room but r19 insisted on walking to the church services. V30 stated she called V2 (DON) and was instructed to send R19 out 911. V30 stated R19 usually goes to the shower room herself. R19 will usually ask if she can shower. The shower room is not locked. Usually someone will supervise her while in the shower and unsure if anyone was with her at time. V30 stated R19's hair was wet and R19 had her walker but no oxygen at time. V30 stated R19 is alert and oriented x 3 and uses rolling walker. V30 stated R19 uses an oxygen concentrator in her room and will get a portable tank that hangs on her walker if she leaves the room. There was no portable oxygen in her room or with R19. V30 stated R19 went down to church without oxygen but V30 checked R19's oxygen saturation level and it was 93-94% on room air. EMS (emergency medical services) arrived. On 10/6/23 at 1:28pm, V2 DON (director of nursing) stated V30 (nurse) reported to V2, R19 had a fall in the shower. V2 stated R19 is a poor historian and can be delusional. V2 stated R19 had an unwitnessed fall in the shower on 10/1/23. V2 stated R19 walks by herself with a rolling walker. V2 stated residents must let staff know before he/she takes a shower so staff can make sure no other resident is in shower. V2 stated the restorative nurse does an assessment to determine if a resident is safe to shower independently. V2 stated the resident's care plan will have documentation if the resident can shower independently. R19's functional abilities assessment, dated 8/9/23, notes for shower/bathing, R19 requires partial/moderate assistance from staff. R19's care plan notes R19's memory is impaired, initiated 11/12/21. R19 has problems with decision-making, insight, logic, calculation, reasoning, planning, organization, sequencing, and judgement. R19's ADL (activities of daily living) care plan, initiated 12/2/22, notes R19 has a self-care deficit and requires assistance with ADLs to maintain the highest level of functioning. Intervention identified R19 requires assistance of one staff member for bathing. R19's falls care plan, initiated 12/2/22, notes R19 is at risk for falls as evidenced by the following risk factors and potential contributing diagnoses - decreased strength and endurance, cardiomyopathy, dementia. Interventions identified on 12/2/22 - nursing staff will complete a fall risk assessment per facility fall protocol and follow facility fall protocol. Review of R19's medical record notes R19 with diagnoses including, but not limited to, COPD (chronic obstructive pulmonary disease), heart failure, hypotension, cardiomyopathy, unsteadiness on feet, lack of coordination, and dependence on supplemental oxygen. Review of R19's POS (physician order sheet) notes an order for oxygen at 4 liters via nasal cannula continuous. Review of R19's hospital medical record, dated 10/1/23, notes after fall at this facility, R19 found to have severe flexion teardrop fracture of C5 (cervical spine, 5th vertebrae) vertebral body with subluxation ligamentous injury posteriorly, as well as concern for anterior longitudinal ligament rupture. R19 hesitant to move due to the pain. R19 was admitted to the neurological critical care unit after anterior cervical corpectomy C5-C6, anterior plate and cage C4-C7, and posterior fusion C2-T1 Review of R19's fall risk assessment, dated 9/28/23, notes R19 is at high risk for falls. R19's MDS (minimum data set), dated 8/9/23, notes R19's BIMS (brief interview of mental status) score is 5 out of 15, bathing requires extensive assistance of one staff member. R19's MDS, dated [DATE], 5/11/23, and 8/9/23, notes R19 has not exhibited any behaviors. This facility's incident report, dated 10/1/23, notes R19 is alert and oriented to person and place. Predisposing physiological factors: confused and gait imbalance. It notes R19 insists on privacy and independence and non-compliance with shower schedule. Review of R19's POC (point of care) charting for the past 30 days notes R19 required physical assistance of one staff member with showers on 9/8, 9/9, 9/13, 9/14, 9/17, 9/18, 9/20, 9/21, 9/23, 9/26, 9/29, and 9/30. R19 required supervision of one staff member with showers on 9/12, 9/22, and 9/24. R19 required physical assistance of one staff member for bed baths on 9/7, 9/11, 9/13, 9/16, 9/18, 9/19, 9/20, 9/23, and 9/30. Review of R19's medical record does not note any documentation R19 insists on privacy and independence and is non-compliant with shower schedule. This facility's fall prevention and management policy, dated 10/29/21, notes high risk residents for falls will receive individualized interventions. High-risk fall precautions will be implemented for residents whose scores on fall risk screen shows high risk. Staff will remain with the resident when assisted to the bathroom. Interventions will depend on identified and assessed risk factors, including root cause(s) after each fall. 39340 2. R2 was admitted on [DATE] with a diagnosis of hemiplegia following cerebral infarction affecting left side, end stage renal disease, type II diabetes, morbid obesity, atrial fibrillation, hypertension, heart disease, hyperlipidemia, dementia with behavioral disturbances, chronic kidney disease, extrarenal uremia, major depressive disorder, lack of coordination, muscle weakness, limitation of activities due to disability. R2's brief interview for mental status dated 7/18/23 documents: 05/15 which indicates severe cognitive impairment. R2's Minimum Data Set, dated dated dated [DATE] documents under functional status: transfer indicates 3-extensive assistance (resident involved in activity; staff provide weight -bearing support and 3- two persons physical assist; bed mobility documents 3-extensive assistance (resident involved in activity; staff provide weight -bearing support and 2 indicating one-person physical assist. Under balance during transitions and walking documents a score of 2 not ready, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around. Moving on and off toilet, surface to surface transfer. R2's incident report dated 7/12/23 documents: writer called by staff member that resident was on the floor. Resident observed sitting on the floor. Resident stated, I fell on the floor on my butt while trying to move to the side of the bed. R2's care plan Interventions created on 7/17/23 with initiated date of 7/13/23 documents fall 7/12/23 visual cue to be placed in the room to ask for assistance. Physical therapy to continue reinforce safety with patient. R2's incident report dated 7/24/23 documents: writer called by staff member that resident was on the floor. Resident observed lying on the floor. Resident stated, I was too close to the end of the bed and fell on the floor while trying to move to the side of the bed. R2's care plan Interventions created dated 7/24/23 document low bed and floor mats. Interventions created date 7/27/23 with an initiated date 7/25/23 documents fall 7/24/23 educate on proper transferring techniques. R2's incident report dated 8/1/23 documents: Patient was on the floor, sitting and leaning on the bedside, trying to get up. Resident stated he was trying to get to the door. R2's care plan Intervention created date 8/4/23 documents bed rest after dialysis and wheelchair for locomotion for fall 8/1/23. R2's dialysis treatment information dated 8/3/23 documents under nurse's notes: patient alert and conscious, a bit aggressive, slip on the floor while trying to transfer to wheelchair, complaints of pain in the hips afebrile. On 9/22/23 at 12:48PM, V2 (DON) said R2 had a short temper and did not like people telling him what to do. R2 had a wheelchair and sometimes he would follow direction and other times he would forget. V2 said she is unsure where they previous staff documented root cause of falls. On 9/26/23 at 3:36PM, V2 (DON) said a resident with a brief interview score of five is a lower score and has lower cognition. Fall interventions should be placed as soon as possible after a fall based on the cause of the fall. When asked how these interventions were effective in preventing R2's falls, V2 said that he had a behavior of trying to get up and leave the building. Staff would redirect resident as needed. On 9/22/23 at 12:06PM, V33 (restorative nurse) said she updated fall care plans but did not help with the development of interventions. Interventions would be placed after cause of fall determined. V33 said she only wrote in the care plan with whatever the new intervention was at the time. When asked if R2 would be able to remember and be educated on proper transferring techniques, V33 said she did not know and that previous staff had developed interventions. V33 verified the that the created date is when intervention was put into the care plan. R2's fall care plan created on 7/28/23 documents R2 is at risk for falls as evidenced by the following risk factors and potential contributing diagnosis: diabetes, end stage renal disease, generalized muscle weakness, atrial fibrillation, and hypertension. Interventions created on 12/7/22: I would like staff to review information on my past falls and attempt to determine the cause of my falls; Staff to provide me with a safe environment with floors free from spills and clutter, a working call light, be din lowest position at night, bed mobility positioning devices and transfer devices to support highest level being; complete fall risk assessment per facility fall. Interventions dated 12/8/22 document: Ensure I'm wearing proper footwear and check to ensure that bed brakes are locked prior to transferring. Interventions on 7/28/22 documents: Physical therapy and occupational therapy, anticipate needs, place call light in reach and encourage use, follow fall policy. Facility falls prevention and management policy reviewed 11/10/22 documents: facility is committed to its duty of care to residents and patients in reducing the risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Under fall risk screening: high risk residents and patient falls will receive individualized interventions as appropriate to risk factors. High risk precautions will be implemented to residents and patients who scores on resident/family notification fall risk screen shows high risk will be considered on this precaution. Universal fall precautions will be implemented in addition to high risk fall precaution interventions; pharmacy medication review; physical therapy and occupational therapy evaluations; restorative program; room near the nursing station. Procedure for post- fall management: post fall observation will be completed; perform verbal assessment to cause for fall and potential for injury; perform physical assessment including head to toe assessment, vital signs, range of motion and neurological assessment as indicated; notify the provider and family; document fall event under risk management; nurse with knowledge of the event will document pertinent facts in the medical record. Other staff will be interviewed and or written witness statements will be completed. Under fall response: evaluate and monitor resident for 72 hours after the fall; investigate fall circumstances; Under procedures for fall with potential head injury: falls where patients/residents may have sustained a head injury or on blood thinners will be assessed for neurological check. R2's fall risk review dated 7/24/23 documents high risk for falls.

Based on interview and record review, the facility failed to prevent a vulnerable resident from being the subject of physical abuse by an employee. This failure affected one (R4) of three residents reviewed for abuse and resulted in (R4) being mistreated while being provided with personal care from staff member. Findings include: R4 is a [AGE] year-old female who was admitted to the facility 1/27/22 with diagnoses that included Respiratory Failure, Tracheostomy, seizures, and history of Cardiac Arrest. MDS (Minimum Data Set) dated 1/14/23 notes that R4 had severely impaired cognition and required maximal assistance with all activities of daily living, was incontinent of bowel and bladder. R4 had a tracheostomy and was receiving full ventilator support. R4's Care Plan was reviewed. Care Plan initiated 2/10/22 Focus: R4 presents with an alteration in ability to communicate related to: Impaired cognitive abilities, Impaired speech. R4 has a hx of Pulseless Electrical Activity, Acute Saddle Pulmonary Embolism, and Ischemic Encephalopathy which could be affecting her cognitive abilities. R4 is also a trach/respiratory patient which could also be affecting her ability to speak. Based on surveyor review, there was no care plan included to address R4's risk of abuse. V2 Director of Nursing was interviewed 2/23/23 at 11:38AM and said, V4 was non-verbal, not responsive, and not able to track with her eyes at baseline. I helped with the allegation investigation regarding R4 and V17 CNA. The family came to the facility and asked to speak to management. She showed us a video where V17 lifted R4's head grabbing with one hand. V17 finished changing the resident and left the room. V1 Administrator was interviewed on 2/23/22 at 11:38AM. V1 said, the family of R4 had a teddy camera in the room that we were not aware of. The daughter (Power of Attorney) for R4 brought it to our attention; a video that showed R4 getting care from V17 CNA. V17 explained that when making the attempt to lift the head, her hand slipped because she was only using one hand. We would have preferred for her to use two hands to lift the head from underneath but unfortunately, she didn't. I called the local police and added to the report, and they said that there was nothing for them to investigate because it didn't appear that there was anything criminal involved. Therefore, we didn't deem this as abuse. V17 was suspended immediately pending investigation and then we decided to terminate her for discourteous behavior. Report obtained from Sheriff Police Department - Incident Report dated 4/13/22 documents: V18 (Police Officer) responded to the above address for Assault service call later reclassified to Suspicious Circumstances. Upon arrival V18 spoke with V1 (Administrator), who stated that this morning his staff removed a video camera from patients (R4) room. At approximately 1130Hrs (R4) family members arrived at the (facility). (R4's daughter) showed him a video where Staff member (V17) lifted (R4) head approximately 4-5 inches, pulled the pillow and did not place (R4) head back on the bed gently. (V1) stated (V17) might scooped or grabbed (R4) hair twice, video was unclear. (V1) said that Patient (R4) is comatose and brain dead, staff members performed head to toe physical and din not observed any signs of abuse. [sic.] (V1) stated that (V17) was suspended pending internal investigation and Illinois Department of Public health was notified via IDPH website (facility reported incident). (V1) said that he had a long conversation with (R4's) family members and explained that (V17) will be suspended pending investigation. Unable to interview (R4) due to her medical condition. Unable interview (V17), (V17) due to her not being on scene (suspended). Unable to interview family member (V20 Family Member) or watch the video of the incident. Supplemental Police Report dated 14-APR-2022 1835, completed by V18 (Police Officer) documents: In summary, V18 (police officer) responded to I.S.P. (Illinois State Police) and spoke with (V20 Family Member) who showed V19 (surveyor) the video footage that was taken in her mother's room located at (facility). (V19) observed a female subject who was identified as (V17 CNA) adjusting (R4's) pillows and body positioning. While doing so she grabs the back of R4's head and raises her off the bed to a semi seated position then roughly slams her head back onto the pillow, (V17) does this same motion twice to (R4). (V20) stated she is willing to sign Criminal Complaints against (V17). (V19) advised (V20) to save any footage for further investigation. Nothing further. V20 (Family Member) provided surveyor with video footage of interaction between V17 (CNA) and R4, in question. Video was reviewed and surveyor confirms description provided in supplemental police report completed by V18 (Police Officer). Facility provided investigation of incident which was reviewed. V17's CNA personnel file was reviewed. Employee Disciplinary Action Form dated 4/13/23 noted V17 was suspended pending investigation of Policy Violation. Employee Disciplinary Action Form dated 4/18/23 noted, After a thorough investigation, it was confirmed that the employee violated a category I offense, specifically, #27 Discourtesy to resident, family, or fell ow employee. Employee was discourteous to a resident on 4/13/22. Employee is terminated effective immediately. Facility provided Employee Standards of Conduct (No revision date) which states in part: This list is intended not be representative of the types of activities that may result in disciplinary action, up to and including termination- Rough handling or abuse of a resident. (Under heading) Disciplinary Action the document explains, Category 1 offenses are most serious and subject to the employee's immediate discharge without rehire privileges. The following are Category 1 offenses: 1. Resident abuse (verbal or physical), or neglect; 27. Discourtesy to the resident, families, or fell ow employees. Facility Abuse Policy revised 1/2019, was reviewed and states in part; As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis.

Based on observation, interview and record review the facility failed to ensure a resident was safely transferred using a mechanical lift device to 1 of 3 residents (R1) reviewed for safe transfers in the sample of 12. This failure resulted in a right scapula fracture to R1. The findings include: R1's electronic medical record accessed on 11/4/22 show R1 has diagnoses that include chronic respiratory failure with trach, morbid obesity and diabetes. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. The same assessment show R1 is dependent to 2 staff for mechanical lift transfers. R1's Facility Reported Incident (FRI) dated 10/22/22 (incident happened 10/21/22) reported to the state agency on 10/22/22 as final report show, Resident was being transferred to her chair from her bed when the mechanical lift slightly tilted in the direction of the chair, touching residents face. Nurse practitioner conducted a head-to-toe assessment and resident indicated that she had some shoulder pain. R1 was transferred to hospital and was diagnosed with closed fracture right scapula. R1's radiology report dated 10/21/22 show, Three view of radiographic evaluation of the right shoulder. Final Result: Inferior scapular fracture. R1's Emergency Department (ED) Notes dated 10/21/22 show that R1 is a 63 y/o with diagnoses that include atrial fib on Eliquis, diabetes, chronic hypoxic respiratory failure on trach collar at 3 liters presenting to the emergency room . she was being transferred from bed to an armchair at her nursing facility she was already in the chair when the [mechanical lift] tipped and fell into her. She endorses a mechanical lift hit her head, right shoulder and landed on her abdomen. The same notes show that given her scapular fracture patient encouraged to have CT scan of the abdomen as well as head, however she declines. Main reason to pursue these tests (CT scan) was because patient is on Eliquis (anticoagulant). The same ED notes show for R1 to be referred to an Orthopedic MD. On 11/4/22 at 9:13 AM, R1 was alert in bed with her trach intact. R1 said when the incident happened, the 2 (Certified Nursing Assistant-CNA) were transferring her from the bed chair to her wheelchair. R1 said there were 2 CNAs- male and female. R1 said the male CNA was busy in his phone during the care and transfer. The female CNA was the one controlling the mechanical lift. R1 said as she was suspended in the air and was being lowered down to her wheelchair, R1 informed the 2 CNAs that she was tilted sideways and need to be positioned well. R1 said then the whole lift tipped over her and the bar (where the mechanical slings were attached) hit her face and right shoulder. R1 said she was sent to the hospital and was told she fractured her right shoulder. R1 said she always had pain n that shoulder but after the incident, the pain had gotten worst. R1 said when she moves her arm over head or when she tries to comb her hair, her pain was at a 6 (0 no pain, 10 worst pain). R1 said she was waiting for his Orthopedic appointment to be scheduled. On 11/4/22 at 9:20 AM, V8 (Registered Nurse-RN) said on 10/21/22 she was called to R1's room. V8 said R1 was sitting in her wheelchair complaining of right shoulder pain. V8 (RN) said R1 was being transferred by the 2 agency CNA (V6 and V7) using a mechanical lift. The mechanical lift tipped over hitting the right side of R1's face and right shoulder. V8 said R1 complained of pain to her right shoulder and R1 was sent to the emergency room . R1 was diagnosed with fractured right shoulder. V8 said the 2 staff (V6 and V7) that transferred R1 on 10/21/22 were both agency CNAs. Both have not been allowed to go back to the facility. On 11/4/22 at 9:32 AM, V9 (Nursing Supervisor) said he investigated the incident on 10/21/22 involving R1 and the 2 agency CNAs (V6 and V7). V9 said the investigations show that when R1 was being transferred, the lift device legs were not opened wide enough. V9 said the mechanical lift device is more stable when the legs are widened preventing the device from tipping over. V9 said the 2 agency CNAs involved were not to return to the facility. V9 said since the incident, the facility staff have been re trained and reeducated how to properly operate the mechanical device. On 11/4/22 at 11:30 AM this surveyor with V10 and V11 (both Restorative Aides) observed the mechanical lift device. Both said the legs of the mechanical lift device should remain wide throughout the transfer of the resident, this ensures the lift device does not tip over and it keeps the device stable. On 11/4/22 at 12:57 AM, V2 (Director of Nursing-DON) said she also investigated the incident on 10/21/22 involving R1 and the 2 agency CNAs (V6 and V7). V2 said (V6 and V7) were operating the mechanical lift device when the incident happened. Both (V6 and V7) were not allowed to go back and work at the facility. V2 said she expected that the 2 staff should have utilized the lift device correctly and would have prevented the incident. V2 said the mechanical lift device legs should have been opened wide enough to provide balance and stability to the mechanical lift. V2 said she was looking into R1's orthopedic referral at this time. The facility policy entitled Policy and Procedure for Mechanical Lift Transfer Usage show, 3. Widen the legs of the Mechanical Lift using the shift handle located in the back. Widening the legs is essential in order to get a stable base under the mechanical lift.

