Every finding on record at Robinson Rehab and Nursing

Based on interview and record review, the facility failed to provide increased staff supervision in order to protect a resident from resident-to-resident abuse for one (R2) of three residents reviewed for abuse in the sample of three. This failure resulted in R1 threatening, hitting and throwing water on R2, and with R2, upon staff directives, curtailing his normal activities to try to avoid R1.Findings include:R2's admission Record documented an admission Date of 12/14/25 and listed Diagnoses including Diabetes Type 2 and Depression. A Minimum Data Set, dated [DATE] documented that R2 had a BIMS (Brief Interview for Mental Status) score of a 12, indicating R2 had moderately impaired cognition.R2's Care Plan dated 5/24/26 documented a problem area, I prefer to help with small chores. I helped my mother and sister for several years. I like to help to give myself a purpose, with a corresponding intervention, I understand that I am only to assist my mom (who is a resident) by pushing her wheelchair and not other residents in this facility, and problem area, I currently have an alteration to my ability to care for self and need assistance due to (being) developmentally delayed.R2's Nurses Notes documented the following:5/24/26: Resident was slapped by (R1) this evening at 19:00 (7pm). Incident was witnessed by two staff members who both stated they observed (R2) was pushing (R1) backwards in their wheelchair and (R1) reached up and slapped this resident across the left side of his face. This nurse was called and upon responding observed this resident and (R1) who struck him in the hallway with a CNA (Certified Nursing Assistant) standing between them. (R1) was still agitated and shaking his fist at this resident. This resident continued to lean in and allow his face to get near other resident's striking distance, further agitating (R1). This nurse intervened and took (R2) to the dining room. (R2) was assessed and no injuries could be determined. (R2) denied any pain. (R2) stated he was pushing (R1) out of the middle of the hall so the CNA could get through with the sit-to-stand lift and noticed (R1) had a clothing protector in his lap, but when he went to take it, (R1) reached up and slapped him. Advised this resident to not interact with (R1) East Hall nurse was notified that (R1) had become aggressive, and that (R1) was taken to their room at 19:15 (7:15pm). Neuro(logical) checks were initiated on (R2) related to head trauma and were consistent with resident's baseline.5/25/26: This nurse has reminded and instructed (R2) to stay away from (R1). Resident continues to go in proximity of (R1). After dinner this resident was close enough to (R1) and was able to throw water on him. Again, this nurse instructed (R2) to stay away from (R1), who is in wheelchair and very slow when wheeling self. Notified (R2's) family who also reminded resident to stay out of proximity of (R1). (V2, Director of Nursing and V1, Administrator) (were)notified of incident.9:15. Neuro checks were initiated on this resident related to head trauma and were consistent with resident's baseline.R1's admission Record documented an admission Date of 4/3/26, a discharge date of 6/5/26, and listed Diagnoses including Chronic Kidney Disease, Osteoporosis, and Cognitive Communication Deficit. A Minimum Data Set, dated [DATE] documented that R1 had a BIMS score of a 14 indicating R1 was cognitively intact.R1's Care Plan dated 5/24/26 documented a problem area, I have an alteration to my behavior- aggressive behaviors: 5/24/26 Incident involving another resident, with a corresponding intervention, 15-minute checks. R1's Wandering/Elopement Risk assessment dated [DATE] documented that R1 was at high risk for wandering and elopement.R1's Nurses Notes documented the following:5/24/26: (V5, Licensed Practical Nurse/LPN), the second nurse in the building informed this nurse that this resident that was under this nurse's care (R1) had, taken a swing at another resident (R2). (R2) was under (V5's) care. This nurse immediately took this resident (R1) back to his room and called V1, Administrator and Abuse Coordinator for this facility. Within minutes (V1) called this nurse back and clarified that this resident had actually made contact and struck (R2) in the jaw. This nurse assisted in preparing (R1) for bed and explained to (R1) that hitting was unacceptable behavior. (R1) is currently resting in bed, eyes closed and call light within easy reach.5/25/26: It was reported to this nurse from dayshift nurse, that (R1) was agitated with (R2) at supper and threw a cup of water on (R2). Also stated that (R1) ran over (R2's) foot with wheelchair. That nurse contacted (V2, Director of Nurses) and (V8, Assistant Director of Nurses) and alerted them of occurrence. Resident placed on 15-minute checks to monitor