Based on interview and record review, the facility failed to urgently seek advanced medical care for a resident who was assessed by Nurse Practitioners and Nursing staff to be actively bleeding and suffering from severe dehydration; the facility failed to communicate and obtain approval from a resident's power of attorney for hospital transfer for a resident with severe cognitive impairment related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R245 was a [AGE] year-old female who was originally admitted to the facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], R245 was assessed for a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R245's MDS (Minimum Data Set assessment) dated [DATE] documents BIMs (Brief Interview for Mental Status) score of 08, which indicates cognitive impairment. Care plan last reviewed [DATE] states: R245 has problems with decision making, insight, logic, calculation, reasoning, planning, organization, sequencing social skills and/or judgment related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Medical record documents that R245 underwent several abdominal surgeries prior to admission and was actively being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R245's records indicate that she was hospitalized twice since admission, with the most recent return to the facility on [DATE] after she was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R245's Nursing progress notes were reviewed from [DATE] to [DATE]. On [DATE] at 1:46PM, nursing staff noted reddish liquid coming out of the fistula and notified V40 Medical Doctor. Later that evening, V40 Medical Doctor assessed R245 at the bedside, and left recommendations for nursing to continue monitoring. On [DATE] at 11:26AM, a nurse documents, Noted bleeding from [CONDITION(S)]. [CONDITION(S)] bag noted with blood drainage, V40 called and order received for STAT GI (gastrointestinal) consult. DON (Director of Nursing) notified, told to send resident to ER. At 12:24PM, note said that R245 refused to go to the hospital. The Healthcare POA (Power of Attorney) was aware, and the resident refused to speak to them. Social Services and DON were notified. On [DATE] at 10:02, nurse writes, Resident still have the blood coming out from the fistula. Resident refused to go to the hospital last night. On [DATE] at 02:30AM, Resident still have blood coming out from her fistula. V40 made aware. Pt. was screaming, complaining of pain. On [DATE] R245 was evaluated by a nurse practitioner who noted that the resident was alert to self and Hospice appropriate. Labs were reviewed with order to give 2 liters of fluid bolus and repeat labs a week later. On [DATE] a nurse noted: pt. has mucousy blood coming out from the rectal; nurse practitioner and infectious disease doctor notified, a urinalysis and culture were ordered. Progress Notes reviewed for [DATE], [DATE], and [DATE] indicate that urine was unable to be collected. No follow up or explanation documented/provided. On [DATE], R245 was seen by a Psychiatric Nurse Practitioner, who assessed the resident to be to oriented only to person and place, limitedly insightful and labile. R245 said to the NP, that she wanted to go home, but did not know where home was. On [DATE] NP assessed R245 and documented to monitor for bleeding, and included orders for a urinalysis and culture, labs, and a GI consult. Notes include: recently patient had some bloody drainage to [CONDITION(S)]. Patient refused to go to hospital. WBC elevated at 13.76. Resident was noted to be weak and confused alert and oriented x1 during assessment. [DATE] NP assessed R245 as alert and oriented x1, non-cooperative and not talkative. Laboratory results were reviewed and noted that BUN was elevated. On [DATE], BUN was 71, while on [DATE] BUN was 57. Nurse Practitioner ordered one liter of Intravenous fluids, repeat labs on [DATE] and a Gastrointestinal Consult. On [DATE], NP assessed R245 and reviewed lab results. WBC's- 13.43 (high), BUN 77 (high), creatinine 0.64 (normal). R245 completed antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Intravenous fluids were discontinued. R245 was seen on [DATE] by NP who documented, Dehydration noted on labs. Lying in bed with legs pulled up underneath her and arms crossed. Agitated with interaction. Unable to start peripheral IV for dehydration-RN instructed to get midline and start IVF, then repeat labs in am. GI consult pending for mucous/bloody rectal drainage noted earlier in the week. An order was placed [DATE] for urine collection, which was unable to be collected as noted by nursing staff. R245 was evaluated by NP on [DATE] and documented, Patient is seen today for leukocytosis and again blood is noted in [CONDITION(S)]. Given WBC trending up, urine sample was ordered. However unable to collect per nursing. Per nursing after (urinary catheter) insertion noted with frank blood. In the assessment/plan, the NP writes: DNR (Do Not Resuscitate) with ok for hospitalization s. Per report, family refusing hospice. Needs hospital send out or hospice. Awaiting (Primary Doctor) response, contacted x2. Review of medical record did not address any further contact with primary physician or Medical Director for additional guidance or interventions. Progress notes document that R245 continued to receive [MEDICATION(S)] medication for clotting prevention after being assessed for acute bleeding. On [DATE] at 5:52AM, Nurse held [MEDICATION(S)] due to signs of bleeding from unknown source. On [DATE] at 6:17AM nurse wrote: signs of bleeding noted at the sacral area from unknown site, site assessed, no wound, no sign of bleeding from the vaginal, ostomy pouch intact. Withheld [MEDICATION(S)], notified supervisor on duty, will continue to monitor. On [DATE] at 9:09AM, nurse wrote, seen by wound care team and noted bleeding to her right ostomy. Notified House NP, Director of Nursing and Assistant Director of Nursing. At 9:18AM, nurse writes: Bleeding noted from her ostomy site, NP made aware. Waiting for any orders. Resident refused to check her vital signs. On [DATE] at 10:05AM, nurse got order from NP to send to the emergency room for further evaluation. PoA made aware and agreed. Private ambulance called. Ambulance picked up R245 at 10:55AM. In the emergency room , R245 had labs collected at 11:25AM and was found to have multiple abnormal lab values. In the ER, R245 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . R245 was alert to person and place, otherwise not responding to questioning. R245 was treated in the ER for abdominal infection and admitted for rectal bleeding. On [DATE] at 10:32PM R245 expired while in the hospital. Death certificate lists Causes of death as [CONDITION(S)] and Gastrointestinal Bleed. [DATE] at 05:15 PM V43 Resident Representative said, in the beginning of November the Nurse Practitioner called to inform me that my mother was bleeding, but they said they weren't sending her because she was coherent and refusing to go. I told them that they should send her anyway because she was suffering from dementia. I didn't think she could have made that decision for herself. They even called my cousin who they had listed as the PoA, and she agreed to send her as well. They didn't send her until it was too late. [DATE] 11:15 AM V40 Medical Doctor said, I'm one of the primary physicians in the facility and I currently round. The facility has their own nurse practitioners who see the residents. I have requested for staff nurses to reach out to me directly about any issues about my patients. I just want to make sure I get the information and know everything that is going on about the patient. There has been an occasion where the patient is at the hospital and I didn't know about it, and I am not always informed. Sometimes there is a situation where there are orders written by the NP that I am not aware of. I always want to be informed, particularly if a resident is clinically assessed to have to go to the hospital or their clinical condition is acutely worsening. I would expect both the NP and the nurse to recognize a medical emergency and the nurse should inform the NP or myself. I vaguely recall R245. Reviewing the labs leading up to hospitalization , that suggests dehydration and an evolving infection. A cause of dehydration could have been more loss of fluid, such as bleeding or diarrhea. Infection can also cause dehydration. Based on the labs she was actively bleeding. In this case, the patient is bleeding, the staff knows, and the next step is to monitor the corresponding lab values. As I recall, the patient had a staff consult with the Gastrointestinal surgeon who was aware and continue monitoring of the CBC. I don't recall if I was notified. I would expect the nurse practitioners to recognize the signs of infection that can lead to [CONDITION(S)] which is life threatening. For a patient that has dementia and cognitive dysfunction, I would talk to the PoA about hospitalization because we're unable to rely on the patient to make the decision. If I was unavailable, I would expect for the staff to call 911 in an emergency or to contact the Medical Director for orders. [DATE] at 12:41 PM V41 In House Nurse Practitioner said, Reviewing these labs and not directly knowing the resident, it looks as if they were suffering from infection, dehydration, and reactive [CONDITION(S)]. I would probably order more tests to determine source of infection if any. If the nurses were unable to obtain urine from the straight catheter despite giving IV fluids, the resident should have been sent out to the hospital. [DATE] at 10:03 AM V34 former Director of Nursing said, I was the DON March of 2021 and I left Early January of 2022. I vaguely recall R245 was suffering from a lot of complications. I expect that if there were a life-threatening situation, we would have called 911 and worried about notifying the doctor later. As a floor nurse I would be looking at the labs and advocating for what was best for the resident to the doctor or nurse practitioner. I'm not aware of what happened to R245 after transfer to the hospital. [DATE] at 11:47 AM V35 Former Social Services Director said, When R245 arrived at the facility she was fully alert and oriented. When she became sick and frail, we recommended hospice, but the POA refused. As she began to decline, she was not able to make her own healthcare decisions. In that condition, we would have done whatever interventions we could to preserve her life. She also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to prevent a resident from developing pressure ulcers who was assessed to be at high risk by and, not assessing a resident's skin regularly while providing personal care; they failed to conduct weekly skin checks as ordered; they failed to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure applied to one (R64) of one resident reviewed for pressure ulcers and resulted in R64 developing a new facility acquired Stage II pressure ulcer to the coccyx. Findings include: R64 is a [AGE] year old woman admitted to the facility 12/01/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R64 has a BIMs (Brief Interview of Mental Status) score of zero and is not alert or oriented. She has a respiratory status requiring a [CONDITION(S)] and mechanical ventilation. Nutrition is provided through gastrostomy feeding tube. R64 has a [CONDITION(S)] and indwelling urinary catheter. R64 has a functional status requiring two person total assistance with personal hygiene, bed mobility and transferring. The facility treated sacral wounds for R64 from the time of admission and healed the sacral wound on 6/13/22. 08/08/22 at 12:40PM, R64 was observed in bed, non-responsive and breathing without any noticeable distress. V44 CNA (Certified Nursing Assistant) was noted to turn and reposition with the help of another CNA. R64 was wearing a disposable brief, lying on an low air loss mattress that was dressed with a flat sheet, a folded flat sheet used as a draw sheet and a disposable incontinence pad. V44 CNA said, this is how we always set R64, because sometimes the urine is leaking, or the [CONDITION(S)] will get too full before I can empty it and it will leak. 08/08/22 at 4:11PM V25 Nurse Wound Care Director was observed conducting a full body skin assessment for R64. V25 said, R64 should not need all of these sheets on the air mattress. She has a disposable brief on because sometimes I know the urinary catheter to leak. It should not be leaking but it does. Too many layers will cause the mattress not to be beneficial. R64 does not have any more wounds. We have finally healed a wound on the sacrum that she had for a long time. In order to heal a wound, we have to assess it for 3 weeks to make sure it does not re-open. Currently, the only treatment is a preventative foam dressing that should be changed by nursing daily. Because she is high risk, the wound care team will still follow and assess weekly. I am not sure when is the last time a skin assessment was done for her. During this observation, R64 had a foam dressing to the sacrum that was dated 8/2/22 (6 days prior). V25 said that the dressing should be changed every day or every other day by the nurses. This dressing has not been changed for several days. After removal of the dressing, R64 was noted to have a skin opening in the center fold of the buttocks and a reddened area surrounding the sacrum. V25 said, I would consider this to be Moisture Associated [CONDITION(S)] and a Stage II Pressure Wound of the coccyx. I was not aware of this new wound so there is no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . They should be checking the skin every time they turn and clean the resident. They are probably not turning or cleaning frequently because she has a [CONDITION(S)] and urinary catheter. 8/11/22 at 2:52PM V24 Medical Director said, the protocol for wound care prevention relies heavily on CNA frequency of turning and repositioning. Patients who are receiving ventilator assistance are more prone to skin breakdown, because they are bedridden and are very vulnerable to having pressure sores. I would expect that a resident who is on a ventilator to be turned and repositioned at least every two hours. I would expect for the skin to be checked and assessed at minimum daily. If there is a sign of breakdown, distinguished early enough, it may help to prevent advanced breakdown. A Stage II wound is already opened and now needs additional prevention to not only heal but also be free of infection. Requested skin care assessments and documentation for R64 for the week of 8/01/22 and it was not provided during the course of this survey. Weekly skin assessments reviewed for 7/11/22, 7/18/22, and 7/25/22 document that R64 did not have any new loss in skin integrity. Weekly Wound Evaluation dated 8/8/22 defines Stage II as partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. New wound was identified 8/8/22 categorized as an In-House Acquired Stage II of the coccyx with measurements: length-1cm, Width: 0.2cm, red in color with small amount of serous drainage and [CONDITION(S)] surrounding tissue. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 4/27/22 includes to apply foam dressing for protection every day on the sacrum. (TAR) Treatment Administration Record for August 2022 were requested from the facility but during the course of this survey, the facility only provided TAR for July 2022. Facility policy titled, Change of Condition, documents: .a significant change in condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. If the resident's physician does not respond to calls of a resident condition status change, the facility Medical Director will be notified to obtain orders, and this will be documented.

Based on observation, interview, and record review, the facility failed to provide effective pain management for a resident who has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure affected one (R129) of one resident reviewed for pain and resulted in R129 experiencing pain rated at a level 8 on a 1-10 scale. Findings include: R129 is an [AGE] year-old male who was originally admitted to the facility on [DATE], with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 8/08/2022 at 11:31AM, resident was observed in his room lying in bed and moaning, resident is awake and alert with some confusion and stated that he is okay, floor mats were noted at both sides of the bed. Resident room is located across the hall from the dining room where the surveyors were during the survey process, and he was heard moaning throughout the day. 08/09/22 1:38 PM, R129 was again observed in his room, awake and was moaning, resident was asked if he was in pain, and he said yes. R129 rated his pain as an 8 on a scale of 1 to 10, he added that he did not receive any pain pill today and cannot remember the last time he had one. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet 50 MG *Controlled Drug*Give 1 tablet by mouth every 8 hours as needed for Pain ordered July 26, 2022. Acetaminophen Tablet Give 650 mg by mouth every 4 hours as needed for pain or fever. 08/09/22 02:05 PM Pharmacy. Resident also has an order to monitor and record pain scale based on a scale of 1 to 10. Review of MAR (Medication Administration Record) for R129 showed that he received one dose of Tylenol on 8/3/2022 and has not at any time received [MEDICATION(S)] as ordered. 08/09/22 1:40PM, V11 (RN/Agency) said that she is the assigned nurse for the resident, surveyor asked if she assessed resident to know why he was moaning and she said that she was told by the outgoing nurse that resident has that as a behavior, it is not pain related. V11 said that when she checked on the resident, he said he just wanted her to come into the room. Surveyor asked V11 to check and see if the resident had any [MEDICATION(S)] in stock, she looked in the narcotic box and said that there is none and she could not find any narcotic sheet for the resident in the narcotic count sheet. 08/09/22 1:59 PM, V2 (DON) said that R129 has cancer in the brain, he used to be alert and oriented x3 but has gone down to two or three. He gets pain medication as needed and is able to verbalize when he is in pain. V2 added that if a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan initiated 4/27/2022 states that resident has potential for pain related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include to assess and document the frequency and intensity of pain on the pain flow sheet, identify physical and psychosomatic causes of pain, medications as ordered, if ineffective, notify the physician, etc. Facility pain management policy (undated) provided by V2 (DON) states in part that the mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The same document states that this will be achieved through promptly and accurately assessing and diagnosing pain. Under procedures, the policy states that nursing observation is an important part of pain assessment, especially in the non-verbal resident. Nursing will observe behaviors that may indicate pain in the non-verbal pr cognitively impaired residents.

Based on interview and record review, the facility failed to follow MD orders for an IV antibiotic to treat an infection. This failure affected 1 resident (R3) of 3 residents reviewed for following physician orders. This failure resulted R3 missing 5 doses of scheduled IV antibiotic, having an acute change in condition to include fever, R3 was transported to the local hospital and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 6-2-22 at 11:24 AM, V2 (Director of Nursing) said R3 did have 5 missing doses of IV antibiotic related to clogged Midline and inability to obtain peripheral IV access. R3 was ordered IV antibiotic every 8 hours x 7 days for [CONDITION(S)] related to pneumonia. Staff made attempts to start peripheral IV line and were unsuccessful. MD/NP and family were made aware. V14 (Nurse Practitioner/ NP) was able to insert peripheral IV and a dose was given. R3 missed 3 doses of IV antibiotic on 4-2-22 (6:00 AM, 2:00 PM, and 10:00 PM) and 2 doses on 4-3-22 (6:00 AM and 2:00 PM). On 6-2-22 at 9:27 AM, V11 (Registered Nurse) said she gave initial dose at facility however, the following morning R3's Midline was clogged. V11 attempted to insert peripheral IV x 2 with no back flow. V11 called MD, MD gave order to insert Midline. V11 called vendor and was told someone will come for Midline insertion with no specific time or time frame given. V11 worked the same night and R3 did not have midline. V11 asked previous nurse and said vendor did not come to insert Midline. RN does not remember if previous nurse followed up with vendor. V11 made follow up call to vendor and they said someone will come with no estimated time of arrival given. On 6-3-22 at 1:46 PM, V22 (Vendor) said Midline was ordered 4-2-22 at @ 6:08 AM, should have been done within 24 hours. Midline completed 4-3-22 at 9:25 PM and this did not meet the 24-hour window. Follow up calls made by facility on 4-2-22 @ 9:30 PM at 9:46 PM. The delay could have been due to the limited resource of vascular nurses (short staffing of vascular nurses). On 6-2-22 at 11:10 AM, V14 (NP) said she was aware of R2's Midline problems. V14 was able to insert R3's peripheral IV and R3 receive a dose of IV antibiotic. V14 said the 5 missing doses of IV antibiotic could have contributed to R3's hospitalization . On 6-2-22 at 11:00 AM, V13 (MD) said missed doses of IV antibiotics could have contributed to [CONDITION(S)] but need specifics. R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Audit Report dated 5-2-22 documents [MEDICATION(S)] HCl Solution Reconstituted 1 GM, Use 1 gram intravenously every 8 hours for [CONDITION(S)] for 6 days (order 4-3-22). Progress Note dated 4-7-22 documents admitted to local hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Record (4-4-22) documents MDM: 66 -year-old male presents from nursing home for fever. R3 was febrile to 40 degrees. R3 has coffee ground emesis coming up through his [CONDITION(S)]. R3 has elevated BUN/creatinine from baseline. UA appears dirty, unsure if this is [CONDITION(S)] or chronic colonization. Chest x-ray is concerning for right-sided pneumonia. CT chest, abdomen and pelvis is also concerning for possible pneumonitis, no signs of acute infection. ED Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Pneumonia due to infectious organism 3. Coffee ground emesis.

A)Based on interview and record review, the facility failed to supervise a resident that was assessed to require monitoring/monitoring during smoke break this affected 1 of 3 residents (R4) reviewed for safe smoking. This failure resulted in R4's shirt catching fire and R4 was sent to hospital, burn unit, and treated for 5% partial thickness burn to right limb/axilla. B)The facility also failed to utilized 2 person assist during direct resident care for a resident that was assessed for two person physical assist for bed mobility. This affected 1 of 3 residents (R8) reviewed for safe transfers and repositioning. This failure also resulted in R8 falling out of bed while being repositioned by1 certified nurse aid (V19). R8 sustained a commuted displaced proximal right distal fracture involving the surgical neck, and greater tuberosity, and possibly the lesser tuberosity and a mildly medially displaced humeral shaft. Findings include: A) On 4-5-22 at 11:25 AM, surveyor observed dressing to right forearm. Dressing and arm is clean and intact. On 4-6-22 at 2:45 PM, 4-7-22 at 8:45 AM and 2:30 PM, 4-8-22 at 8:45 AM, 4-12-22 at 8:45 PM, 12:00 PM, and 2:30 PM, surveyor observed R4 on the smoking patio smoking a cigarette with a large embar at the end. On 4-7-22 at 10:20 AM, V1 (Administrator) said the facility uses 2 staff for monitoring resident smoke breaks. The facility uses 2 staff as an extra layer of safety and protection. The more eyes, the better. This is to ensure safety and well-being of residents who are smoking. On 4-6-22 at 9:53 AM, V2 (Director of Nursing/ DON) said has been acting as DON for 5 days at the facility. V2 said R4 requires supervision while smoking and staff has educated R4 about flicking his (R4)cigarette. When supervising a smoking resident, the staff will light the cigarette and distribute cigarettes. Staff should be in close proximity of smoker in order to prevent unwanted behavior or injury. On 4-5-22 at 11:40 AM, V3 (Social Service Director/ SSD) said R4 has the behavior to tap his cigarette which could cause a burning [NAME] to fall and ignite. V3 was talking to another resident smoker when she(V3) saw R4 with flames on his right arm bicep and V4 (SSA) was trying extinguish R4's shirt flame by hugging R4. On 4-7-22 at 8:59 AM, V3 (Social Service Director/ SSD) said the facility uses 2 staff to monitor smoking residents. The monitors will position themselves in a place to get a good view of smokers within close proximity. At the time of R4's incident V3 was inside the building at the door of the smoking patio talking with a resident smoker. V4 saw R4 with flames on his right arm bicep and V5 was extinguishing resident flame by hugging/smothering resident. On 4-5-22 at 12:13 PM, V4 (Social Service Assistance/ SSA) said he was assigned to R4's smoke break. V4 was on the patio and V3 was at the patio door inside of the building. All smokers at that time were smoking in their assigned smoking seats. V4 observes R4 tap his cigarette to release the [NAME]. It was a windy day. V4 believes when R4 tapped the cigarette to lose the [NAME], the wind carried lit [NAME] to his clothing. R4 was wearing a thin cotton flannel which is more flammable. V4 was sitting on the outside couch observing the 5 smokers on the patio. V4 saw R4's bicep on fire and immediately provided R4 a hug to extinguish the bicep fire and activated code red. On 4-5-22 at 12:45 PM, V5 (CNA) said R4 is forgetful and can be irritable and agitated. R4 has poor safety awareness due to impulsivity R4 uses only 1 arm and the other arm is impaired. R4 requires strict supervision because R4 can only use one arm and is forgetful. On 4-5-22 at 1:28 PM,V6, (nurse) stated; R4 is alert, oriented x 2-3, and able to make his(R4) needs known. R4 can be forgetful a times. R4 is redirectable. Smokers are supervised by 2 staff. R4 requires supervision during smoking breaks. R4 is risk for injury during smoking. R4's Final Reportable (dated 3-14-22) documents R4 was out in the smoking patio having a cigarette. R4 flicked his cigarette to displace the ash. The ash floated and landed onto the patient's shirt, subsequently igniting the upper section of the shirt. R4's Smoking Safety Risk Observations document scores of 4 prior to incident (5-5-21, 8-2-21, 11-1-21, and 1-31-22) and 10 after smoking incident (3-24-22). These scores document R4 requiring supervision while smoking. Hospital Record (dated 3-9-22) documents Diagnosis: partial thickness burn of right upper arm. Dermatologic: Non circumferential burn on the right arm first degree. Hospital Record (Burn Unit) dated (3-9-22) documents R4 was evaluated for 5% partial thickness burn to upper right limb/ axilla status post clothing fire. R4 underwent excision burn with debridement with placement of allograft of right upper extremity and excision debridement burn right upper extremity, right chest, skin graft of right arm, and recell. Smoking Policy (revised 11-27-11) documents Purpose: To provide a healthy and smoke free environment for all residents, employees and visitors. B) On 4-12-22 at 10:00 AM, R8 was in bed with right arm sling in place, floor pad (both sides), and bed in low position. R8 had bilateral quarter rails up and in place. On 4-12-22 at 10:00 AM, R8 is alert and forgetful. R8 does not recall the details of her(R8)fall. R8 denies pain at this time. No fall concerns received. On 4/12/22 at 10:15 AM, V2 (Director of Nursing) said there was one agency CNA providing care to R8. R8 needs 2 person assist with bed mobility. The facility uses 2 person assist for the safety of the resident and employee. On 4-7-22 at 2:50 PM, V15 (Restorative Nurse) said R8 needs 2 person assist with bed mobility (pulling up and turning side to side) for safety. On 4-8-22 at 9:49 AM, V19 (Agency CNA) said R8 needs 2 staff to turn her(R8) on her(R8) side because she(R8) is heavy. When V19 was providing patient care (by herself), V19 asked R8 to turn her (R8) to other side and R8's leg slipped out of bed and R8 fell out of bed. V19 went to other side to grab R8's other leg which is very heavy. There was no other staff to assist and V19 had to call another staff to put her(R8)back in bed. On 4-8-22 at 10:29 AM, V18 (RN) said R8 is alert, oriented x 1, and is confused and forgetful. R8 is bedbound. R8 is obese and requires 2 people for repositioning because for safety. For rolling side to side, there should be one person on each side to prevent fall. According to V19, she (V19) was giving R8 perineal care for bowel movement after breakfast by herself. V19 asked resident to turnover and assisted R8 to turn on her (R8) side, R8's leg dropped off the bed and R8 rolled over. R8 landed on floor pad with the bed in lowest position. R8's Final Investigation Reportable (dated 4-8-22) documents R8 was in bed on her(R8) right side receiving perineal care. R8 unexpectedly rolled out of bed and landed on the floor on her(R8) right side. R8's MDS (ARD 2-14-22) documents Bed Mobility requires 2 person physical assistance and Diagnoses of Obese Morbidity, Weakness, Other reduced Mobility, Lack of Coordination, and Functional [CONDITION(S)]. Restorative Observation (dated 2-14-22) Bed Mobility: turn left to right, turn right to left is 2 person assist. Bed Mobility support provided 2 person physical assist. R8's Kardex (Point of Care) documents Bed Mobility- extensive assistance x 2 staff. R8's Facility Radiology Report (dated 4-5-22) documents Findings: there is an acute fracture of the humeral neck extending into the proximal humeral shaft with minimal separation of fracture fragments and there is an acute oblique fracture of the humeral neck extending into the proximal humeral shaft, with minimal separation of fracture fragments. Impression: Acute oblique fracture extending from the humeral neck into the proximal humeral shaft. Hospital Record (dated 4-5-22) documents Findings: there is a comminuted and mildly displaced proximal right distal fracture, involving the surgical neck, greater tuberosity, and possibly the lesser tuberosity. The humeral shaft is also mildly medially displaced. Fall Prevention and Management Program Policy (dated 8-3-17) documents this facility is committed to safety and maximizing each resident's physical, mental, and psychosocial well-being. The purpose of our Fall Prevention and Management Program is to provide appropriate intervention to prevent falls. The Fall Prevent and Management Program uses clinically accepted guidelines to guide the prevention and management of falls. The program will decrease the incident of falls and decrease the incident of falls with injuries.

Based on interview and record review the facility failed to follow the Fire Plan Policy and utilize the fire blanket or fire extinguisher after an unsupervised resident shirt caught fire during a smoke break. This affected 1 of 3 residents (R4) reviewed for emergency fire policy and procedures. This failure resulted in R4 being hugged by V4 (Social service assistant) to extinguish R4 shirt. R4 was sent to the local hospital, burn unit, and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 4-6-22 at 10:39 AM, V1 (Administrator) said R4 admitted to flicking his cigarette which caused cigarette embar to fall and ignite R4's shirt. The staff did not notice R4's embar fall and ignite his shirt. V1 described R4's shirt as an ultra thin western shirt. It was a windy day and the wind could have carried the embar to R4's shirt. V4 did not use the smoking blanket or fire extinguisher to extinguish R4's shirt. On 4-6-22 at 9:53 AM, V2 (Director of Nursing) said R4 requires supervision while smoking and staff has educated R4 about flicking his(R4)cigarette. V2 said she(V2) would use fire extinguisher or fire blanket to extinguish a resident on fire. On 4-5-22 at 11:40 AM, V3 (Social Services Director/ SSD) said she was talking to another smoker in the facility by the patio door during the incident. V3 saw R4 with flames on his right arm bicep and V4 was trying to extinguish R4's blazed shirt by hugging R4. V3 said there was a fire extinguisher and fire blanket on the patio during this incident. V4 made the decision to directly extinguish R4's shirt on fire and did not use extinguisher or blanket. V3 said V4 felt V4 could extinguish the fire by himself without using fire blanket or extinguisher. On 4-5-22 at 12:13 PM, V3(Social Services Director/ SSD), said V4 was assigned to R4's smoke break 2:30 PM and 4:00 PM smoke breaks on 3-9-22. V4 was sitting on the outside couch observing the 5 smokers on the patio when V4 saw R4's bicep on fire. V4 immediately provided R4 a hug to extinguish the bicep fire and yelled code red. V3 and V7 came with fire extinguisher. V4 said he did not use a fire extinguisher or smoking blanket to extinguish R4's shirt fire. On 4-5-22 at 1:54 PM, V8 (Maintenance Director) said facility provides fire safety in-services annually and during employee orientation upon hiring. If resident caught on fire, staff should maintain resident safety and extinguish the fire. The smoking patio has a fire blanket, smoking jackets, and fire extinguisher on premise. Employees are taught to smother fire with blanket or use extinguisher P-A-S-S method (Pull, Aim, Squeeze, Sweep). The facility teaches staff to use the safety blanket to smother fires. R4's Final Reportable documents R4 was out in the smoking patio having a cigarette. R4 flicked his cigarette to displace the ash. The ash floated and landed onto the patient's shirt, subsequently igniting the upper section of the shirt. Facility Fire Plan (no date) documents if a fire is small and controllable, attempt to extinguish fire by covering, smothering, eliminating fuel source, etc. Use only wet curtains, wet towels, or wet linen. Do not use articles of clothing as clothing is extremely flammable.

A. Based on interview and record review, the facility failed to comprehensively assess and recognize a decline in resident condition requiring treatment interventions for 2 of 4 residents (R2, R3) reviewed for change in condition. These failures resulted in R2 becoming non-responsive requiring Emergency Medical Services (EMS) being called and R2 subsequently expiring at the facility and resulted in R3 presenting to the hospital with severe dehydration and hypovolemic shock and expiring in the emergency department. Findings include: 1. On [DATE] at 12:30pm, V22, RT(Respiratory Therapist) stated that there is a respiratory therapist on each nursing unit on the third floor. V22 stated that respiratory therapy is responsible for managing respiratory care for all residents with a [MEDICAL CONDITION] and/or ventilator. On [DATE] at 11:30am, V3, NP(Nurse Practitioner) stated that V6 (Nurse) first attempt to reach V3 was at 5:09am on [DATE]. V3 stated that V3 called the facility at 6:30am when V3 saw message from V6. V3 stated that V6 informed V3 that R2 was stable. V3 stated that V3 instructed V6 to continue monitoring R2. V3 stated that V19 (Nurse) called V3 to inform V3 of R2's second change in condition, instructed V19 to send R2 out 911. V3 stated that R2 coded while waiting for ambulance. On [DATE] at 1:35pm, V12 (RT) stated that V12 worked on [DATE] 7:00am to 7:30pm. V12 stated that V12 does walking rounds with the off-going RT. V12 stated that V12 finished rounds 7:30am-8:00am. V12 stated that V12 told V11(RT) that R2 did not look good; V11 informed V12 that R2's blood pressure was low during the night. V12 stated that she finished rounds then returned to R2's room. On [DATE] at 1:50pm, V13(RT) stated that if a resident does not look good while doing walking rounds with the off-going RT, V13 will get the resident's nurse and discuss the resident's condition with the nurse and RT. V13 stated that RT should obtain vital signs of resident, blood pressure, pulse, oxygen saturation level. V13 stated that RT should stabilize the resident first before leaving the resident's room to finish getting shift report. When asked what interventions RT should implement for an unstable resident, V13 stated that to stabilize the resident, RT would ventilate resident with bag valve mask to maintain oxygenation at 100%. V13 stated that if resident is still unstable, the resident should be sent out via 911 EMS. On [DATE] at 11:28am, V18 (EMS paramedic) stated that V18 reviewed V18's report, dated [DATE], and does recall responding to this facility for R2. V18 stated that there was one staff member standing in R2's room when EMS entered, but was not touching R2. V18 stated that the staff member informed paramedics that R2's pulse was weak. V18 stated that crew immediately checked for pulse, R2 was pulseless and CPR (cardiopulmonary resuscitation) was initiated immediately by EMS crew. V18 stated that R2's blood sugar level was checked and registered low. V18 stated that staff was asked when the last time R2's blood sugar was checked. Staff informed V18 that R2's blood sugar level was 92 at 5:33am. V18 stated that 6:50am was the last time the nurse stated vital signs were done and documented this in his report. V18 stated that R2's ventilator was not alarming when EMS arrived. V18 stated that when EMS arrived, it did not appear that staff even recognized R2's current condition. V18 stated that the respiratory therapist was not present in room when EMS arrived or while EMS was performing CPR and the crash cart was not in or near R2's room. Review of V11 (RT) documentation, dated [DATE] at 9:35pm, notes vital signs: heart rate 62 beats/minute, respirations 32/minute, oxygen saturation level 96% on ventilator, lung sounds with rhonchi (coarse breath sounds) throughout all lung fields. There is no further documentation found by V11 on [DATE] or [DATE]. Review of R2's progress notes, dated [DATE] at 5:09am, notes R2 awake during care, unable to obtain oxygen saturation level, blood pressure ,[DATE], heart rate 51 beats/minute, respirations 30/minute, blood sugar level 92, temperature 96.8 degrees Fahrenheit. Message sent to V3 (NP) and V20 (Attending Physician), message marked as urgent. On [DATE] at 5:25am, family notified that R2 awake in respiratory distress while receiving care from V11 (RT). Awaiting call back from V3 and/or V20. On [DATE] at 5:54am, V3 and V20 called with message left on R2's status. On [DATE] at 6:23am, V3 returned call, made aware of R2's status, vital signs: heart rate 62 beats/minute, respirations 14/minute, blood pressure ,[DATE], temperature 96.8. Oxygen saturation 94% via ventilator and tracheotomy. No new orders given at this time. On [DATE] at 7:24pm (time note was written), V19 (Nurse) documented right after report, vital signs: blood pressure ,[DATE], respirations 14/minute, heart rate 44 beats/minute irregular, temperature 95.9 degrees Fahrenheit, unable to read oxygen. R2 did not respond to painful stimuli, pulse was weak. V20 (Attending Physician) called twice but no response. V3 (NP) called and updated on R2's condition. Order was received to call 911 and send R2 to hospital. R2's family updated on condition and plan of care. 911 called. R2's pulse was becoming weaker. At 7:53-no more pulse palpated. Code blue initiated. 911 crew arrived at 7:55 and CPR continued. At 8:09 R2 was pronounced dead. Review of R2's EMS report, dated [DATE] notes EMS received call at 7:41am, on scene at 7:44am, and at R2's bedside at 7:47am. R2 was without blood pressure, heart rate, or respirations. CPR initiated by paramedics at 7:47am. Crew called to this facility for unresponsive person. Upon arrival, the nurse stated R2's pulse was weak. During EMS assessment, R2 found to be pulseless, CPR was started and R2 had an existing tracheotomy that paramedics were able to ventilate R2 through. The nurse stated that they last had vitals at 6:50am. R2 remained in asystole throughout the incident. Hospital contacted and crew ordered to stop resuscitative efforts at 8:09am. R2 pronounced expired on scene. 2. Review of the medical record notes R3 with [DIAGNOSES REDACTED]. On [DATE] at 11:05am, V4, CNA (Certified Nurse Aide) stated that when V4 rounded on R3 around 9:00am, R3 did not look good, R3's coloring was off, and R3 was short of breath. V4 stated that V4 notified V7 (Nurse), then proceeded to attend to other assigned residents. On [DATE] at 11:30am, V3, NP (Nurse Practitioner) denied being informed by nurse on [DATE] of R3's change in condition. V3 stated that V3 was notified on [DATE] R3's oxygen saturation level 86% on room air. V3 stated that when V3 arrived to R3's room, V3 called for respiratory therapy to place R3 on oxygen via non-rebreather mask and call 911. On [DATE] at 2:06pm, V7 (Nurse) stated that V7 provided care for R3 on [DATE]. V7 stated that V15 ST (Speech Therapist) informed V7 that R3's pulse was high. V7 stated that V7 went to R3's room and assessed R3, full set of vital signs obtained; V7 stated only R3's pulse was abnormal. V7 stated that V7 left R3's room and called V3 (NP). V7 stated that when V3 arrived at R3's room, V3 instructed V7 to notify respiratory therapist. V7 stated that the respiratory therapist came and applied oxygen to R3. V7 stated that V3 instructed V7 to wait ,[DATE] minutes to see how R3 responds to oxygen therapy before calling 911. Review of R3's transfer form, dated [DATE] at 12:38pm, V7 (Nurse) noted R3 with shortness of breath, vital signs at 11:50am: blood pressure ,[DATE], heart rate 149 beats/minute, respirations 26, and oxygen saturation level 86% on room air. V3 (NP) notified at 12:00pm. V3 came to R3's room, called respiratory therapist to put R3 on oxygen with non-rebreather mask. V3 instructed V7 to monitor R3 for 10 minutes and call 911. On [DATE] at 2:57pm, V15 (ST) stated that on [DATE] R3 was exhibiting changes in cognitive status. V15 stated that V15 observed R3 was not as alert as baseline. V15 stated that R3 was lethargic, difficult to arouse, not accepting food. V15 stated that V15 informed V23 (Nurse) of change. V15 stated that if R3's mental status change continued, R3 was at risk for choking on food or liquids. V15 stated that on [DATE], R3 appeared the same way, lethargic, not responding. V15 stated that V15 spoke to V7 (Nurse), informed V7 of increased heart rate and shortness of breath. Review of R3's progress notes, dated [DATE] at 10:42am, V23 RN (registered nurse) noted R3 observed pocketing medication and with a gurgling sound while holding medication in his mouth. R3 does not appear to be choking but is not following cue to swallow. Unsafe to administer nectar thicken liquid while medication still in mouth. Head of bed at 90 degrees, bed at lowest position with bed mat on the floor. Staff made aware R3 pocketing in mouth and to be very observant for choking. At 12:30pm, V15(ST) approached V23(RN) to inform V23 that R3 was noted with decrease in oral intake. V15 (ST) stated that prior to [DATE], R3 was accepting maximum of 75% of food and fluids by mouth, with the occasional request of additional fluid intake. On [DATE] R3 was observed with a fixated stare, no reaction to staff presence or interaction. V15 ST stated that V15 also noted that R3's food and fluid intake had decreased drastically with R3 pocketing the one spoon of food R3 had accepted. V15 (ST) stated that this is not known as R3's normal behavior. V15 (ST) stated today R3 is noted not to be accepting anything by mouth; food or fluid, and that it is becoming a concern for V15. Mouth care provided, head of bed elevated for choking precaution. At 5:22pm, R3 observed pocketing medication in mouth. On [DATE], V15 (ST) reported that V15 noted R3 had a pulse of 149. V7 (Nurse) went to R3's room, took R3's vital signs, observed R3's breathing was 24/minute, pulse 149, and oxygen saturation level 86% on room air. V3 (NP) called and notified. Review of V15's speech therapy treatment encounter, dated [DATE], notes R3 seen at dinner meal. CNA attempted but R3 appeared lethargic and non-verbal. V15 (ST) told CNA to not attempt oral intake at present time as R3 did not appear safe for any food due to lethargy. On [DATE], V15 noted V15 spoke with CNA prior to lunch meal. CNA indicated R3 was lethargic and not very responsive. R3 seen at lunch meal. Elevated head of bed for safety. R3's eyes open but limited responsiveness. R3 eventually indicated R3 wanted to eat not attempting to close lips around spoon placement and allowed nectar thick liquids to spill from lips. R3 with severe delayed to potentially absent swallow response. Oral care to remove any remaining food from mouth. R3's head of bed remained elevated. Discussed findings with V23 (RN) who indicated awareness of similar behavior when attempting to give R3 medications. V23 indicated to hold feeding. On [DATE], V15 noted R3 in semi-reclined position in bed. Eyes open and breathing rapidly. R3 not verbally responsive. Informed V7 (Nurse). V15 instructed V4 (CNA) to hold feeding meal. Review of R3's hospital medical record, dated [DATE] at 1:05pm, notes R3 presented to the emergency department with shortness of breath and worsening altered mental status which began earlier this morning. Physical exam notes R3 is frail, malnourished, ill-appearing, cachetic, tired, and toxic appearing. Coarse breath sounds noted throughout all lung fields. R3's mucous membranes were very dry. R3's heart rate was ,[DATE]s and oxygen saturation level was 95% on 10 liters oxygen via non-rebreather mask, and blood pressure was ,[DATE]. Laboratory results noted sodium level 155 (normal range is ,[DATE]), which is consistent with R3's exam, extremely dry. Kidney function laboratory results noted BUN (blood urea nitrogen) 50 (normal range is ,[DATE]) and creatinine 1.75 (normal range is 0XXX,[DATE].17). WBC (white blood cell count) 29.2 (normal range is 4XXX,[DATE].0) [MEDICAL CONDITION] markers elevated. R3's in hypovolemic and septic shock resulting in [MEDICAL CONDITION]. R3 expired in the emergency department. B. Based on observation, interview and record review, the facility failed to ensure safe medication administration according to physician orders [REDACTED]. Findings include: On [DATE] at 11:00am, this surveyor observed V17 (Nurse) passing medications to R18 in R18's room. R17 is observed ambulating in halls with physical therapy. V17 skips R17 and proceeds to R19's room to pass 9:00am scheduled medications. On [DATE] at 11:35am, V17 (nurse) is observed administering 9:00am scheduled medications to R20. On [DATE] at 11:45am, V17 is observed administering 9:00am scheduled medications to R21. On [DATE] at 12:15pm, V17 is observed administering 9:00am scheduled medications to R23. On [DATE] at 12:30pm, V17 is observed administering 9:00am scheduled medications to R4. On [DATE] at 12:42pm, V17 is observed administering 9:00am scheduled medications to R22. On [DATE] at 12:55pm, V17 is observed administering 9:00am scheduled medications to R24. On [DATE] at 1:10pm, V17 is observed administering 9:00am scheduled medications to R25. On [DATE] at 1:15pm, V17 is observed administering 9:00am scheduled medications to R5. On [DATE] at 1:55pm, V17 administered 9:00am scheduled medications to R17. On [DATE] at 11:15am, V17 stated that V17 has not passed 9:00am scheduled medications yet. On [DATE] at 2:00pm, V2 DON (Director of Nursing) stated that the nursing staff are expected to pass medications at time scheduled. V2 stated that medications can be administered up to one hour before and one hour after the scheduled time. V2 stated that if medications are not administered within this timeframe, the nurses are expected to call the resident's physician to find out if medications should still be given and document in the resident's progress notes. On [DATE] at 2:40pm, V21 (Nurse) stated that medications can be administered up to one hour before and one hour after the scheduled time. On [DATE] at 2:50pm, V9 (Nurse) stated that medications can be administered up to one hour before and one hour after the scheduled time. Review of R17 and R20's medical records do not note any documentation that R17 and R20's physician was notified regarding delay in receiving scheduled medications.