whereabouts and behaviors. Resident removed from other resident and no behaviors are present at this time. Sitting in wheelchair drinking hot chocolate, at this time wheeling down hallway. Staff frequently visual monitoring. No behaviors present at this time.There was no documentation in R1 or R2's record to indicate an abuse investigation was started following R1 throwing water on R2. There was no documentation in either record to indicate an increased level of monitoring was implemented after this incident.An IDPH (Illinois Department of Public Health) Long Term Care Serious Injury Incident and Communicable Disease Report dated 5/24/26 documented, Incident date: 5/24/26 at 7:00pm. Location: Common/Dining area. Detailed incident summary: (R1) and (R2) were in the dining/common area of the facility. (R1) was in his wheelchair and (R2) attempted to 'move' him a little. (R1) swung at (R2) and struck (R2) open handed on the jaw. Staff witnessed the incident and immediately de-escalated and separated the two residents. Nursing staff completed an injury assessment on both individuals, there were no visible or serious injuries or trauma noted. No further incident occurred. Immediate interventions and safety actions: 1. Individuals were immediately separated. 2. Staff remained with both residents to ensure de-escalation. 3. Residents had increased monitoring to ensure separation and safety of all individuals. 4. (R1) will be on 15 minute checks. 5. Physician was notified for further assessments and treatments if needed.On 6/10/26 at 1:35pm, V3, R1's Power of Attorney, stated R1 has dementia and as a result has had issues with physical aggression. V3 stated R1 hit another resident, and V3 believed it was because the facility did not provide adequate supervision. V3 stated R1 was transferred to a smaller facility where he had lived previously and had no issues there. V3 stated he was not aware there had been an episode of R1 throwing water at another resident. On 6/11/26 at 910am, V4, Social Services Designee, stated behavior interventions for R1 included 15-minute checks, redirection, activities engagement. V4 stated she talked to R1 and R2 on multiple occasions about avoiding each other and told R1 aggression toward others was unacceptable. V4 stated R1 had periods of confusion, and R2 had developmental delays. On 6/11/26 at 10:15am, R2 stated R1 would threaten him, flip him off, he threw water on him, he tried to run over R2's toes with R1's wheelchair, would shake his fist at him, and one time he hit him. R2 said staff told him to stay away from R1. R2 stated he had been upset because he felt he could not do activities he normally enjoyed, such as cleaning tables after meals, because he needed to avoid R1. On 6/12/26 at 8:50am, V5 (LPN) stated on 5/24/26 after supper, he had been walking down the hall when V9 (CNA), alerted him that R1 hit R2. V5 stated R1 and R2 were in the activity area leading to the dining room and had been separated by staff. R2 said R1 hit him on the left cheek. V5 stated he examined R2 who had no injuries. V5 stated he notified V2, who told him to, Keep them separated. V5 stated earlier in the evening, dietary staff had asked for somebody to come get R1 out of the dining room as he was threatening R2. V5 stated R1 had been moved out into the TV area but had apparently self propelled back into the dining room. V5 stated he knows before this happened they had talked about getting R1 into a local mental health hospital, but it didn't happen for whatever reason. V5 stated R1 was sent back to his previous placement. V5 stated R1 had been known to have behaviors including hitting staff. Interventions were to keep them separated, they told R2 to stay away from R1, but he is low functioning and doesn't always understand.On 6/11/26 at 9:10am, V4, Social Services Designee, stated R1 had been aggressive with staff, struck R2, and verbally threatened him. V4 stated she talked to R1 and R2 about avoiding each other.On 6/11/26 at 10:15am, R2 was alert and oriented to person, place, and time, but not purpose. R2 stated R1 threatened, hit him, would shake his fist at him, flipped him off, threw water on him, and tried to run over his toes with R1's wheelchair although he did not make contact. R2 stated R1 also yelled at and hit staff and yelled at other residents if he felt like they were in his personal space. R2 stated staff told him to try to stay away from R1, and this upset R2 because he couldn't do things he normally liked to do, such as clearing off the dining room tables, because R1 was always around. R2 stated the police never questioned him about R1's behavior toward him. On 6/12/26 at 8:50am, V5, Licensed Practical Nurse, stated on 5/24/26 after supper, V9, Certified Nursing Assistant, notified him R1 had hit R2. V5 stated R1 and R2 were in the activity area leading to the dining room and they had been separated by staff. R2 stated he had been hit on the left cheek, but he was not hurt, and upon exam V5 stated there were no injuries. V2 stated he notified V2, Director of Nurses, who told V5 to keep R1 and R2 separated. V5 stated he did not notify V1, Administrator. V5 stated he understood that earlier that evening, dietary staff had asked that staff remove R1 from the dining room as he was threatening R2.V5 stated R1 must have self-propelled back into the dining room. V5 stated staff told R2 multiple times to stay away from R1, but R2 is low functioning and doesn't always understand. V5 stated R1 was alert with periods of confusion and had a history of aggression toward staff and verbal aggression toward R2. On 6/12/26 at 9:00am, V6, Registered Nurse, stated on 5/24/26, V5 notified her of the altercation between R1 and R2. V6 stated she immediately notified V1 as she is the Abuse Coordinator. V6 stated V1 told V6 to, Keep them separated, that's about all she said. V6 stated she thought that R1 may have already been on 15 minute checks at that point. V6 stated R1 self-propelled throughout the facility and was alert with periods of extreme confusion. V6 stated staff had talked to R2 about staying away from R1, but as R2 was developmentally delayed, he might not have understood why he needed to stay away.On 6/12/26 at 10:15am, V1 stated she was notified about the incident between R1 and R2 immediately after it happened, and she began an investigation. V1 stated she told staff to make sure R1 and R2 stay separated and to do 15-minute checks, which V1 stated in retrospect R1 might have already been on. V1 stated she was unaware of dietary staff asking for R1 to be removed from the dining room earlier in the evening. V1 stated at no time did she consider placing R1 on one-to-one supervision as they do not have enough staff. V1 stated she did not notify the police of the physical assault. On 6/12/26 at 11:10am, V7, Dietary Aid, stated she did not witness the incident with R1 and R2, but earlier in the evening, she saw R1 with his finger in R2's face, with a mean look on R1's face, and she asked CNA staff to remove R1. V7 stated R1 obviously didn't stay out of the dining room, and he was always pretty much all over the place in his wheelchair.On 6/12/26 at 12:25pm, V9 (CNA) stated R1 was sitting in his wheelchair, and was kind of in the way of traffic. V9 stated R2 was trying to be helpful and pushed R1's wheelchair out of the way and tried to remove R1's clothing protector when R1 hit R2 in the face. V9 stated she notified R2's nurse, V5, who said to keep them separated, and she told R2 to stay away from R1. V9 stated later on she heard that dietary staff heard R1 threaten R2, but she had no firsthand knowledge of that. V9 stated she was not sure if R1 was put on 15 minute checks at that point or if he was already on them, and there were no further incidents that night. On 6/12/26 at 12:35pm, V1 stated she did not notify law enforcement of R1 hitting R2. On 6/16/26 at 11:0pm, V1 stated she was not aware of R1 throwing water on R2 as referenced above. V1 stated she did not therefore begin an abuse investigation.On 6/17/26 at 8:50am, V2 stated R1 was started on every 15-minute checks on 5/24/26 around 7-730pm after he hit R2. V2 stated prior to that R1 had been on, High frequency checks, which meant all staff are keeping eyes on him, because he was never in his room unless he was in bed asleep. V2 stated R1 remained on 15-minute checks until he was discharged . V2 stated she had been notified of the incident where R1 threw water on R2. V2 stated staff had reported to her that R1 ran over R2's toes with R1's wheelchair, but when she interviewed R2 he said R1 almost ran over his toes, and when she examined his feet there were no injuries. V2 stated she was, Upset at staff for not keeping them apart. V2 stated R2 had difficulty staying away from R1 as R2 had an intellectual disability and wanted everybody to be his friend. V2 stated one to one monitoring for R1 was never considered because they don't have enough staff, and even if overtime was offered, staff would not be willing to come in. V2 stated when residents require one to one monitoring, the family will be notified and asked to provide it. V2 stated she did not think R1's family had been asked to provide one on one, and both R1's sons were difficult to get hold of.The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure dated 2026 documented, in part, Purpose: To ensure that all of (the facility's) residents are free from abuse, neglect, misappropriation of their property, and exploitation. Procedure: 3. The facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to: Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, (or intimidating); Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. 4. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately.