Based on interview and record review, the facility failed to follow its policies and procedures to prevent a significant medication error for one of three residents (R1) reviewed for significant medication error. This failure resulted in R1 being sent to the local hospital for treatment of [REDACTED]. The facility also failed to monitor and assure medications were administered according to physician orders [REDACTED]. Findings include: 1. Review of the medical record notes R1 with [DIAGNOSES REDACTED]. Review of R1's POS (physician order [REDACTED]. On 10/23/2020, notes an order for [REDACTED]. Review of R1's MAR (medication administration record), dated February 2021, notes R1 received [MEDICATION NAME] 5mg on 2/7 for BP (blood pressure) 123/76; on 2/10 for BP 133/80, on 2/16 for BP 122/69, on 2/17 for BP 132/74, on 2/20 for BP 124/76, on 2/27 at 9:00am for BP 137/76, on 2/27 at 2:00pm for BP 136/75, on 2/27 at 9:00pm for BP 132/70, and on 2/28 at 9:00pm for BP 128/71. Review of R1's MAR, dated March 2021, notes R1 received [MEDICATION NAME] on 3/1 at 9:00pm for BP 130/76, on 3/2 at 9:00am for BP 129/71, on 3/2 at 9:00pm for BP 121/65, on 3/3 at 9:00pm for BP 133/69, on 3/4 at 9:00am for BP 122/56, on 3/4 at 9:00pm for BP 122/74, on 3/6 at 9:00am for BP 150/69, and on 3/7 at 9am for BP 132/68. On 3/4/2021 at 9:40am, R1 stated that R1 questioned the nurse regarding the dosage of the [MEDICATION NAME] (brand name for [MEDICATION NAME] a diuretic) because the amount of the liquid was more than R1 routinely takes. R1 stated that the nurse informed R1 the dosage was 12.5mg (milligrams). R1 stated that this is the usual dose so R1 took the medication. R1 stated that afterwards, the nurse returned to R1's room and informed R1 that R1 was given 125mg [MEDICATION NAME] instead of the prescribed dose of 12.5mg. R1 stated that R1 was sent to the hospital for monitoring. Review of R1's progress notes, dated 2/23/2021 at 9:22am, V14, RN (registered nurse), noted during the morning medication pass, V14 gave incorrect dose of [MEDICATION NAME] 10mg/ml oral solution. The order is for 1.25ml/ 12.5mg dose in morning. V14 poured 12.5 ml and gave to R1. R1 asked how much that dose was. V14 explained 12.5 mg was given. V14 left room to recheck the order from the electronic medical record and the bottle, it was to be 1.25ml given. Notified V16 (former Director of Nursing) immediately, V16 ordered to send to hospital via 911. R1's vital signs: blood pressure 122/67, heart rate 54 beats/minute, oxygen saturation level 96%. V14 explained to R1 the situation regarding the [MEDICATION NAME] and the need to send R1 to the hospital. Then V14 called 911, and R1 was sent to the hospital. Review of R1's hospital medical record, dated 2/23/2021, R2 was admitted with [DIAGNOSES REDACTED]. R1's respiratory assessment in the emergency room notes crackles noted in all lobes. On two occasions during hospital stay, R1's blood pressure decreased to 76/61 at 12:18am and then to 77/59 at 3:11am, requiring medication and intravenous fluids to improve blood pressure. R1's laboratory results for kidney function: BUN (blood urea nitrogen) was 27 (normal range is 6-20) on 2/23 and 40 on 2/24; creatinine was 0.17 (normal range is 0.51-0.95) on 2/23 and 0.25 on 2/24. Sodium level was 138 (normal range is 135-145) on 2/23 and 136 on 2/24. Magnesium level was 1.9 (normal range is 1.7-2.4) on 2/23 and 1.8 on 2/24. Potassium level was 4.3 (normal range is 3.4-5.1) on 2/23 and 4.4 o 2/24. On 3/5/2021 at 11:30am, V3 NP (Nurse Practitioner) stated that the nurse called V3 at home. V3 stated that V3 instructed the nurse to send R1 to the hospital 911 when informed R1 received 125mg instead of 12.5mg of [MEDICATION NAME]. V3 stated that R1 required additional monitoring of electrolytes, sodium, magnesium, and potassium, as well as vital sign monitoring. V3 stated that R1's kidneys are functioning well and the medication will clear out of R1's system within days. V3 stated that it is not good for a resident to receive 125mg of [MEDICATION NAME]; there is potential for negative side effects. V3 stated that [MEDICATION NAME] is administered to residents with low blood pressure to increase their blood pressure. V3 stated that when this medication is prescribed, there are parameters for when to hold this medication. V3 stated that it is not good to be administering this medication when the resident's blood pressure is outside of these parameters, because it causes an increase in the resident's blood pressure even further. Review of this facility's medication administration procedure, updated 6/19/2012, notes to remove medication from drawer, read each label carefully: when removing from drawer, before pouring, and after pouring. Pour each dose of medication using an appropriate measuring device. 2. Review of R5's medical record notes R5 with [DIAGNOSES REDACTED]. Review of R5's POS, dated 2/13/2021, notes an order for [REDACTED]. Review of R5's MAR, dated March 2021, notes R5 received [MEDICATION NAME] on 3/1 at 9:00am for BP 145/69, on 3/1 at 9:00pm for BP 125/76, on 3/2 at 9:00am for BP 121/78, on 3/2 at 2:00pm for BP 121/78, on 3/2 at 9:00pm for BP 126/79, on 3/3 at 2:00pm for BP 108/46, on 3/4 at 9:00am for BP 129/82, on 3/4 at 2:00pm for BP 133/73, on 3/4 at 9:00pm for BP 125/81, on 3/5 at 9:00am for BP 125/75, on 3/5 at 2:00pm for BP 125/75, on 3/6 at 9:00am for BP 121/63, on 3/7 at 9:00pm for BP 127/78, on 3/11 at 9:00am for BP 124/79, and on 3/11 at 2:00pm for BP 124/79. 3. Review of R14's medical record notes R14 with [DIAGNOSES REDACTED]. Review of R14's POS, dated 1/6/2021, notes an order for [REDACTED]. Review of R14's MAR, dated March 2021, notes R14 received [MEDICATION NAME] on 3/6 at 9:00am for BP 139/69, on 3/6 at 2:00pm for BP 139/69,on 3/6 at 9:00pm for BP 130/70, on 3/7 at 9:00am for BP134/72, on 3/7 at 2:00pm for BP 134/72, and on 3/7 at 9:00pm for BP 132/64. 4. Review of R17's medical record notes R17 with [DIAGNOSES REDACTED]. Review of R17's POS, dated 6/20/2020, notes an order for [REDACTED]. Review of R17's MAR, dated March 2021, notes R17 received [MEDICATION NAME] on 3/1 at 9:00pm for BP 132/88, on 3/2 at 9:00am for BP 115/69, on 3/2 at 9:00pm for BP 115/69, on 3/3 at 9:00am for BP 107/77, on 3/3 at 9:00pm for BP 121/56, on 3/4 at 9:00am for BP 112/74, on 3/4 at 9:00pm for BP 111/71, on 3/5 at 9:00pm for BP 111/69, on 3/7 at 9:00pm for BP 126/78, on 3/8 at 9:00pm for BP 125/76, and on 3/11 at 9:00am for BP 118/62. Per Medline plus website, [MEDICATION NAME] medication is used to treat low blood pressure at rest. It is in a class of medications that cause blood vessels to tighten which increases blood pressure. Per the FDA (Food and Drug Administration) website, [MEDICATION NAME] can cause a marked increase in blood pressure at rest. The most potentially serious adverse reaction associated with [MEDICATION NAME] therapy is high blood pressure at rest.

Based on observation, interview and record review the facility failed to follow its fall prevention and management policy to complete fall assessments after each fall, failed to revise and implement additional individualized care plan interventions to prevent future falls, and failed to notify the State Agency within 24 hours after a fall with injury. This deficiency affects two (R5, R6) of three residents reviewed for fall prevention program. This failure resulted in R5 being sent out to the hospital a second time after a fall and receiving stitches to her right eyebrow. Findings include: 1. On 2/9/21 at 9:49am R5 observed in bed sleeping. She has floor mat and bed is not on lowest position. Bed height is above the knee. Observed gold star marked on her name by the door. ( indicated on fall prevention program). On 2/9/21 at 9:59am called V25 Licensed Practical Nurse (LPN) to R5's room. Observed R5's bed raised above knee level. R5 has on low bed with floor mat on side of the bed. Housekeeping aide inside the room cleaning. V12 Certified Nurse Assistant ( CNA) explained that housekeeping raises the bed when she is cleaning the room so she could clean underneath the bed. R5 had multiple unwitnessed fall incidents dated: 1/28/21, 1/29/21 and 2/5/21. Active care plan for risk of fall given by V2 DON indicated: Intervention updated on 1/28/21- Encourage R5 to ask for assistance when wanting to sit on the edge of the bed and floor mats by the bed. On 1/29/21- R5 was sent to ER for CT scan and lab work. She returned from hospital on the same day, care plan was not revised and no implementation of additional individualized intervention to prevent other falls based on root cause analysis review. Care plan was not updated after she fell on [DATE]. Review of R5's fall assessment after each fall incident with V2 DON and V29 Restorative Nurse showed no fall assessment was done for R5 for post fall incident on 1/29/21. R5 had unwitnessed fall with injury on 2/5/21, she was found on floor next to her bed. She sustained laceration on right upper eyebrow with bleeding. She was sent out to hospital for evaluation and treatment. She returned to the facility on the same day. She received stitches to her right eyebrow. V1 Administrator completed reportable fall incident with injury dated 2/7/21 and transmitted to IDPH (Illinois Department of Public Health (State Agency)) via fax on 2/8/21 at 1:37pm. Facility failed to notify IDPH within 24 hours after a fall with injury, per policy. V1 completed the final report on 2/11/21 and transmitted to IDPH after surveyor asked for the investigation follow up after the fall. R5 was placed on 1:1 supervision for safety after the completion of final report on 2/11/21. No new interventions were implemented from 2/5/21 to 2/11/21. 2. On 2/9/21 at 10:22am observed R6 sleeping in bed. She is not on low bed. No floor mat on floor. Gold star marked on her name by the door ( indicated fall prevention program). V28 Registered Nurse (RN) stated that she is the assigned nurse for R6. She does not know if R6 is on fall precaution or on fall prevention program. On 2/10/21 at 10:38am V29 Restorative Nurse stated that she is making round to check that residents on the list for the falling prevention program ( falling star) have the gold star marked on their name by the door. She just updated the list. The units do not have list of residents on fall prevention program. V29 stated that resident on fall prevention program and on fall precaution should reflected on care plan. On 2/11/21 at 10:02am V32 Agency CNA stated that she does not know if R6 is on fall precaution or fall prevention program. V33 RN stated that R6 was on low bed and floor mat when she was in 3 West unit. R6 is currently on standard bed, no floor mat on each side of the bed. V32 CNA and V33 RN searched the room and cannot find floor mat. V32 raised R6's bed while getting ready to provide care, she left the room to get face shield on 1st floor. Called V33 and showed R6 bed in higher position ( waist level) when V32 left the room. V33 stated I will lower the bed. She donned PPE and lower the bed. R6 had unwitnessed falls dated 12/11/20 and 1/31/21. Active care plan for fall risk given by V2 DON indicated intervention: Falling star program. Bed in low position. Care plan intervention updated on 1/31/21 post fall- Encourage R6 to call for help when wanting to get out of bed. Per MDS assessment, R6 has short term and long term impairment and has severe cognitive impairment. Care plan does not reflect resident needs. No care plan implemented after 12/11/20 fall incident. Facility's fall prevention and management policy indicated: Fall prevention protocol: Risk assessment I. Fall risk assessment is completed: D. Post fall III Fall prevention: B. Implement individualized approaches/interventions based upon resident risk 2. Approaches/interventions should focus on risk factors identified. IV. Falling indicator program A. Resident who are assessed at high risk for falls, have has multiple falls or have had a significant fall within the last six months may be included in the fall indicator program C. Care plan may be updated to reflect that the resident status D. Staff should visually check residents to ensure safety, assist with care needs and prevent unsafe transfers whenever possible V. Care plan A. 1. Intervention to prevent falls B. 2. Evaluation of the intervention is completed 2. Post fall 3. Interventions are modified as indicated based upon evaluated efficacy of the intervention. Post fall management protocol VI Implement additional interventions to reduce risk A. Fall prevention strategies/interventions may be used as a guide to develop appropriate interventions V Notification of the state when indicated A. If the fall results in a serious injury, the IDPH is notified within 24 hours or as soon as possible VI Documentation B. Fall risk and care plan are reviewed and updated. 1. Completed fall risk assessment 3. Review intervention to prevent falls 4. Revise or implement additional individualized interventions as appropriate

Based on interview and record review the facility failed to follow manufacturer specification or accepted professional standard for anti-fungal medication that was not for ophthalmic use and was given topically to R1's bilateral eyes resulting in redness, swelling and drainage to both eyes that required resident to be sent out to the hospital for evaluation and diagnosed with [REDACTED]. Findings include: On 5/23/19 at 3:45PM (V8 Family member) stated that (R1) has been admitted to the facility since Oct (YEAR). (R1) had gunshot wound in his head. (R1) came from hospital then to acute long-term hospital before coming to this facility. (V8) discussed and showed to surveyor pictures from (V8)'s cell phone of the following she made complaint of and sent picture to public health. 1) 5/7/19 (V8) showed picture of eye medication that was left at bedside with label indicated [MEDICATION NAME] cream 0.77% ([MEDICATION NAME]) apply to both eye Q day x 14 days. 2) 5/13/19 (V8 Family member) showed picture of (R1) in hospital emergency room with redness to both eyes with yellowish discharges. (V8) stated that eye irrigation was done and ordered to stop the anti-fungal medication. (R1) was sent back to the facility. Record review of (R1)'s medication incident dated 5/7/19 documented by (V2 DON (Director of Nursing)) indicated (V8) felt that medication was going inside of the eyes, but it was applied topically around the eyes of the (R1). (R1) received [MEDICATION NAME] cream 0.77% ([MEDICATION NAME] Olamine) apply to bilateral eyes topically two times a day from 4/29/19 to 5/7/19. Record review of (R1)'s POS (Physician order [REDACTED]. MAR indicated [REDACTED]. Record review of (R1)'s hospital record dated 5/13/19 indicated a [AGE] year old male with primary history of recent [MEDICAL CONDITION] following gun shot wound, chronic hypoxic [MEDICAL CONDITION] status [REDACTED]. This all started when R1 developed what sounds like a [MEDICAL CONDITION]. (V8) stated that they have been applying this cream to (R1)'s lashes from 5/1/19 to 5/7/19. Right eye specifically gotten worse. (R1) was reluctant to open his eyes and in a lot of pain. Differential Diagnosis: [REDACTED]. Bilateral eye irrigation was done with 2 liters of normal saline. Ophthalmologist recommended to treat (R1) with lots of lacri-lube ointment and artificial tears. discharged [DIAGNOSES REDACTED]. Avoid any anti- fungal creams near the eye. Follow up with Optha if symptoms worsen. On 5/28/19 at 10:08AM (V24 RN (Registered Nurse)) recalled taking care of (R1) and reviewed electronic chart of (R1). (V24) stated that she applied the medication [MEDICATION NAME] cream around his eyes and use sterile gauze with gloves to apply around the bilateral eyes. (R1) had ongoing eye redness and facial redness. On 5/28/19 at 10:18AM (V25 RN (Registered Nurse) recalled taking care of (R1). (V25) stated she apply the [MEDICATION NAME] cream around both eyes of (R1) with gloves. (V25) stated (R1) had eye redness, no discharges. On 5/28/19 at 10:24AM (V26 Nurse Practitioner Infectious Disease) reviewed record of (R1) with her computer laptop. (V26) stated she has been seeing (R1) for facial skin problem of seborrheic [MEDICAL CONDITION]. (R1) had history of [MEDICAL CONDITION] with eye redness and swollen. Tried different medications such as [MEDICATION NAME], Cirpo eye drops. (R1)'s eye improved but (V8) family member insisted of no eye improvement. (V26) ordered [MEDICATION NAME] cream 0.77% ([MEDICATION NAME] olamine) apply to bilateral eyes topically twice a day on 4/29/19 while R1 still [MEDICATION NAME]. [MEDICATION NAME] cream should be applied around the eyes. (V26) did not specify ordered because she assumed if applied to the eye topically it should be around the eye. (V26) stated that [MEDICATION NAME] cream is not the best treatment for [REDACTED]. (R1) has chronic eye redness with drainage. Blepharitis is inflammation of the eyelids. One of the causable factors is [MEDICAL CONDITION]. Lorpox cream was ordered mainly for fungal rash, which may cause irritation of the eyes. (V26) admitted that she should write the medication instruction clearly. (V26) was not aware of R1 was sent out to the hospital on [DATE] for evaluation of eye redness with discharges and was [DIAGNOSES REDACTED]. On 5/28/19 at 11:00AM (V27 Pharmacist) stated that [MEDICATION NAME] cream 0.77% ([MEDICATION NAME] olamine) is anti-fungal medication and is not indicated for ophthalmic use. (V27) stated that manufacturer and package insert of medication indicated not to use for the eye. (V27) stated that the pharmacy has process in medication dispensing. The prescription order was reviewed, and pharmacist verified the final check before it was delivered to the facility. (V27) have to check and will get back to the surveyor. (V27) will send pharmacy's policy on dispensing medication. On 5/28/19 at 12:39PM (V27 Pharmacist) stated that the medication is not applied inside the eye but topically, outside the eye. It was applied to eyelids. (V27) stated that there is possibility or chances of medication will get into the eye when applying into eyelids. [MEDICATION NAME] cream (anti-fungal) is not the first line of treatment for [REDACTED]. On 5/29/19 at 11:47AM (V30 Ophthalmologist) stated that he saw (R1) for stat consultation on 5/8/19 regarding complaint of anti-fungal medication have gotten into his eye. [MEDICATION NAME] cream is anti-fungal medication and not to be given ocular. Blepharitis is not cause by fungal, most of the time it is cause by infection. Best treatment for [REDACTED]. (V30) discontinued the [MEDICATION NAME] and started (R1) on [MEDICATION NAME] 20mg twice a day. On 5/29/19 at 12:47PM (V29 Physician) stated that he was not aware of (V26 Nurse Practitioner) ordered of anti-fungal cream to be applied topically to both eyes. [MEDICATION NAME] cream ( anti-fungal) was not the best treatment for [REDACTED]. (V29) added that if he will be treating blepharitis, (V29) will order antibiotics because it is most cause by infection. (V29) stated that the nurse pratitioner should be responsible for his order and demonstrate to the nurses how to apply the medication. Record review of Facility's policy in Medication administration and Physician orders [REDACTED]. Record review of Pharmacy's policy in medication dispensing not dated given by (V2 DON). Requested policy in labeling but was not given.