Based on interview and record review, the facility failed to report resident-to-resident physical abuse to local law enforcement for one resident (R2) of three residents reviewed for abuse in the sample of three. Findings include:An IDPH (Illinois Department of Public Health) Long Term Care Serious Injury Incident and Communicable Disease Report dated 5/24/26 documented, Incident date: 5/24/26 at 7:00pm. Location: Common/Dining area. Detailed incident summary: (R1) and (R2) were in the dining/common area of the facility. (R1) was in his wheelchair and (R2) attempted to 'move' him a little. (R1) swung at (R2) and struck (R2) open handed on the jaw. Staff witnessed the incident and immediately de escalated and separated the two residents. Nursing staff completed an injury assessment on both individuals, there were no visible or serious injuries or trauma noted. No further incident occurred. Immediate interventions and safety actions: 1. Individuals were immediately separated. 2. Staff remained with both residents to ensure de escalation. 3. Residents had increased monitoring to ensure separation and safety of all individuals. 4. (R1) will be on 15 minute checks. 5. Physician was notified for further assessments and treatments if needed.There was no documentation in either R1 or R2's record to indicate law enforcement was notified of R1 hitting R2.On 6/12/26 at 10:15am, V1 (Administrator) stated she was notified about the incident between R1 and R2 immediately after it happened, and she began an investigation. On 6/12/26 at 12:35pm, V1 stated she did not notify law enforcement of R1 hitting R2. The facility's Elder Justice Act and Reporting Suspected Crimes Policy dated 2026 stated, It is (the facility's) policy to empower and enable any and all owners, operators, employees, managers, agents or contractors of the facility (Covered Individual(s)) to make reports to the relevant authorities pursuant to the provision of the Elder Justice Act (EJA the Act) and CMS (Centers for Medicare Medicaid) regulations. The Facility will not retaliate against any Covered Individual in response to lawful acts done by the covered individual pursuant to the EJA. Abuse, (definition): The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse includes resident to resident altercations, including, but not limited to any willful action that results in physical injury, mental anguish, or pain. Pursuant to the EJA, Covered Individuals must report reasonable suspicions of a crime to the State Survey Agency and at least one local law enforcement entity.

Based on interview and record review, the facility failed to identify and thoroughly investigate allegations of resident-to-resident abuse and failed to ensure residents were not at risk for further abuse for one resident (R2) of three residents reviewed for abuse in the sample of three. Findings include:R2's admission Record documented an admission Date of 12/14/25 and listed Diagnoses including Diabetes Type 2 and Depression. A Minimum Data Set, dated [DATE] documented that R2 had a BIMS (Brief Interview for Mental Status) score of a 12, indication R2 had moderately impaired cognition. R2's Care Plan dated 5/24/26 documented a problem area, I prefer to help with small chores. I helped my mother and sister for several years. I like to help to give myself a purpose, with a corresponding intervention, I understand that I am only to assist my mom (who is a resident) by pushing her wheelchair and not other residents in this facility, and problem area, I currently have an alteration to my ability to care for self and need assistance due to (being) developmentally delayed.R2's Nurses Notes documented the following:5/24/26: Resident was slapped by (R1) this evening at 19:00 (7pm). Incident was witnessed by two staff members who both stated they observed (R2) was pushing (R1) backwards in their wheelchair and (R1) reached up and slapped this resident across the left side of his face. This nurse was called and upon responding observed this resident and (R1) who struck him in the hallway with a CNA (Certified Nursing Assistant) standing between them. (R1) was still agitated and shaking his fist at this resident. This resident continued to lean in and allow his face to get near other resident's striking distance, further agitating (R1). This nurse intervened and took (R2) to the dining room. (R2) was assessed and no injuries could be determined. (R2) denied any pain. (R2) stated he was pushing (R1) out of the middle of the hall so the CNA could get through with the sit-to-stand lift, and noticed (R1) had a clothing protector in his lap, but when he went to take it, (R1) reached up and slapped him. Advised this resident to not interact with (R1) East Hall nurse was notified that (R1) had become aggressive, and that (R1) was taken to their room at 19:15 (7:15pm). Neuro(logical) checks were initiated on (R2) related to head trauma, and were consistent with resident's baseline.5/25/26: This nurse has reminded and instructed (R2) to stay away from (R1). Resident continues to go in proximity of (R1). After dinner this resident was close enough to (R1) was able to throw water on him. Again this nurse instructed (R2) to stay away from (R1),who is in wheelchair and very slow in when wheeling self. Notified (R2's) family who also reminded resident to stay out of proximity of (R1). (V2, Director of Nursing and V1, Administrator) (were) notified of incident. 