Based on interview and record review the facility failed to follow individualized plan of care associated with fall prevention during incontinence care for 1 of 3 residents(R1), in the sample of 13, reviewed for falls. This failure resulted in R1 sustaining a [MEDICAL CONDITION] and hematoma requiring hospitalization . Findings include: 12/26/18 1:05 PM V5 (CNA-Certified Nursing Assistant) said, I was changing R1, I turned R1 to R1's left side, R1 hands shakes with whole body movements. Every time R1 moved, R1 slid closer to the edge of the air mattress. I couldn't catch R1. R1 fell on the mattress on the floor. R1's head hit the legs of the table. It is one of the tables that we use for meals. R1 was bleeding. R1 head got cut on the table. I called the nurse (V7, RN-Registered Nurse). We called (V6, RN-Registered Nurse) who was the supervisor that day. At 2:45 PM V5 said, R1 was supposed to have two assist for repositioning and one assist for changing. I was R1's permanent CNA. We check the computer and check with the nurse to find out how the care is supposed to be done. The facility provided a handwritten statement dated 12/16/18 by V5 (CNA) which reads, I was changing R1's incontinent brief, I had R1 on R1's left side and while I was changing R1, R1 kept moving and throwing around R1's hands, which caused R1 to move closer to the edge of the bed and R1 started to slip off. When I had realized that R1 was slipping off the bed, I reached over to try to grab on to R1. It was too late and R1 fell on the floor mattress. The facility provided a Bed Mobility and Positioning Competency dated 9/14/18 for V5 which indicated that V5 is competent in Bed Mobility and Positioning. 12/26/18 1:57 PM V6 (RN-Registered Nurse) said, I was paged to the room. The patient, was on the mat on the floor. I checked the patient and assessed and called 911 because of the head injury. There was a small amount of blood, small cut, no loss of consciousness. We put a pressure dressing on and the bleeding stopped. Patient was on the floor mat when the paramedics arrived. There were two floor mats and an over bed table near the bed. The bed was in the low position. Floor mats are used beside the bed sometimes when the patient is at risk for falls. The CNAs should know the patient when they are going to care for them. 12/27/18 9:45 AM V7 (RN) said, I worked with R1 on 12/16/18. The CNA (V5) was changing R1 and turning R1 on the side. R1 started to lay down on the floor and (V5) wasn't able to catch R1. R1 was on the floor. I did body check. There was no loss of consciousness, the v/s (vital signs) were good. There was a small cut on the occipital area and I put a dressing on it. The paramedics came right away. Sometimes R1 required two people to change. R1 had jerking motions when you touched R1. A progress note by V7 dated 12/16/18 11:30 reads, Observed resident lying on the floor landing mattress. Noted a cut on the occipital area with minimal bleeding. Pressure dressing applied. Called 911 and went to (Hospital). 12/26/18 4:00 PM V3 (Assistant Director of Nursing) said, The CNAs look at the kiosk for Point of Care for basic needs e.g. feeding, one person assist and care instructions. They should check the kiosk based on their assignment for the day. The care instructions are updated by restorative care. 12/27/18 V3 (Assistant Director of Nursing) said, The CNAs and nurses are expected to look into the workstation screen and see what is needed for the patients daily. Based on R1's MDS (Minimum Data Set) I would expect two person assist to provide incontinence care. It could be the CNA and the nurse, a fell ow CNA, the CNA supervisor and Restorative CNAs, Therapy department could provide a backup. The Restorative Department trains CNAs at hire and administers a Comprehension Quiz for Plan of Care use. 12/26/18 4:20 PM V8 (Restorative Nursing Director) said, The amount of care that is needed for a resident is determined by the initial and quarterly assessments. The information is put into care instructions on PCC (Point Click Care) for the nurses' reference. This information is also put into P[NAME] (Point of Care) for the CNA's reference. The care instructions should be reviewed daily by the nurses and CNAs. R1 had special instructions that were accessible on PCC and P[NAME]. The instructions are for two assist with bed mobility. The facility provided a Care Profile Report for R1 which reads, Special Instructions-2 Staff assist with Bed mobility. The Minimum Data Set for R1 in bed mobility reads that R1 is rated 4 in Self-Performance which indicates that R1 is totally dependent. That rating for Support is 3 which indicates that two plus person physical assist is needed. The Fall Policy and Procedure reads: 4. A Plan of Care will be initiated utilizing fall prevention strategies to reduce or eliminate each resident's fall risk. Records from the hospital contain the results of the CT (Computerize Tomography) Scans: 12/16/18 at 12:41 PM CT Head or Brain without Contrast: Impression: 1. Small bilateral isodense subdural hematomas adjacent to the frontal lobes. These are without mass effect. 2. Tiny acute subdural hrmorrhage within the posterior interhemispheric fissure. 12/16/18 at 10:26 PM, an addendum by V19 (MD) reads in part: Follow-up CT demonstrated evidence of severe worsening of the tentorial subdural hematoma with parafaicine extension and severe intraparenchymal hemorrhage with intraventricular hemorrhage and [DIAGNOSES REDACTED] However I think it is very likely that no matter what intervention we take this is likely a fatal hemorrhage.

Based on interview and record review, the facility failed to identify and treat a resident's injury of unknown origin (R45) and failed to complete a thorough head, neck and mouth assessment for one resident (R13) with jaw swelling, This applies to two of 18 residents (R13, R45)reviewed for change of condition, in a sample of 69. These failures resulted in three days of pain and a delay in treatment of [REDACTED]. In addition, R13 required acute care for IV (intravenous) antibiotic treatment for [REDACTED]. Findings include: 1. Review of R45's medical record (Face Sheet) documents in part, R45 was admitted to the facility from acute care hospital with [DIAGNOSES REDACTED]. An additional [DIAGNOSES REDACTED]. R45's MDS (Minimum Data Set) of 02/07/2017 notes the following: -Cognitive Skills for Daily Decision Making: 3 or severely impaired. A Brief Interview for Mental Status (BIMS) was not completed because resident is rarely/never understood. -Activities of Daily Living (ADL): Bed Mobility, Transfer and Toilet Use 4/3 or total dependence with two+ persons physical assist. Review of the facility's Final Incident Investigation Report of 03/08/2017 notes in part, On 3/1/17, Nurse on duty noted swelling and redness on the left upper extremity, near shoulder of the resident. Upon assessment resident would grimace when area is touch(ed). MD (Medical Doctor) informed and ordered resident to be sent out to hospital for further evaluation. Per hospital ER (emergency room ) doctor, resident will be admitted for left humeral fracture. Initial investigation initiated. 57 y.o. (year old) admitted to the facility for long term care. Resident dependent on all ADLs (Activities of Daily Living), bed mobility, transfers and toileting. Resident incontinent of B/B (bowel/bladder). Resident aphasic, unable to make needs known verbally. Resident with contractures on (to) extremities and currently on restorative program for PROM (Passive Range Of Motion). On 3/1/17 resident was sent out to hospital for evaluation and treatment of [REDACTED]. In the mid shaft result (humerus) revealed comminuted acute fracture with angulation. Staff stated they did not noticed(notice) the swelling and redness to the left arm. There is also no report of any incident that occurred. However, the resident's (family member) who came to visit on 2/26/17, noticed that the arm was loose. (Family Member) brought this to the attention of the wound nurse present in the room at that time. Nurse assessed the arm and stated that (nurse) did not noticed (notice) any redness or indication of non-verbal pain. There is slight swelling of the elbow. Nurse stated (nurse) did not call MD as presumed there is nothing wrong with the arm. E26 (Nurse, 07/19/2017 at 1:06 PM) said in part, E26 assessed R45's arm because R45's family member told E26 that R45's arm was swollen, resident was experiencing pain and family member thought arm was fractured. E26 said R45's hand was swollen, however, R45 didn't document R45's record or notify R45's nurse and physician regarding the swelling. E26 said: I was new to the facility, I was busy. I should have documented the record and notified (R45's) nurse and doctor. E35 (Nurse Practitioner, 07/27/2017 at 1:50 PM) said in part, E35 was asked to see R45 on 03/01/2017 because resident's arm didn't look right. E35 said R45's left arm was swollen, resident was grimacing with movement. E35 described R45's as looked dislocated. E35 said E35 should have been notified by E26 when E26 noted swelling to R45's arm three days earlier. Review of Progress Note (03/01/2017, written by E35) notes in part: HPI (History of Present Illness): Patient seen and examined this morning per nursing request. Nursing reports swelling of left arm with pain upon movement that was noted this morning. Patient given [MEDICATION NAME] for pain. Nursing denies any falls or incidents related to left arm. Extremities: +left arm swelling. +left arm appears dislocated. +left arm pain upon rom (range of motion) evidenced by grimacing. Assessment and Plan: Left arm unknown possible injury-Send to hospital for Eval. (evaluation). 2. The clinical record documents R13 as a [AGE] year old resident admitted to the facility on [DATE]. R13 has [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 6/15/17, section C100 Cognitive Skills for Daily Decision Making notes R13 as severely impaired. Progress Notes for R13 dated 5/18/17 document that the resident (R13) had a blood clot flowing from the mouth which was seen by the respiratory therapist. The incident was relayed to the supervisor. He checked the resident and could find out a wound on the side of lips. Surveyor is unclear as to the meaning of this note. Resident was on observation after that. Progress Note dated 5/24/17 by E35 NP (Nurse Practitioner) documents in part, Patient R(13) seen and examined per nursing request for swelling of left parotid gland, nursing reports swelling was noted this morning, no report of fever, chills, sob (shortness of breath). Assessment and Plan. Acute bacterial parotitis start patient on Augnebtin twice a day for seven days, [MEDICATION NAME] twice a day for ten days. Nursing to monitor patient and notify NP/MD (Medical Doctor) of worsening symptoms. Discussed with MD. Progress Note dated 5/24/17 E44 RN (Registered Nurse) documents in part noted (R13) Left jaw swollen. No redness noted. Small swelling noted. E35 NP (Nurse Practitioner) saw resident with new orders received noted and carried out. Progress Note dated 6/5/17 E44 RN documents in part, resident (R13) left jaw remains swollen. Z2 MD saw resident with new orders received, noted and carried out. Progress Notes dated 6/8/17 documents in part; Resident (R13) still with swelling of the left jaw. Still on oral antibiotics. Progress Note dated 6/12/17 by E35 NP documents in part; Resident (R13) seen and examined per nursing request for swelling of left parotid gland, patient was treated with [MEDICATION NAME] twice a day for seven days, swelling re-occurred seen by MD with another order for [MEDICATION NAME] twice a day for ten days, no report of fever, chills, sob (shortness of breath). Ultrasound 6/1/17 normal left [MEDICAL CONDITION]. On 7/21/17 at 1:30 PM E35 NP stated in part; R13's jaw was slightly swollen with no redness. R13 was put on [MEDICATION NAME] for seven days, it slightly improved, The MD added another ten days. When you looked at R13 it was hard to tell it was swollen. I never looked in R13's mouth. Progress Note dated 6/14/17 by E43 MD documents in part; Neck supple, no JVD (jugular vein distention) no lymphadenopathy. Writer of this note has no documentation related to R13's mouth or jaw swelling. On 7/26/17 at 1:15 PM E43 MD stated in part; The nurse called me to see R13 about neck swelling. When I examined the neck it was supple. I didn't look in R13's mouth because I didn't have a flashlight. Progress Notes dated 6/14/17 by E44 RN documents E43 MD notified of R13's left jaw remains swollen after antibiotic treatment and warm compress orders completed. MD ordered dental consult. E1 Administrator spoke with dental office and will send Z16 Dentist or Z17 Dentist to see R13 tomorrow (6/15/17). Progress Note dated 6/15/17 documents in part; R13 is for (scheduled) dental consult due to swollen left jaw. R13's son requested for a hospital transfer to local hospital for further management. Notified MD via phone call with order of May (may) transfer out. On 7/26/17 at 10:30 AM E44 RN stated in part; I spoke to the dental office with E1 Administrator on 6/14/17, they said they would send Z16 Dentist on 6/15/17 to see R13. I called the the office on 6/15 17 and they said they were still coming. Z16 Dentist never came, so the family requested R13 be sent out to the hospital. Review of local hospital Emergency Department records for R13 document in part; L (left) face distinct region of [MEDICAL CONDITION] mass, no skin [DIAGNOSES REDACTED], just anterior to level of tragus an tracking inferiorly to level of mandible. Intraoral (mouth) region with lots of purulent whitish-yellow drainage and diffusely poor dentition, no distinct periapical flutuance or abscess; tonsils and uvula with slight [MEDICAL CONDITION], no distinct asymmetry or bulge. [MEDICAL CONDITION] with yellow white purulent discharge suctioned out. Concern for soft tissue infection of face that is odontogenic origin. Will admit for IV (intravenous) antibiotics for significant infection not improved on oral antibiotics as outpt (out patient). This patient requires care that is expected to transcend at least two nights. The patient's medical condition safety or health would be threatened if care was provided in a less intensive setting due to : Severity of signs and symptoms. Unstable condition and need for diagnostic studies and/or availability of diagnostic procedures at time and location of presentation. Pre-existing medical problems and/or extenuating circumstances. Failed out patient treatment.

Based on interview and record review, the facility failed to use two staff members when turning a resident's body from one side of the bed onto another side during care. This failure affected one of three residents (R1) reviewed for injury in a sample of three. This resulted in R1 falling from the bed after a staff member physically assisted R1 to turn in a bed and sustained a left distal femur fracture. Findings include: An accident/incident report with a signed date of 12/19/15 documented: R1 noted sitting on the floor with her back FN (front) upright position facing at the bed side. Patient accidentally slid down to the floor during CNA (certified nurse aide ) patient care. Patient alert and oriented and complained of pain 7 out 10 (10 being the highest amount of pain)scale to her left knee. The accident/incident investigation form dated 12/19/15 documented R1 was in bed at the time of the fall incident . Also R1 was alert, oriented in all spheres with no change in functional , mental or behavioral status at the time of the incident. The report indicated R1 was at risk for falls and had a stroke (CVA) with flaccid [DIAGNOSES REDACTED] affecting the right dominant side that predispose the resident to falls. R1's nurses notes dated 12/19/2015 17:10 hour stated: Patient sent to hospital emergency room via ambulance for evaluation due to pain at left knee. The hospital's general diagnostic report with a procedure date/ time of 12/19/2015 18:50 hour reported R1 had a left distal femoral fracture. On 1-7-16 at 2:30 PM, E2 CNA (certified nurse aid) states she was going to check R1's diaper on the day of the incident involving R1. E2 states R1 was agreeable for a diaper check and peri care but refused to get up to wheelchair. While R1 was in the bed, E2 was on R1's right side performed the frontal peri care. E2 asked R1 to roll to her right side without help from another cna, E2 assisted R1 to turn left by pushing on R1's back. Immediately after the roll, R1's legs slid off the bed and R1 slid down to the floor in a sitting position. E2 was unable to catch or prevent R1 from sliding to the floor. According to E2, this was the first time working with R1. E2 received report that R1 can turn over with 1 person assist and would require 2 person assist with mechanical lift when transferring out of bed. E2 did not review the kardex. E2 did not remember reporting R1's right sided weakness. E2 states that if E2 would have known about the right sided weakness, she would have been on R1's left side during the turn. On 1-7-16 at 10:40 AM, E6 (physical therapist/PT) states she did the initial physical therapy evaluation. Based on the initial physical therapy evaluation dated 10-18-15 to 11-28-15, R1 is a total assist (2 person assist) with rolling side to side. For safety, 2 people should assist R1 with rolling side to side. On 1-7-15 at 12:19 PM, E5 (physical therapy aide) states based on documentation PT Discharge Summary dated 11-28-15 state R1 is two person max assist rolling to left and right. If the cna was not guarding the side the R1 was rolling toward, there is a safety risk. On 1-7-16 at 1:30 PM, E7 (restorative nurse) stated R1 is supposed to be 2 person assist especially with [DIAGNOSES REDACTED]. Depending on the time of day and condition of the R1, she can be 1 assist with bed mobility (side to side), but should be 2 person assist standard. R1's MDS bed mobility is 4 (dependent) /3 (2+ person assist). Even on good days, R1 should be 2 person assist. Nursing updates the kardex. Kardex dated 12-08 states 1 physical assist. E7 states kardex should indicate 1 or 2 person assist. R1's Physical Therapy Plan of Care dated 10-8-15 to 11-28-15 indicates Bed Mobility, Rolling side to side: Total Assistance (100% assist). PT Therapist Progress & Discharge Summary dated 11-28-15 indicates Bed Mobility- Rolling: Prior Level as of 11-24-15: requires max x 2 to roll towards the right side. End Goal Status as of 11-28-15: Goal Not Met. R1 requires max x 2 to roll towards the left side. Minimum (MDS) data set [DATE] indicates Bed Mobility: Self Performance: 4 (total dependence), Support: 3 (two+ persons physical assist). R1's Kardex dated indicates ADL: Bed Mobility: total dependence (dated 12-8-15), 1 person physical assist. R1's minimum data set (MDS) assessment dated [DATE] indicated R1 had total dependence for bed mobility and need a two persons physical assist and had function limitation in range of motion on side of the body for the upper and lower extremities.

Based on observation, interview and record review the facility failed to implement a resident's plan of care for fall prevention, modified a resident's individualize care plan after a fall based on an identified cause factor, and provide supervision for a cognitive impaired resident while close to stairs. This applies to three residents of four residents (R1, R2 and R3) reviewed for falls, in a sample of five. As a result, R2 a cognitively impaired resident was allowed to remain near stairs and fell from the wheelchair down the flight of 10 stairs and fractured a shoulder bone and the pubic bone in two places. Findings Include: 1. R2's face sheet [DIAGNOSES REDACTED]. R2's fall risk assessment dated [DATE] indicates that R2 was at high risk for falls, with intermittent confusion and had 1-2 falls in the last three months. R2's Minimum Data Set ((MDS) dated [DATE] indicates R2 was moderately impaired with poor decisions and cues and supervision required. R2's MDS under signs and symptoms of delirium indicates that R2 had disorganized thinking. According to the facility's incident reports: -On 9/09/15 R2 fell from her wheelchair with no injuries involved. -On 11/13/15 R2 was noted sitting in the floor in front of the wheelchair, with complaint of pain to her right leg. The initial report does not indicate that R2 fell down the stairs. R2's final for fall incident 11/13/15 indicates: an alarm was heard and when staff responded R2 was observed with the wheelchair going over the lobby stairs causing her to fall. R2's hospital admission and discharge records indicate R2 was admitted for a fall on 11/13/15 and discharged back to the facility on [DATE]. R2's shoulder x-ray dated 11/14/15 indicates R2 had a distal clavicle fracture. R2's pelvis x-ray dated 11/15/15 indicates R2 had a fracture of the right pubic bone and superior pubic ramus. R2's fall care plan with an initiated date of 4/15/15 indicates R2 was at high risk for falls. R2's fall care plan includes interventions to do hourly round checks on R2 for safety and provide activities that minimize the potential for fall while providing diversional distraction. R2's fall care plan includes an intervention dated 11/19/15 to continue with fall prevention program, falling star, bed and chair alarm and floor mat added for safety. R2's care plan does not include interventions to address R2's routine of sitting in the lobby at the top of the stairs in her wheelchair. The facility's fall policy undated indicates that the facility will implement individualized approaches/interventions based upon resident risk and approaches/interventions should focus on risk factors identified. On 11/24/15 at 11:09 am E9 (Front Desk Receptionist) stated she saw R2 as she (R2) was falling down the stairs. E9 stated she heard a beeping sound and looked up to see R2 falling down the stairs along with her wheelchair. E9 stated R2 frequently sits on the landing in the lobby at the top of the stairs in her wheelchair. At the reception area there are two flight of stairs. One leading to a lower lever and one leading to the upper area. It was this upper level in which R2 fell from the wheel chair. The upper level set of stairs, contained 10 stairs. On 11/24/15 at 11:15 am E3 (R2's Physician/Medical Director) stated R2's normal behavior is to sit in the lobby at the top of the stairs in her wheelchair. E3 stated that R2 had the mental capacity of a 6 or 7 year old and suffered from mental retardation. E3 stated that R2 was too unsteady to walk independently and used the wheelchair to navigate throughout the facility. 2. R3's fall risk assessment dated [DATE] indicates that R3 is at high risk for falls with intermittent confusion and three or more falls in the past three months. On 11/23/15 at 10:00 am R3 was observed resting in bed with an over bed table resting on the floor toppled on its side, positioned on top of the fall mat. R3's bed was not in the lowest position. On 11/23/15 at 3:00 pm R3 was observed with a non-working body alarm in place. R3's body alarm did not sound when it was checked for operational status. R3's fall care plan dated 10/2/15 includes interventions to maintain an environment free of clutter, pressure sensitive body alarm and to place floor mat or landing mat on the floor next to bed. 3. On 11/23/15 at 12:00 pm, 1:45pm and 3:00pm R1 was observed without a personal alarm on the bed or attached to R1's body. R1's physician order [REDACTED]. In addition, R1's fall care plan dated 11/13/15 includes an intervention for a body alarm.

Based on interview and record review, the facility failed to assure that effective fall prevention monitoring and interventions were implemented for one resident (R13) out of four residents reviewed for falls in the sample of 24. This resulted in, R13 sustained repeated falls, pain and injury. Findings include: R13's medical record indicates R13 has a history of falls and upon readmission 7/1/15, R13 was assigned a staff member to function as a sitter for supervision. From 8/8/15 to 9/14/15, R13's Fall Risk Assessment progressed from a fall risk score of 12 to 20, consistently classified as High Risk for Falls. On 8/8/15 at 11:00 AM, R13's Accident/Incident Report and Investigation includes a witness statement from E37 (Sitter) that described R13's fall from the wheelchair that occurred in the resident room. E37's written statement indicates E37 was distracted by R13's roommate, and reads in part Resident in B Bed was in wheelchair looking through her bedside drawer. Every time she moved the chair alarm would alarm. I turned to turn the alarm off. That's when I saw all the knots in the cord. I disconnected the alarm and out of the corner of my eye I saw (R13) move. I turned with my arm stretched out but (R13( fell , scraping her arm on the wheelchair . (R13} said elbow hurt. R13 was assessed to have an abrasion on the right arm, below knee and bump on right side of the head. On 8/20/15 at 4:00 PM, R13's Accident/Incident Report and Investigation, under Analysis of Findings, reads Sitter left the room to call somebody and let them know he is leaving. Resident observed sitting on the floor. Nurse called by roommate's family member. R13 fell from the wheelchair, no injuries were sustained. A Care Plan History form indicates that on 8/22/15 Staff was reeducated to stay with the resident at all times while up in chair. On 10/26/15 at 1:50 PM, E2 (Director of Nursing) named R13's sitter during this event as E42 (Activity Aide). On 9/2/15 at 5:15 PM, R13's Accident/Incident Report and Investigation notes fifteen minutes after monitoring patient, (R13) was observed on the floor crawling. No mention was made of a sitter being present at the time of R13's fall. On 10/26/15 at 1:50 PM, E2 stated a sitter was assigned to R13 on 9/2/15 at 5:15 PM, naming E43 (Ward Clerk/Certified Nurse Aide). The fall was attributed to R13 trying to get out of bed. No injuries were sustained. On 9/10/15 at 4:45 PM, R13's Accident/Incident Report and Investigation included a witness statement from E37 that reads in part I wheeled (R13) from BINGO. We turned on television, I tilted the chair back a little and placed the chair parallel with bed, locked the chair. I turned to write in the log book (about 20-30 seconds) when I heard resident fall. R13 was assessed and sustained two parallel half-inch cuts with bleeding on the head. First was was documented as given with sterile wound adhesive strips applied to R13's cuts. On 10/14/15 at 1:20 PM, R13's Accident/Incident Report and Investigation includes a witness statement from E37 reads in part I walked behind (E38 -Certified Nurse Aide) and said I'm going. She was facing the television and she turned her head slightly I realize now her head gesture was not an acknowledgement to me but a random movement. The Analysis of Findings reads Resident not within the close proximity of staff. R13 was assessed as having an abrasion to the right forehead and was treated for [REDACTED]. On 10/22/15 at 10:35 AM, E39 (Restorative Nurse) and E3 (Assistant Director of Nursing) indicated R13 was at high risk for falls and a key intervention for R13's fall prevention plan was providing a sitter, which began on or before 7/1/15. E39 stated Sitters are to report off to one another before leaving the resident. The prevention plan also was to include evaluating R13's activity interests to keep her engaged and prevent attempts to get up. R13's care plans include interventions that read: 8/8/15 - Resident continue to have 1:1 close monitoring. 9/3/15 - (R13) should be in direct supervision while up in the chair. (undated) - Resident will not be left alone when changing staff. On 10/22/15 at 2:45 PM, Z7 (Physician) stated R13's falls are related to a [DIAGNOSES REDACTED]. Z7 stated R13 has Parkinson's disease but does not have sudden, involuntary movements that would cause falls. Z7 stated a sitter and close supervision are part of the plan to prevent falls for R13 as long as they are doing their job. Personnel files indicate that on 10/15/15, E37 was disciplined by E2 in the form of a documented verbal warning, noting Employee failed to provide continued surveillance for safety. Employee was counseled. On 10/22/15 at lunchtime, E37 was again present as the sitter for R13. On 10/22/15 at 5:05 PM, Z6 (Family) expressed frustration that E37 continues to be used as a sitter for R13, since three falls occurred in E37's presence. The facility policy, Fall Prevention and Management Program, ver 5, reads in part: Falls and Accident/Incidents Resident Management Review, I. Interdisciplinary team meeting, C. Identify trends for residents or facility early.

Based upon observation, interview and record review the facility failed to apply pressure relief devices, keep a resident's skin clean and dry as much as possible, rotate a resident for relief of pressure on bony prominces, track and monitor a resident for pressure ulcer development, asses the reason why a resident developed a pressure ulcer and implement interventions to prevent further development, follow physician's orders [REDACTED]. This applies to three of three residents (R1, R2, R3) reviewed for the care and treatment for [REDACTED]. As a result, R1and R3 had acquired pressure ulcer development. R1 developed multiple deep tissue injuries and pressure sores to the feet. R3 acquired five pressure sores while at the facility. Findings include; 1. According to a face sheet R1 was admitted to the facility on [DATE]. Also, had listed the [DIAGNOSES REDACTED]. As a result of R1's physical condition, R1 requires extensive assistance with all ADLs (Activities of Daily Living). An assessment for determining pressure sore risk dated 8/13/15 denoted R1 was at high risk for development of a pressure ulcer. R1's nursing admission assessment conducted on 8/13/15 did not denote any skin abnormalities on the feet. R1's wound documentation dated 8/23/15 had the following documented pressure ulcers : Left foot plantar (ball of foot) intact blister measuring 3.0 cm (centimeters) width x 6.4 cm. Right foot 4th MTH (Metatarsal Head) intact blister 2.6 cm x 1.8 cm. Right foot 5th MTH intact blister 2.0 cm x 1.3 cm. According to nursing progress notes dated 8/23/15, R1's wounds were identified by the family on that same date. -On 8/27/15 at 1:37pm, R1 was lying in bed his heels were elevated with a pillow. R1's head of bed and knees were noted to be elevated. Surveyor requested that E5 (Treatment Nurse) reposition the foot of bed to be flat, as E5 proceeded to lower the bed R1's left great toe touched the foot board (the bed was nowhere near flat). E5 stopped lowering the bed, with assistance from another staff member, repositioned R1 then proceeded to raise (not lower) the foot of bed as requested. E5 stated I think he needs an extender on his bed. I mentioned it to environmental services. The surveyor inquired when the request for an extender transpired, E5 responded this morning. During this time, R1 had a dressing on both feet, some parts of R1's feet were visible. R1's left foot had a reddened area (Deep Tissue Injury/ DTI ) on the 1st, 3rd and 5th toe. R1's right foot had dried blood beneath the skin (reddish black in color) on the 4th and 5th toes. The surveyor inquired about the aforementioned observations. E5 responded, He has blisters on both feet, they're intact now. He's got the DTI. The surveyor asked how did R1's DTI happened? E5 stated, They're speculation so I can't really say. He has boots though we are not using them right now. At the time, R1's pressure relief boots were noted lying in the chair at the foot of the bed. Next, E5 removed the dressings from R1's feet, the right foot had a large broken blister noted on the plantar/lateral surface covering roughly 20% of the foot, the blistered area was reddish black in color and appeared to be dried blood pooled beneath the skin. R1's left foot had a large fluid filled blister on the plantar/lateral surface covering roughly 20% of the foot. R1's emergency department documentation progress notes dated 8/24/15 included the following information: History of Present Illness: 2 weeks ago was sent into ED (emergency department) by family request for bil (bilateral foot pressure ulcers. Per family, patient is approximately 6 foot 7 inches and feet were pressed up against the bed. Patient subsequently developed pressure sores on the bottom of his feet. Chief complaint: Discolored toes. Physical Examination: Skin: Blistering along the plantar surface and lateral edges of feet bilaterally, right appears to have slight hemorrhage of the blister, left is without. No overlying [DIAGNOSES REDACTED], no surrounding [DIAGNOSES REDACTED], no induration, no exudates. Emergency Department Course: Patient with what appears to be pressure ulcers on bilateral feet. Patient with poor pulses particularly on right foot which raises concern for possible arterial insufficiency as etiology. Exam: Bilateral vascular lower extremity ABI (Ankle-Brachial Index). Normal ABI on both legs, no evidence of [MEDICAL CONDITION]. discharged Diagnosis: [REDACTED]. On 9/3/15 at 10:35am, inquired about R1's feet, E8 (Registered Nurse) responded It was my second day working there but my first day working with him. After (8/23/15 observation), I checked with the CNA (Certified Nursing Assistant) regarding repositioning every two hours. There was pressure applying to bed they removed the footboard. Inquired if the CNA reported R1's skin integrity impairments, E8 stated No one else but the family told me anything about that. The facility's Etiology of the Wound policy and procedure (7/30/14) includes but not limited to; Policy: It is the policy of this facility to provide an aggressive skin care program following guidelines of current standards of practice. Management will be based upon the etiology of the wound. Procedure: Pressure Ulcers; A pressure ulcer is a lesion caused by unrelieved pressure that results in damage to the underlying tissues. treatment of [REDACTED]. 2. According to a face sheet, R2 was admitted to the facility on [DATE]. Also, R2 had listed on the sheet, [DIAGNOSES REDACTED]. R2 requires extensive assistance with ADL's as a result of her physical condition. R2's pressure sore risk assessment dated [DATE] indicated R2 was at high risk for developing a pressure ulcer. R2 has physician orders [REDACTED]. Also, apply boots to BLE (Bilateral Lower Extremity) on 8am-off 12 (noon). On 8/20/15 a concern forms were filed on behalf of R2 which include the following; I've been here over 2 hours and (R2) hasn't been turned or put in the chair. They left the wound cover patch on (R2) full of stool. (7/22/15) R2's foot was noted against the foot board of the bed. (4/16/15) Family arrived and checked R2's diaper there was stool residue on her abdomen and back. R2's vagina was full of stool. Resolution: Staff was in-serviced on proper peri-care, ensuring the vaginal area is properly cleaned. On 8/27/15 at 1:13pm, R2 was sitting in a specialty wheelchair covered by a top of a sheet. The sheet from R2's knees to her feet was noted to be wet. R2's was wearing a gown that was also wet from her abdominal area to the bottom of the gown. Z3 (family) was present at the time of the observation. Z3 stated She (nurse) was giving medicine and the (gastrostomy) tube popped loose. The surveyor inquired about care provided to R2 by the facility. Z3 responded, They supposed to turn her, they don't turn her. Next, Z3 played a recording on his phone which states on 8/25/15, R2 was not changed, turned or nothing (3:00pm through 6:15pm). Z3 was advised by the party on the phone to request staff assistance, because he cannot care for R2 himself. On 9/3/15 at 11:15am, the surveyor observed a wound treatment provided by E4 (Wound Care Coordinator) R2 had a sacral wound and redness was noted to R2's right heel. E4 advised the surveyor, it was healed on 9/1/15. R2 was not wearing bilateral lower extremity boots as ordered. The facility's pressure ulcer prevention policy and procedure (7/30/15) includes but not limited to; Policy: It is the policy of this facility to implement measures to protect the resident's skin integrity and prevent skin breakdown whenever possible. Procedure: Residents who are unable to turn and reposition independently will be assisted to turn and reposition every two hours or as appropriate. Heels may be elevated off the bed to totally relieve pressure; boots, pillows, etc may be used for this purpose. R2's wound documentation includes the following; (2/5/15) Sacrum: 2.0 cm x 0.6 cm x 1.3 cm depth/stage III. (4/29/15) Sacrum: 2.0cm x 2.0cm x 2.5cm depth/stage IV. (8/19/15) Sacrum: 2.2 cm x 1.0 cm x 2.4 cm depth/ stage IV. R2's Physician assessment was conducted on 8/27/15 which denotes the following; stage IV pressure wound of the sacrum- no change. Recommendation: off-load wound, reposition per facility protocol and place order for wound vac. 3. R3 is a [AGE] year old with [DIAGNOSES REDACTED]. R3 requires extensive assistance with ADL's. R3 was admitted to the facility on [DATE]. On 8/11/15 a pressure ulcer risk assessment indicated R3 was at high risk. R3's admission assessment (7/14/15) includes the following skin integrity impairments; unstageable wound to right antecubital forearm, and right heel necrosis. The facility tracking log dated 8/14/15 through 8/20/15 includes the following wounds for R3; Sacrum: 1cm (centimeter) width x 3 cm length x 0.1cm depth (stage 3), Left distal dorsal calf: 3cm x 1.5cm : unstageable (US), Left ear: 1.4cm x 0.4cm x 0.1cm (stage 3), Right heel : 5.5cm x 7cm :US, Left heel: 4cm x 4cm :US . R3's (August 2015) physician orders [REDACTED]. Turn and reposition every 2 hours. (7/15/15) [MEDICATION NAME] to right heel, apply with dry dressing daily. (7/22/15) [MEDICATION NAME] to left heel, apply daily. Bilateral shins; apply skin prep and cover with foam dressing. (8/12/15) Skin prep and foam to right calf and left upper back every 3 days. (8/17/15) Santyll ointment to right buttock daily and as needed. Left ear; apply [MEDICATION NAME] every 2 days and as needed. (8/27/15) [MEDICATION NAME] and dry dressing to left upper back wound every 3 days. On 8/27/15 at 12:12pm, during R3's full body assessment the following was noted; E2 (Director of Nursing) opened R3's incontinence brief the external catheter was noted to be falling off. R3 had a washcloth (saturated with urine) lying atop of his groin area. The surveyor inquired about the observation. E2 did not respond. Next, R3 was turned to his left side there was a large opened dressing package on top of the sheet which he was lying on. There was a large foam dressing noted to R3's left upper back, the dressing was removed. The surveyor inquired about the left upper back wound. E2 responded Looks like a healing wound. Requested a description of the wound, E2 described the wound as a stage healing III which is now a stage II. The surveyor asked, Why this wound was not listed on the tracking log? E2 responded Let me check with my wound care team. R3's sacral wound had a foam dressing on top of [MEDICATION NAME] instead of the Santyll ointment as ordered. R3's shins were covered with ABD (abdominal dressing) pads instead of the foam dressings as ordered. Finally, R3 was turned to his right side there was a distinct non-blanchable indentation noted to his left flank from lying on the gastrostomy tube clamp. On 8/27/15 at 1:00pm, the surveyor questioned E5(Treatment Nurse) regarding the care and treatment of [REDACTED]. The surveyor inquired about the lack of a dressing for R3's left ear. E5 responded I know we were putting a [MEDICATION NAME] on it but it may have come off. E5 noted a [MEDICATION NAME] dressing in R3's bed picked it up and stated He sweats a lot, they should be replacing it. Afterward, E5 and E6 (Treatment Nurses) assessed R3's left upper back wound. E6 stated It's like stage II but that's what I say. The surveyor asked why ABD pads were on R3's shins. E6 responded For the foam we can just put the ABD pad for a protector. Surveyor responded so you did not follow physician orders? E6 responded That's correct. The facility's wound cleansing and dressing policy/procedure (7/30/14) includes but not limited to; Policy: It is the policy of this facility to perform wound dressing changes as ordered by the physician. R3's skin care assessment performed 8/12/15 includes a left upper back and right calf wounds, there are no measurements and/or description of either wound. physician progress notes [REDACTED]. Wound dimensions are 1.0 cm width x 1.0 cm length x 1.0 cm depth. Physician assessments were also conducted on 8/17/15 and 8/12/15, there is no mention of R3's left upper back wound (acquired on 8/12/15). 4. The facility's risk and skin assessment (7/30/15) includes but not limited to; Policy: It is the policy of this facility to asses all residents for factors that place them at risk for developing pressure ulcers. It is also the policy of this facility to monitor the skin integrity of our residents for development of wounds or other skin conditions. These assessments will begin upon admission and continue throughout the resident's stay in our facility. Procedure: The standardized risk assessment will be completed using the braden scale for predicting pressure ulcer risk and is completed by the licensed nurse. The braden scale is completed: Upon admission/readmission, weekly for the first four weeks, quarterly and change in condition, cognition or functional ability. R2 was admitted to the facility on [DATE], braden scale assessments (for predicting pressure sore risk) were conducted on 2/5/15, 3/5/15 and 6/20/15. All of which denote they were done on admission, there were no additional assessments. R3 was admitted to the facility on [DATE], braden scale assessments were conducted on 7/14/15, 7/21/15 and 8/11/15, there were no additional assessments. On 9/3/15 at 1:47pm, inquired about the requirements for braden scale assessments E3 (Assistant Director of Nursing) responded We do upon admission, then weekly times four. Then quarterly unless change of condition of the wound then we do change in condition.

Based on interview and record review the facility failed to implement an effective smoking monitoring program to ensure a resident's smoking materials were returned to the facility's staff after smoking. R3, who had a history of [REDACTED]. The facility failed to provide training for all staff members to implement correct emergency procedures during a fire. As a result, on 2/19/2015, R3 set a mattress on fire on a unit with residents who were receiving oxygen therapy. Staff members present on the unit at the time, failed to implement disaster procedures for removing a resident (R1) from a room with fire and smoke and properly contain the fire until the fire department arrived to the facility. This failure affected 25 of 25 residents (R1, R3, R6 through R28) in a sample of 28 living on a unit in which a fire occurred on 2/19/2015. This was identified to be an immediate jeopardy. On 3/13/2015 at 11:55am, E1 (administrator) was informed of the immediate jeopardy. The immediate jeopardy was identified to have started on 2/19/2015 and was removed on 3/13/2015. The facility remains out of compliance at level 2. Findings include: 1.) The facility's preliminary incident report date 2/19/15 read at 8:10am, there was a smoke smell noted on unit 2 east. It was determined there was a fire in room 217. R3 was not in the room at the time of the fire. R3's roommate (R1) was in bed during the fire. R1 was evacuated by the fire department. Twenty-five residents (R1, R3, R6 through R28) were evacuated from the area of the fire to other rooms in the facility. 23 out of these 25 residents required assistance in evacuating the area. R1 was sent to the hospital after the fire and returned to the facility the same day without any injuries. On 2/19/15 at 2:45pm, R1 stated I woke up to water coming down on me. That is all I remember from the fire. I don't really talk to my roommate. R1 is not able to walk according to the Minimum Data Set (MDS) assessment dated [DATE]. On 2/19/2015, while in the facility, the surveyor observed area in which the fire occurred on 2 East. R1, R3, R6 through R28 are 25 residents according to the facility's roster that resided on 2 East unit at the time of the fire. R6, R10, R12, R14, R20 and R22 are dialysis residents on 2 East. The facility's in house dialysis area is across the hall from room in which the fire occurred. R6, R10, R14, R17, R24, R25 and R27 are mechanical ventilator dependent residents. R18, R23 and R26 have tracheostomy collars with high humidity oxygen. R9, R15 and R20 are on oxygen via nasal cannula. On 2/19/15 at 3pm, R3 was sitting in his wheelchair with staff 1:1 supervision. The surveyor asked R3 if he knew how the fire started in his bed that morning. R3 stated in a loud voice "I have no idea how the fire started. I'm sick of everyone asking me. On 2/20/15 at 10am, Z1 (Fire Investigator) stated R3 had 2 lighters in his possession at the time of the fire on 2/19/15. The fire at the facility on 2/19/15 was intentionally started. The fire originated in R3's mattress. On 2/24/15 at 1:15pm, E4 (CNA) stated R3 came barreling out of his room on 2/19/15 about 10 minutes before the fire and stated that he hated this f----- place, he hated the f----- people. 2/20/2015 at 1:30pm, E9 (Certified Nursing Assistant/CNA) stated, A few months ago, I saw R3 with a lighter and cigarettes. E9 stated that she told the nurse but could not remember the nurse's name. E9 stated R3 is mean and aggressive. He was always agitated. He would say that he hated this place and hated the people. E9 stated R3 ran over her foot with his motorizes wheelchair a few months ago. E9 stated R3 was always aggressive. On 2/24/15 at 1:50pm, E3 (CNA) stated she heard R3 and E4 exchange words before the fire. E3 stated E4 told R3, "You can't be whipping the food cart around." R3 said Well, I don't care. then shoved the cart in the room. E3 stated R3 went to the dining room. Ten minutes later, the fire alarm went off. On 2/24/15 at 1:55pm, E10 (Social Worker) stated R3 has a history of non-compliance with not returning smoking materials. E10 stated that she would periodically check R3's backpack for smoking materials. E10 stated that there was not a schedule on how often she would check R3's backpack. E10 stated that the facility does not have a policy for room checks. E10 stated she did not check R3's clothing for smoking materials. E10 stated she did not check (R3's) backpack that week for lighters or cigarettes. I've had conversations with R3 but they are not documented. E10 stated R3 would become agitated very often because R3 did not like the rules about smoking. R3 was admitted to the facility on [DATE]. R3's clinical progress notes with the dates that follows, documented R3's noncompliance with the facility's smoking policy. R3 was either found with unauthorized smoking materials or smoking in an non-designated smoking area on 7/5/13, 9/17/13, 12/18/13, 6/26/14, 7/5/13, 9/9/14, 9/11/14, 9/17/14, 10/8/14, 10/21/14 and 12/15/14. R3's care plan problem onset dated 12/18/13 reads "Place smoking materials at nurses' station for storage." The facility did not have a plan to ensure R3 did not have smoking materials in his possession. R3's care plan problem onset dated 6/26/14 reads "R3 is told to smoke with a person to oversee, given times to smoke outside with supervision. Instructed also to keep smoking materials at the nursing station. Target date 9/2014. R3's care plan reviewed on 9/9/14 reads "R3 is reminded of the policy on smoking due to his refusal to abide by the policy." R3's care plan reviewed date 12/15/14 reads "R3 keeps his own cigarettes." The facility did not have a plan in place to address R3's non-compliance to the smoking policy. The facility did not have a plan to monitor R3 possession of smoking materials. R3's smoking schedule dated 9/15/14 reads "R3 cannot go smoke or be given his cigarettes from the cabinet until one of representatives arrives at the nurses' station to supervise him. When R3 returns, he must give his cigarettes and lighter to a representative at the nurse's station who will then place all items back in his basket (in the first cabinet)." The facility did not have a plan for checking R3 to ensure that he did return all smoking materials to a representative at the nurse's station. On 2/27/15 at 10:45am, E11 (MDS nurse) stated that (R3)'s friends would bring him smoking materials. On 3/5/15 at 9:30am, E1 (administrator) stated the facility does not have a smoking program. E1 stated that currently, the facility does not have any smokers. On 3/5/15 at 9:35am, E2 (director of nursing) stated E10 was in charge of the smoking program for (R3). On 3/5/15 at 10am, E10 (social service) stated that "It really was not a smoking program for R3. It was a schedule or plan for the times that R3 could go out and smoke with supervision. The facility policy governing smoking- the subject "Smoke Free Campus" with an effective date of 12/01/13 reads from the addendum, All smoking materials including tobacco and lighter/matches will be retained at the nursing station. A resident wishing to smoke will do so only in the designated area. If supervision is required, a staff or family member must be present and stay with resident during the activity. 2.) On 2/19/15 at 1:30pm, E3 (Certified Nursing Assistant/CNA) stated "The alarm went off this morning. Someone yelled that there was a fire down the hall. I went to room 217 to check the room. I saw black smoke so I went to the nursing station. I called the administrator and told him that there is a fire and a resident (R1) is trapped in the room. The fire department arrived and helped evacuate all the residents. Before the fire department arrived, E12 (plant operation) moved the burning bed into the hallway." On 2/19/15 at 2:20pm, E5 (Central Supply clerk) stated "Smoke was coming from room 217. R1 was still in the room. E12 (plant operations staff) pulled the burning bed from the room into the hallway. No one knows how R1 got out of the room." On 2/26/15 at 1pm, E3 stated that the reason she did not rescue R1 from the room with the fire is that she thought telling the administrator that there is a fire and a resident is trapped in the room was more important. According to facility in-service records for fire drills, the last time E3's attended a fire drill in-service was 11/26/14. Surveyor asked E3 what were the fire drills like at the facility. E3 stated that during a fire drill, an alarm would go off, everyone would shut doors and go the nursing station and sign a sheet that they participated in a fire drill. On 2/19/15 at 2:10pm, E4 (CNA) stated, The fire alarm went off at the nursing station. I started shutting doors and went to room 217 and the room was completely filled with black smoke. I saw there was a fire in room 217. The sprinkler was on in the room. I could not step in the room because I couldn't breathe with all the smoke. I went back to the nursing station. R3 was out of the room. I told everyone at the nursing station, We have got to get R1 out of the room. I don't know who got R1 out of the room with the fire. I went down to the first floor to direct the fire department to go to the second floor. On 2/26/15 at 3pm, E4 stated "I didn't get R1 out of the room because there was too much smoke." According to facility's fire drill records, the last fire drill (E4) attended was on 6/21/14. Z1 (District Fire Chief, Fire Investigator) stated on 2/20/15 at 10:15am The facility did everything except evacuate R1. Z1 stated an employee broke the window in R1's room. Z1 stated that he did not understand why (R1) was not removed from his room with the fire. Z1 stated that when the fire fighters arrived on the unit where the fire was, the burning bed was in the hallway. Z1 stated 5 fire extinguishers were used by employees to put out the fire in the burning mattress. Z1 stated that the fire fighters began to coordinate the evacuation of the 25 residents on the unit with the fire. Z1 stated that the fire fighters did not know that R1 was in bed in room where the fire occurred. Z1 stated when the fire fighters entered the room, R1 was soaked from the sprinklers. Z1 stated the fire fighters were concerned about hypothermia regarding R1 because the temperature was about 20 degrees and R1's window had been broken. Z1 stated the issue about how the staff handled not evacuating (R1) has to do with training. On 2/26/15 at 1:10pm, E17 (CNA) stated that she has been working at the facility for about one month. E17 stated that she has not received any fire in-services or training. (E17 stated that she worked the day of the fire (2/19/15) but was not on the floor where the fire occurred. On 2/26/15 at 1:30pm, E16 (Respiratory Therapist) stated that he was on the floor where the fire occurred. E16 stated that he went up to the room but did not go inside because there was too much smoke. E16 stated that he went back to the nursing station and then the fire department came to the floor. According to the facility's fire drill records, the last fire drill E16 attended was on 1/22/15. On 2/26/15 at 1:45pm, surveyor asked E16 what he would do if he discovered a fire in a resident's room. E16 stated "Try to pull resident out, call for help, close doors and move away from the fire." On 2/26/15 at 1:45pm, E15 (Housekeeper) stated she worked on the unit the day of the fire. E15 stated she closed doors and stayed at the nursing station. E15 stated she did not try to remove R1 from his room with the fire because she could not breathe. According to the facility's fire drill records, the last fire drill E15 attended was on 5/2/14. On 2/26/15 at 2pm, E6 (Nurse) stated when the fire alarm went off on 2/19/15, the staff thought it was a drill, so they closed doors. E6 stated she heard screaming and E6 saw smoke coming for room 217. E6 stated the door was closed the in room (with the fire). E6 stated she used a fire extinguisher and aimed the fire extinguisher in the bottom of the door at the smoke that was coming out from the bottom of the door. E6 stated she did not open the door to try to rescue (R1) because she was afraid of an explosion. Surveyor asked E6 what do you do if a fire alarm goes off? E6 stated try to extinguish fire. E6 did not state rescue resident. On 2/26/15 at 2:15pm, E13 (Housekeeper) stated if a fire alarm goes off, she "pushes fire button, gets the spray bottle and calls her supervisor." E13's response did not mention RACE (rescue, alarm, contain and extinguish). On 2/27/15 at 9:30am, E1 (Administrator) stated that fire drills are conducted monthly. E1 stated fire drills are conducted for all employees. (E1) stated the fire drills do not instruct employees on how to remove a resident from a room that is on fire The facility's witness statement for E12 (Maintenance) reads "I saw fire under the bed on the frame of the bed on the spring. The sprinklers were going off but could not put out the fire because it was under the mattress. So I grabbed the mattress and pulled it and grabbed the extinguisher to try to extinguish the fire. Then I heard the resident (R1) saying it's hard to breathe. I tried to get the other patient. I touched the bed while trying to get to there other patient and got an electric shock. The fire department came a few minutes later. Someone got the patient (R1) out of the room and I don't know who." The local fire department's incident report dated 2/19/15 at 8:09am reads " Upon arrival found no evacuation or smoke showing. Upon arrival second floor landing found staff stating fire in 2 east. Second floor hallway charged with light white smoke. Smoke tastes like chemical possibly from fire extinguishers used for fire extinguishment. Approximately 6 fire extinguishers found on floor. Staff state bed in hallway was from fire room and had been involved in fire. No fire found at this time. Continued down hallway towards room of origin. Smoke still white. Sound of flowing water heard. Found sprinkler head off in room of origin, room 217. Fire extinguished prior to arrival in room. Windows had been broken by staff prior to arrival. Found a resident still in bed in room of origin. Removed person from room with assistance. Person (R1) is wet from sprinkler and cold. Notified command to send ambulance to second floor elevator where person will be." The facility's Life Safety Fire Safety Plan reads the objective is to establish a fire safety program that will maintain a fire safe environment for residents, staff and visitors. The Fire Safety Plan reads "Educate staff in all departments in fire prevention, fire safety, managing residents and visitors in the event of a fire, and the use of fire extinguishers." The facility's evacuation procedure reads "Place bedridden residents in wheelchairs if possible; if not possible, arrange beds so they can be pushed out through the doorway of the resident room." The facility failed to place R1 in a wheelchair and failed to arrange R1's bed so it could have been pushed through the doorway of his room. The facility left (R1) in his bed during the fire. The Fire Safety Procedures reads all fires " 1) RACE (rescue, alarm, contain, extinguish 2) Protect all residents, visitors and employees, pull the fire alarm, close door in the fire area, use extinguisher. 3) In the unique case that a staff member who discovers the fire must immediately go to the aid of an endangered person, that staff member must articulate the code phrase, which will be "Code Red." The facility took the following actions to remove the immediacy: R3 is no longer in the facility. R3 was discharged the day of the fire. R3 was the only resident who was a smoker and the facility no longer has any resident that is a smoker. On 3/13/2015 the policy and procedure on RACE ( rescue, alarm, contain, extinguish) and PASS (pull, aim, squeeze, sweep) have been reviewed during a safety committee. An in-service has been conducted with staff on RACE and PASS and will continue until all staff members not present have been in-serviced. On 3/13/2015 a safety committee was held including the medical director to review the fire incident. The committee reviewed the fire policy including RACE and PASS policy and procedure as well as the smoking policy and procedure. Staff were in-serviced on fire policy, RACE and PASS and the smoking policy and procedure. A fire drill was initiated on all shifts to validate competency of staff with the in-servicing provided. Charge Nurses will perform spot checks at least once daily to determine level of staff compliance with understanding of RACE and PASS. These will be documented on a Quality Assurance checklist. New staff will receive orientation to include RACE and PASS. Staff will receive annual competency to review RACE and PASS during the fire drills. A QAPI/Safety committee meeting will be held monthly to review compliance with all of the above. The Administrator and/or his designee will monitor overall compliance through his general supervision and reports from department heads on staff compliance.

Based on interview and record review, the facility failed to use resources effectively to provide adequate supervision of a high risk smoker (R3), implement a smoking schedule and monitoring program, ensure staff members are trained and implement policy and procedures for a fire emergency. As a result, on 2/19/2015, R3 set a mattress on fire on a unit with residents who were receiving oxygen therapy. Staff members present on the unit at the time, failed to implement disaster procedures for removing a resident (R1) from a room with fire and smoke and properly contain the fire until the fire department arrived to the facility. This failure applies to 25 of 25 residents (R1, R3, R6 through R28) on the unit at the time of the fire, in a sample of 28. This was identified to be an immediate jeopardy. On 3/13/2015 at 11:55am, E1 (administrator) was informed of the immediate jeopardy. The immediate jeopardy was identified to have started on 2/19/2015 and was removed on 3/13/2015. The facility remains out of compliance at level 2. Findings include: 1.) The facility's preliminary incident report date 2/19/15 read at 8:10am, there was a smoke smell noted on unit 2 east. It was determined there was a fire in room [ROOM NUMBER]. R3 was not in the room at the time of the fire. R3's roommate (R1) was in bed during the fire. R1 was evacuated by the fire department. Twenty-five residents (R1, R3, R6 through R28) were evacuated from the area of the fire to other rooms in the facility. 23 out of these 25 residents required assistance in evacuating the area. R1 was sent to the hospital after the fire and returned to the facility the same day without any injuries. On 2/19/15 at 2:45pm, R1 stated I woke up to water coming down on me. That is all I remember from the fire. I don't really talk to my roommate. R1 is not able to walk according to the Minimum Data Set (MDS) assessment dated [DATE]. On 2/19/2015, while in the facility, the surveyor observed area in which the fire occurred on 2 East unit. R1, R3, R6 through R28 are 25 residents according to the facility's roster that resided on 2 East unit at the time of the fire. R6, R10, R12, R14, R20 and R22 are [MEDICAL TREATMENT] residents on 2 east. The facility's in house [MEDICAL TREATMENT] area is across the hall from room in which the fire occurred. R6, R10, R14, R17, R24, R25 and R27 are mechanical ventilator dependent residents. R18, R23 and R26 have [MEDICAL CONDITION] collars with high humidity oxygen. R9, R15 and R20 are on oxygen via nasal cannula. On 2/19/15 at 3pm, R3 was sitting in his wheelchair with staff 1:1 supervision. The surveyor asked R3 if he knew how the fire started in his bed that morning. R3 stated in a loud voice "I have no idea how the fire started. I'm sick of everyone asking me. On 2/20/15 at 10am, Z1 (Fire Investigator) stated R3 had 2 lighters in his possession at the time of the fire on 2/19/15. The fire at the facility on 2/19/15 was intentionally started. The fire originated in R3's mattress. On 2/24/15 at 1:15pm, E4 (CNA) stated R3 came barreling out of his room on 2/19/15 about 10 minutes before the fire and stated that he hated this f----- place, he hated the f----- people. 2/20/2015 at 1:30pm, E9 (Certified Nursing Assistant/CNA) stated, A few months ago, I saw R3 with a lighter and cigarettes. E9 stated that she told the nurse but could not remember the nurse's name. E9 stated R3 is mean and aggressive. He was always agitated. He would say that he hated this place and hated the people. E9 stated R3 ran over her foot with his motorizes wheelchair a few months ago. E9 stated R3 was always aggressive. On 2/24/15 at 1:50pm, E3 (CNA) stated she heard R3 and E4 exchange words before the fire. E3 stated E4 told R3, "You can't be whipping the food cart around." R3 said Well, I don't care. then shoved the cart in the room. E3 stated R3 went to the dining room. Ten minutes later, the fire alarm went off. On 2/24/15 at 1:55pm, E10 (Social Worker) stated R3 has a history of non-compliance with not returning smoking materials. E10 stated that she would periodically check R3's backpack for smoking materials. E10 stated that there was not a schedule on how often she would check R3's backpack. E10 stated that the facility does not have a policy for room checks. E10 stated she did not check R3's clothing for smoking materials. E10 stated she did not check (R3's) backpack that week for lighters or cigarettes. I've had conversations with R3 but they are not documented. E10 stated R3 would become agitated very often because R3 did not like the rules about smoking. R3 was admitted to the facility on [DATE]. R3's clinical progress notes with the dates that follows, documented R3's noncompliance with the facility's smoking policy. R3 was either found with unauthorized smoking materials or smoking in an non-designated smoking area on 7/5/13, 9/17/13, 12/18/13, 6/26/14, 7/5/13, 9/9/14, 9/11/14, 9/17/14, 10/8/14, 10/21/14 and 12/15/14. R3's care plan problem onset dated 12/18/13 reads "Place smoking materials at nurses' station for storage." The facility did not have a plan to ensure R3 did not have smoking materials in his possession. R3's care plan problem onset dated 6/26/14 reads "R3 is told to smoke with a person to oversee, given times to smoke outside with supervision. Instructed also to keep smoking materials at the nursing station. Target date 9/2014. R3's care plan reviewed on 9/9/14 reads "R3 is reminded of the policy on smoking due to his refusal to abide by the policy." R3's care plan reviewed date 12/15/14 reads "R3 keeps his own cigarettes." The facility did not have a plan in place to address R3's non-compliance to the smoking policy. The facility did not have a plan to monitor R3 possession of smoking materials. R3's smoking schedule dated 9/15/14 reads "R3 cannot go smoke or be given his cigarettes from the cabinet until one of representatives arrives at the nurses' station to supervise him. When R3 returns, he must give his cigarettes and lighter to a representative at the nurse's station who will then place all items back in his basket (in the first cabinet)." The facility did not have a plan for checking R3 to ensure that he did return all smoking materials to a representative at the nurse's station. On 2/27/15 at 10:45am, E11 (MDS nurse) stated that (R3)'s friends would bring him smoking materials. On 3/5/15 at 9:30am, E1 (administrator) stated the facility does not have a smoking program. E1 stated that currently, the facility does not have any smokers. On 3/5/15 at 9:35am, E2 (director of nursing) stated E10 was in charge of the smoking program for (R3). On 3/5/15 at 10am, E10 (social service) stated that "It really was not a smoking program for R3. It was a schedule or plan for the times that R3 could go out and smoke with supervision. The facility policy governing smoking- the subject "Smoke Free Campus" with an effective date of 12/01/13 reads from the addendum, All smoking materials including tobacco and lighter/matches will be retained at the nursing station. A resident wishing to smoke will do so only in the designated area. If supervision is required, a staff or family member must be present and stay with resident during the activity. 2.) On 2/19/15 at 1:30pm, E3 (Certified Nursing Assistant/CNA) stated "The alarm went off this morning. Someone yelled that there was a fire down the hall. I went to room [ROOM NUMBER] to check the room. I saw black smoke so I went to the nursing station. I called the administrator and told him that there is a fire and a resident (R1) is trapped in the room. The fire department arrived and helped evacuate all the residents. Before the fire department arrived, E12 (plant operation) moved the burning bed into the hallway." On 2/19/15 at 2:20pm, E5 (Central Supply clerk) stated "Smoke was coming from room [ROOM NUMBER]. R1 was still in the room. E12 (plant operations staff) pulled the burning bed from the room into the hallway. No one knows how R1 got out of the room." On 2/26/15 at 1pm, E3 stated that the reason she did not rescue R1 from the room with the fire is that she thought telling the administrator that there is a fire and a resident is trapped in the room was more important. According to facility in-service records for fire drills, the last time E3's attended a fire drill in-service was 11/26/14. Surveyor asked E3 what were the fire drills like at the facility. E3 stated that during a fire drill, an alarm would go off, everyone would shut doors and go the nursing station and sign a sheet that they participated in a fire drill. On 2/19/15 at 2:10pm, E4 (CNA) stated, The fire alarm went off at the nursing station. I started shutting doors and went to room [ROOM NUMBER] and the room was completely filled with black smoke. I saw there was a fire in room [ROOM NUMBER]. The sprinkler was on in the room. I could not step in the room because I couldn't breathe with all the smoke. I went back to the nursing station. R3 was out of the room. I told everyone at the nursing station, We have got to get R1 out of the room. I don't know who got R1 out of the room with the fire. I went down to the first floor to direct the fire department to go to the second floor. On 2/26/15 at 3pm, E4 stated "I didn't get R1 out of the room because there was too much smoke." According to facility's fire drill records, the last fire drill (E4) attended was on 6/21/14. Z1 (District Fire Chief, Fire Investigator) stated on 2/20/15 at 10:15am The facility did everything except evacuate R1. Z1 stated an employee broke the window in R1's room. Z1 stated that he did not understand why (R1) was not removed from his room with the fire. Z1 stated that when the fire fighters arrived on the unit where the fire was, the burning bed was in the hallway. Z1 stated 5 fire extinguishers were used by employees to put out the fire in the burning mattress. Z1 stated that the fire fighters began to coordinate the evacuation of the 25 residents on the unit with the fire. Z1 stated that the fire fighters did not know that R1 was in bed in room where the fire occurred. Z1 stated when the fire fighters entered the room, R1 was soaked from the sprinklers. Z1 stated the fire fighters were concerned about hypothermia regarding R1 because the temperature was about 20 degrees and R1's window had been broken. Z1 stated the issue about how the staff handled not evacuating (R1) has to do with training. On 2/26/15 at 1:10pm, E17 (CNA) stated that she has been working at the facility for about one month. E17 stated that she has not received any fire in-services or training. (E17 stated that she worked the day of the fire (2/19/15) but was not on the floor where the fire occurred. On 2/26/15 at 1:30pm, E16 (Respiratory Therapist) stated that he was on the floor where the fire occurred. E16 stated that he went up to the room but did not go inside because there was too much smoke. E16 stated that he went back to the nursing station and then the fire department came to the floor. According to the facility's fire drill records, the last fire drill E16 attended was on 1/22/15. On 2/26/15 at 1:45pm, surveyor asked E16 what he would do if he discovered a fire in a resident's room. E16 stated "Try to pull resident out, call for help, close doors and move away from the fire." On 2/26/15 at 1:45pm, E15 (Housekeeper) stated she worked on the unit the day of the fire. E15 stated she closed doors and stayed at the nursing station. E15 stated she did not try to remove R1 from his room with the fire because she could not breathe. According to the facility's fire drill records, the last fire drill E15 attended was on 5/2/14. On 2/26/15 at 2pm, E6 (Nurse) stated when the fire alarm went off on 2/19/15, the staff thought it was a drill, so they closed doors. E6 stated she heard screaming and E6 saw smoke coming from room [ROOM NUMBER]. E6 stated the door was closed the in room (with the fire). E6 stated she used a fire extinguisher and aimed the fire extinguisher in the bottom of the door at the smoke that was coming out from the bottom of the door. E6 stated she did not open the door to try to rescue (R1) because she was afraid of an explosion. Surveyor asked E6 what do you do if a fire alarm goes off? E6 stated try to extinguish fire. E6 did not state rescue resident. On 2/26/15 at 2:15pm, E13 (Housekeeper) stated if a fire alarm goes off, she "pushes fire button, gets the spray bottle and calls her supervisor." E13's response did not mention RACE (rescue, alarm, contain and extinguish). On 2/27/15 at 9:30am, E1 (Administrator) stated that fire drills are conducted monthly. E1 stated fire drills are conducted for all employees. (E1) stated the fire drills do not instruct employees on how to remove a resident from a room that is on fire The facility's witness statement for E12 (Maintenance) reads "I saw fire under the bed on the frame of the bed on the spring. The sprinklers were going off but could not put out the fire because it was under the mattress. So I grabbed the mattress and pulled it and grabbed the extinguisher to try to extinguish the fire. Then I heard the resident (R1) saying it's hard to breathe. I tried to get the other patient. I touched the bed while trying to get to there other patient and got an electric shock. The fire department came a few minutes later. Someone got the patient (R1) out of the room and I don't know who." The local fire department's incident report dated 2/19/15 at 8:09am reads " Upon arrival found no evacuation or smoke showing. Upon arrival second floor landing found staff stating fire in 2 east. Second floor hallway charged with light white smoke. Smoke tastes like chemical possibly from fire extinguishers used for fire extinguishment. Approximately 6 fire extinguishers found on floor. Staff state bed in hallway was from fire room and had been involved in fire. No fire found at this time. Continued down hallway towards room of origin. Smoke still white. Sound of flowing water heard. Found sprinkler head off in room of origin, room [ROOM NUMBER]. Fire extinguished prior to arrival in room. Windows had been broken by staff prior to arrival. Found a resident still in bed in room of origin. Removed person from room with assistance. Person (R1) is wet from sprinkler and cold. Notified command to send ambulance to second floor elevator where person will be." The facility's Life Safety Fire Safety Plan reads the objective is to establish a fire safety program that will maintain a fire safe environment for residents, staff and visitors. The Fire Safety Plan reads "Educate staff in all departments in fire prevention, fire safety, managing residents and visitors in the event of a fire, and the use of fire extinguishers." The facility's evacuation procedure reads "Place bedridden residents in wheelchairs if possible; if not possible, arrange beds so they can be pushed out through the doorway of the resident room." The facility failed to place R1 in a wheelchair and failed to arrange R1's bed so it could have been pushed through the doorway of his room. The facility left (R1) in his bed during the fire. The Fire Safety Procedures reads all fires " 1) RACE (rescue, alarm, contain, extinguish 2) Protect all residents, visitors and employees, pull the fire alarm, close door in the fire area, use extinguisher. 3) In the unique case that a staff member who discovers the fire must immediately go to the aid of an endangered person, that staff member must articulate the code phrase, which will be "Code Red." The facility took the following actions to remove the immediacy: R3 is no longer in the facility. R3 was discharged the day of the fire. R3 was the only resident who was a smoker and the facility no longer has any resident that is a smoker. On 3/13/2015 the policy and procedure on RACE ( rescue, alarm, contain, extinguish) and PASS (pull, aim, squeeze, sweep) have been reviewed during a safety committee. An in-service has been conducted with staff on RACE and PASS and will continue until all staff members not present have been in-serviced. On 3/13/2015 a safety committee was held including the medical director to review the fire incident. The committee reviewed the fire policy including RACE and PASS policy and procedure as well as the smoking policy and procedure. Staff were in-serviced on fire policy, RACE and PASS and the smoking policy and procedure. A fire drill was initiated on all shifts to validate competency of staff with the in-servicing provided. Charge Nurses will perform spot checks at least once daily to determine level of staff compliance with understanding of RACE and PASS. These will be documented on a Quality Assurance checklist. New staff will receive orientation to include RACE and PASS. Staff will receive annual competency to review RACE and PASS during the fire drills. A QAPI/Safety committee meeting will be held monthly to review compliance with all of the above. The Administrator and/or his designee will monitor overall compliance through his general supervision and reports from department heads on staff compliance.

Based on interview and record review, the facility failed to provide appropriate training that ensures every staff member knows and demonstrates the emergency procedure for protecting residents during a fire within the facility. On 2/19/15 a resident (R3) set a fire to his mattress, the facility staff did not follow the facility's policy for a fire emergency regarding evacuation of a resident (R1) and containing a fire until the arrival of the fire department. This failure applies to 25 of 25 residents (R1, R3, R6 through R28) on the unit at the time of the fire, in a sample of 28. This was identified to be an immediate jeopardy situation. On 3/13/2015 at 11.55am, E1 (administrator) was informed of the immediate jeopardy. The immediate jeopardy was identified to have started on 2/19/2015 and was removed on 3/13/2015. The facility remains out of compliance at level 2. Findings include: On 2/19/15 at 1:30pm, E3 (Certified Nursing Assistant/CNA) stated "The alarm went off this morning. Someone yelled that there was a fire down the hall. I went to room [ROOM NUMBER] to check the room. I saw black smoke so I went to the nursing station. I called the administrator and told him that there is a fire and a resident (R1) is trapped in the room. The fire department arrived and helped evacuate all the residents. Before the fire department arrived, E12 (plant operation) moved the burning bed into the hallway." On 2/19/15 at 2:20pm, E5 (Central Supply clerk) stated "Smoke was coming from room [ROOM NUMBER]. R1 was still in the room. E12 (plant operations staff) pulled the burning bed from the room into the hallway. No one knows how R1 got out of the room." On 2/26/15 at 1pm, E3 stated that the reason she did not rescue R1 from the room with the fire is that she thought telling the administrator that there is a fire and a resident is trapped in the room was more important. According to facility in-service records for fire drills, the last time E3's attended a fire drill in-service was 11/26/14. Surveyor asked E3 what were the fire drills like at the facility. E3 stated that during a fire drill, an alarm would go off, everyone would shut doors and go the nursing station and sign a sheet that they participated in a fire drill. On 2/19/15 at 2:10pm, E4 (CNA) stated, The fire alarm went off at the nursing station. I started shutting doors and went to room [ROOM NUMBER] and the room was completely filled with black smoke. I saw there was a fire in room [ROOM NUMBER]. The sprinkler was on in the room. I could not step in the room because I couldn't breathe with all the smoke. I went back to the nursing station. R3 was out of the room. I told everyone at the nursing station, We have got to get R1 out of the room. I don't know who got R1 out of the room with the fire. I went down to the first floor to direct the fire department to go to the second floor. On 2/26/15 at 3pm, E4 stated "I didn't get R1 out of the room because there was too much smoke." According to facility's fire drill records, the last fire drill (E4) attended was on 6/21/14. Z1 (District Fire Chief, Fire Investigator) stated on 2/20/15 at 10:15am The facility did everything except evacuate R1. Z1 stated an employee broke the window in R1's room. Z1 stated that he did not understand why (R1) was not removed from his room with the fire. Z1 stated that when the fire fighters arrived on the unit where the fire was, the burning bed was in the hallway. Z1 stated 5 fire extinguishers were used by employees to put out the fire in the burning mattress. Z1 stated that the fire fighters began to coordinate the evacuation of the 25 residents on the unit with the fire. Z1 stated that the fire fighters did not know that R1 was in bed in room where the fire occurred. Z1 stated when the fire fighters entered the room, R1 was soaked from the sprinklers. Z1 stated the fire fighters were concerned about hypothermia regarding R1 because the temperature was about 20 degrees and R1's window had been broken. Z1 stated the issue about how the staff handled not evacuating (R1) has to do with training. R1, R3, R6 through R28 are 25 residents according to the facility's roster that resided on 2 East unit at the time of the fire. On 2/26/15 at 1:10pm, E17 (CNA) stated that she has been working at the facility for about one month. E17 stated that she has not received any fire inservices or training. (E17 stated that she worked the day of the fire (2/19/15) but was not on the floor where the fire occurred. On 2/26/15 at 1:30pm, E16 (Respiratory Therapist) stated that he was on the floor where the fire occurred. E16 stated that he went up to the room but did not go inside because there was too much smoke. E16 stated that he went back to the nursing station and then the fire department came to the floor. According to the facility's fire drill records, the last fire drill E16 attended was on 1/22/15. On 2/26/15 at 1:45pm, surveyor asked E16 what he would do if he discovered a fire in a resident's room. E16 stated "Try to pull resident out, call for help, close doors and move away from the fire." On 2/26/15 at 1:45pm, E15 (Housekeeper) stated she worked on the unit the day of the fire. E15 stated she closed doors and stayed at the nursing station. E15 stated she did not try to remove R1 from his room with the fire because she could not breathe. According to the facility's fire drill records, the last fire drill E15 attended was on 5/2/14. On 2/26/15 at 2pm, E6 (Nurse) stated when the fire alarm went off on 2/19/15, the staff thought it was a drill, so they closed doors. E6 stated she heard screaming and E6 saw smoke coming for room [ROOM NUMBER]. E6 stated the door was closed the in room (with the fire). E6 stated she used a fire extinguisher and aimed the fire extinguisher in the bottom of the door at the smoke that was coming out from the bottom of the door. E6 stated she did not open the door to try to rescue (R1) because she was afraid of an explosion. Surveyor asked E6 what do you do if a fire alarm goes off? E6 stated try to extinguish fire. E6 did not state rescue resident. On 2/26/15 at 2:15pm, E13 (Housekeeper) stated if a fire alarm goes off, she "pushes fire button, gets the spray bottle and calls her supervisor." E13's response did not mention RACE (rescue, alarm, contain and extinguish). On 2/27/15 at 9:30am, E1 (Administrator) stated that fire drills are conducted monthly. E1 stated fire drills are conducted for all employees. (E1) stated the fire drills do not instruct employees on how to remove a resident from a room that is on fire The facility's witness statement for E12 (Maintenance) reads "I saw fire under the bed on the frame of the bed on the spring. The sprinklers were going off but could not put out the fire because it was under the mattress. So I grabbed the mattress and pulled it and grabbed the extinguisher to try to extinguish the fire. Then I heard the resident (R1) saying it's hard to breathe. I tried to get the other patient. I touched the bed while trying to get to there other patient and got an electric shock. The fire department came a few minutes later. Someone got the patient (R1) out of the room and I don't know who." The local fire department's incident report dated 2/19/15 at 8:09am reads " Upon arrival found no evacuation or smoke showing. Upon arrival second floor landing found staff stating fire in 2 east. Second floor hallway charged with light white smoke. Smoke tastes like chemical possibly from fire extinguishers used for fire extinguishment. Approximately 6 fire extinguishers found on floor. Staff state bed in hallway was from fire room and had been involved in fire. No fire found at this time. Continued down hallway towards room of origin. Smoke still white. Sound of flowing water heard. Found sprinkler head off in room of origin, room [ROOM NUMBER]. Fire extinguished prior to arrival in room. Windows had been broken by staff prior to arrival. Found a resident still in bed in room of origin. Removed person from room with assistance. Person (R1) is wet from sprinkler and cold. Notified command to send ambulance to second floor elevator where person will be." The facility's Life Safety Fire Safety Plan reads the objective is to establish a fire safety program that will maintain a fire safe environment for residents, staff and visitors. The Fire Safety Plan reads "Educate staff in all departments in fire prevention, fire safety, managing residents and visitors in the event of a fire, and the use of fire extinguishers." The facility's evacuation procedure reads "Place bedridden residents in wheelchairs if possible; if not possible, arrange beds so they can be pushed out through the doorway of the resident room." The facility failed to place R1 in a wheelchair and failed to arrange R1's bed so it could have been pushed through the doorway of his room. The facility left (R1) in his bed during the fire. The Fire Safety Procedures reads all fires "RACE - 1) Rescue, alarm, contain, extinguish 2) Protect all residents, visitors and employees, pull the fire alarm, close door in the fire area, use extinguisher. 3) In the unique case that a staff member who discovers the fire must immediately go to the aid of an endangered person, that staff member must articulate the code phrase, which will be "Code Red." The facility took the following actions to remove the immediacy: R3 is no longer in the facility. R3 was discharged the day of the fire. R3 was the only resident who was a smoker and the facility no longer has any resident that is a smoker. On 3/13/2015 the policy and procedure on RACE ( rescue, alarm, contain, extinguish) and PASS (pull, aim, squeeze, sweep) have been reviewed during a safety committee. An in-service has been conducted with staff on RACE and PASS and will continue until all staff members not present have been in-serviced. On 3/13/2015 a safety committee was held including the medical director to review the fire incident. The committee reviewed the fire policy including RACE and PASS policy and procedure as well as the smoking policy and procedure. Staff were in-serviced on fire policy, RACE and PASS and the smoking policy and procedure. A fire drill was initiated on all shifts to validate competency of staff with the in-servicing provided. Charge Nurses will perform spot checks at least once daily to determine level of staff compliance with understanding of RACE and PASS. These will be documented on a Quality Assurance checklist. New staff will receive orientation to include RACE and PASS. Staff will receive annual competency to review RACE and PASS during the fire drills. A QAPI/Safety committee meeting will be held monthly to review compliance with all of the above. The Administrator and/or his designee will monitor overall compliance through his general supervision and reports from department heads on staff compliance.

Based interview and record review facility failed to follow their fall assessment, prevention and care plan procedure for one resident (R4) out three residents reviewed for falls. This failure resulted in the interdisciplinary team not evaluating and considering new fall interventions for R4 after his second fall and subsequently R4 had a third fall and sustained a broken neck (fracture of C4). Findings Include: Review of the facility ' s Fall Assessment, Prevention, and Care Plan Procedure notes this policy establishes guidelines for proactively identifying and assessing those residents at risk for falls, planning preventative strategies and facilitating safe environment. Process: Fall assessment- Fall interventions documented on the resident interim/comprehensive plan of care will be reviewed and or revised at the discretion of the fall committee. The nurse will chart interventions in the progress notes. Fall prevention-Fall prevention is the goal for every resident. In order to meet this goal the interdisciplinary care team members, in collaboration with the resident and the designated family and may consider use of the following interventions (Nursing rounds, Evaluating bed/chair heights and application of personal alarms). Fall documentation and reporting-Every fall will be considered an incident requiring documentation, reporting, and follow up. The restorative nurse revises the Comprehensive Care Plan. The plan of care includes appropriate interventions for the prevention of falls. R4 ' s fall risk assessment dated [DATE] notes R4 scored 15= High risk 14+. R4 ' s comprehensive care plan initiated 5-18-13 notes R4 greater than normal risk for falls. R4 ' s incident report dated 6-11-13 notes R4 fell getting out of wheel chair. R4s ' fall risk model dated 7-26-13 notes 4 points for confusion with total score of 9= High risk for falls. R4 ' s current risk for fall care plan initiated 8-21-13 notes R4 will not fall or injure self. Approaches- assess meds for side effects, make sure environment free from hazards and obstacles, remind to ask for assistance, keep call light in reach, implement fall precaution. R4 ' s nurses dated 6-19-13 and 6-20 13 note R4 was angry each time the alarm went off and threw away the alarm. R4s ' nurse note dated 8-24-13 notes R4 was found sitting on the floor leaning on the night stand, no injury noted doctor notified. R4s ' fall assessment dated [DATE] notes side rails up, body alarm not applicable, alarm activated not applicable. R4s ' incident report dated 8-24-13 notes R4 alert and oriented X1, found R4 sitting on the floor leaning on the night stand. R4 doesn ' t know how he got on the floor. E11 (Registered Nurse) states on 9-3-13 at 11:10 AM, works 7pm-7am shift. E11 states in the middle of night (8-24-13) R4 fell out of his bed. R4 was assessed had no injuries and doctor notified no new orders. E11 states R4 did not have an alarm on at the time of the fall. E11 states did not apply a bed pad alarm under R4 or place a floor mat next to R4s ' bed after the fall. E11 states did not change/revise his fall care plan with any new interventions. E11 states R4 was monitored all night and current fall precautions were maintained. E12 (Licensed Practical Nurse) on 9-3-13 at 10:50 AM states, R4 was confused sometimes, " in & out " and forgetful and used to wear a body alarm. E12 states works 7am- 7pm when came to work on 8-25-13 told that R4 fell out of his bed in the middle of the night. E12 states just kept an eye on R4 to monitor him and reminded him to use his call light. E12 states there were no new fall interventions introduced and kept the current approaches per fall care plan. E12 states did not try bed pad alarm and that R4 in the past refused the body alarm. E12 states did not put a pad on the floor next to R4s ' bed. E10 (Care Plan Coordinator) on 9-3-13 at 10:00 AM states, the facility has in stock body, chair and pad alarms. E10 states after R4 fell out of bed nursing could have used their judgment and placed a pad alarm under R4 after he fell on [DATE]. E1 (Assistant Director of Nursing) on 9-3-13 at 11:00 AM states R4 fell over the weekend on Friday night. E1 states regarding the fall on 8-24-13 restorative nurse was going to do fall assessment on that Monday (8-26-13) but R4 fell again before that happened. E1 states the nurses that worked over the weekend could have gotten a pad alarm from the storage room for R4. E1 states in the past R4 used to have a body alarm but did not comply with wearing it. R4s ' nurses note dated 8-26-13 written at 1:00 PM notes CNA found R4 on the bathroom floor; forehead with 3.5 centimeter wound, doctor notified and ordered R4 to emergency room . R4s ' incident report dated 8-26-13 notes At 12:50 PM CNA found R4 on the bathroom floor without alarm, sitting up. Injury to forehead cleansed with saline and dressing applied admitted to hospital. On 9-4-13 at 10:50 AM E15 (Occupational Therapist Assistance) states, was in another resident ' s room next to R4s ' room on 8-26-13 when a family member came to her and stated that R4 fell . E15 states she went in R4s ' room and saw R4 on bathroom floor with lots of blood and did not see or hear and any alarm going off. E15 states she got the CNA (E14) and they assisted R4 into a wheel chair. E14 (Certified Nurse Aide) on 9-4-13 at 10:40 AM states, R4 has been for the past week or two not himself, seemed more confused. E14 states she fed R4 lunch on 8-26-13 and assisted him back to bed placed a body alarm on him. E14 states she did not know R4 had history of removing his body alarm. E14 states E15 called her from the nurses ' station and went into R4s ' room, did not hear alarm going off when entering the R4s ' room. E14 states saw (R4) bleeding from his forehead on the bathroom floor. E13 (Registered Nurse) on 9-4-13 at 12:50 AM, states was coming from lunch when E14 informed her that R4 had fallen. E13 states R4 was assessed and sent to the hospital. E13 states did not know that R4 had fallen the previous night on 8-24-13. E13 states if she had known that R4 had fallen two days ago would had put in place a new fall intervention and followed the facility ' s fall procedure. R4s ' hospital record dated 8-26-13 notes R4 was found to have large laceration across the upper forehead, Computed Tomography showed linear nondisplaced fracture of C4, R4 place in a C-collar. Z2 (Medical Doctor) states on 9-3-13 at 10:40 AM, R4 has slight dementia and forgetful at times and hurts himself trying to get out of the bed unassisted. Z2 states R4 had fracture of C4 vertebrae and requires him to wear a C-collar for 6-8 weeks. Z2 states R4 also had a laceration on his forehead that required 8 stitches.

Based on observation, interview and record review, the facility failed to provide a safe environment by failing to: 1. supervise nursing care resulting to serious injury of unknown origin to one resident (R1) in the sample. 2. assess, analyze the circumstances of falls, develop interventions, re-evaluate for the effectiveness of interventions, attempt alternative interventions and supervise residents to minimize the risk for recurring falls resulting to minor injuries for 2 residents (R7 and R18) in the sample. Findings include: During this investigation, observation, interview and record review was conducted regarding the allegations. R1 is a [AGE] year old female with [DIAGNOSES REDACTED]. The resident (R1) was observed on 9/27/10 in bed, non responsive with non purposeful eye movements, on full ventilation support via tracheostomy, on TPN (Total Parenteral Nutrition) via PICC line (Peripherally Inserted Central Catheter) and an indwelling urinary catheter. Z1(family member was at the bedside) during surveyor's initial tour of the facility, Z1 stated to surveyor that R1's cast to her R arm was recently removed. Review of facility assessments regarding R1, showed a totally dependent resident in all aspects of ADL's (Activities of Daily Living). Review of facility incident report dated 7/4/10 at 11:30PM, R1 was noted with R(right) upper forearm and deltoid area with redness and swelling 5-6cm in size, according to nurses documentations. Radiology (X-Ray done in the facility) result dated 7/5/10 of R1's R humerus showed an Angulated fracture of the proximal shaft of the humerus. Review of hospital records indicated that R1's primary condition in the hospital was fracture R humerus on 7/6/10, non-operable due to multiple co-morbidities, admitted to rehabilitation on 7/9/10. Staff interviews (E1-Administrator, E2-DON/Director of Nursing and E3-Nurse on duty) on 7/28/10 revealed that R1 had sustained a serious injury of unknown origin on 7/4/2010. E3 during this interview told surveyor that he was thinking of Cellulitis during his initial assessment as he (E3) had administered an insulin SQ (subcutaneously) few hours prior to the appearance of redness on R1's upper arm. E3 recounted that he again had assessed the site of his SQ injection, and found out that this redness was in much higher area of R1's R arm, he administered the insulin SQ in the lower arm area. E3 then told surveyor that his shift ended after giving his report to the NP, (Nurse practitoner) that early morning and that he was scheduled off the next 2 days. Interview of Z3 (Caregiver on duty during the incident on R1) on 7/28/10, stated that she starts her shift at 10PM every night, started washing up R1's face, change her GT (gastrostomy tube) site dressing, and when she " slowly pulled night gown on R arm she saw very red arm, looks like allergy something ", so she called the nurse (E3). Z3 then stated that they do everything for the patient, and that the facility staff just help. Z3 further stated the following to surveyor: " This is situation not very comfortable, been taking care of her for 3 years. Now found out she has broken arm. I'm shock, she is almostlike a mom to me, I have no idea what happened as she can not tell you anything. "