9:15. Neuro checks were initiated on this resident related to head trauma, and were consistent with resident's baseline.R1's admission Record documented an admission Date of 4/3/26, a discharge date of 6/5/26, and listed Diagnoses including Chronic Kidney Disease, Osteoporosis, and Cognitive Communication Deficit. A Minimum Data Set, dated [DATE] documented that R1 had a BIMS score of a14 indicating R1 was cognitively intact.R1's Care Plan dated 5/24/26 documented a problem area, I have an alteration to my behavior- aggressive behaviors: 5/24/26 Incident involving another resident, with a corresponding intervention, 15-minute checks. R1's Wandering/Elopement Risk assessment dated [DATE] documented that R1 was at high risk for wandering and elopement.R1's Nurses Notes documented the following:5/24/26: (V5, Licensed Practical Nurse/LPN), the second nurse in the building informed this nurse that this resident that was under this nurse's care (R1) had, taken a swing at another resident (R2). (R2) was under (V5's) care. This nurse immediately took this resident (R1) back to his room and called V1, Administrator and Abuse Coordinator for this facility. Within minutes (V1) called this nurse back and clarified that this resident had actually made contact and struck (R2) in the jaw. This nurse assisted in preparing (R1) for bed and explained to (R1) that hitting was unacceptable behavior. (R1) is currently resting in bed, eyes closed and call light within easy reach.5/25/26: It was reported to this nurse from dayshift nurse, that (R1) was agitated with (R2) at supper and threw a cup of water on (R2). Also stated that (R1) ran over (R2's) foot with wheelchair. That nurse contacted (V2, Director of Nurses) and (V8, Assistant Director of Nurses) and alerted them of occurrence. Resident placed on 15-minute checks to monitor whereabouts and behaviors. Resident removed from other resident and no behaviors are present at this time. Sitting in wheelchair drinking hot chocolate, at this time wheeling down hallway. Staff frequently visual monitoring. No behaviors present at this time.There was no documentation in R1 or R2's record to indicate an abuse investigation was started following R1 throwing water on R2. There was no documentation in either record to indicate an increased level of monitoring was implemented after this incident.An IDPH (Illinois Department of Public Health) Long Term Care Serious Injury Incident and Communicable Disease Report dated 5/24/26 documented, Incident date: 5/24/26 at 7:00pm. Location: Common/Dining area. Detailed incident summary: (R1) and (R2) were in the dining/common area of the facility. (R1) was in his wheelchair and (R2) attempted to 'move' him a little. (R1) swung at (R2) and struck (R2) open handed on the jaw. Staff witnessed the incident and immediately de escalated and separated the two residents. Nursing staff completed an injury assessment on both individuals, there were no visible or serious injuries or trauma noted. No further incident occurred. Immediate interventions and safety actions: 1. Individuals were immediately separated. 2. Staff remained with both residents to ensure de escalation. 3. Residents had increased monitoring to ensure separation and safety of all individuals. 4. (R1) will be on 15 minute checks. 5. Physician was notified for further assessments and treatments if needed.On 6/10/26 at 1:35pm, V3, R1's Power of Attorney, stated R1 has dementia and as a result has had issues with physical aggression. V3 stated R1 hit another resident, and V3 believed it was because the facility did not provide adequate supervision. V3 stated R1 was transferred to a smaller facility where he had lived previously and had no issues there. V3 stated he was not aware there had been an episode of R1 throwing water at another resident. On 6/11/26 at 910am, V4, Social Services Designee, stated behavior interventions for R1 included 15 minute checks, redirection, activities engagement. V4 stated she talked to R1 and R2 on multiple occasions about avoiding each other, and told R1 aggression toward others was unacceptable. V4 stated R1 had periods of confusion, and R2 has developmental delays. On 6/11/26 at 10:15am, R2 stated R1 would threaten him, flipped him off, he threw water on him, he tried to run over R2's toes with R1's wheelchair, would shake his fist at him, and one time he hit him. R2 said staff told him to stay away from R1. R2 stated he had been upset because he felt he could not do activities he normally enjoyed, such as cleaning tables after meals, because he needed to avoid R1. On 6/12/26 at 8:50am, V5 (LPN) stated on 5/24/26 after supper, he had been walking down the hall when V9 (CNA), alerted him that R1 hit R2. V5 stated R1 and R2 were in the activity area leading to the dining room, and had been separated by staff. R2 said R1 hit him on the left cheek. V5 stated he examined R2 who had no injuries. V5 stated he notified V2, who told him to, Keep them separated. V5 stated earlier in the evening, dietary staff had asked for somebody to come get R1 out of the dining room as he was threatening R2. V5 stated R1 had been moved out into the TV area, but had apparently self propelled back into the dining room. V5 stated he knows before this happened they had talked about getting R1 into a local mental health hospital but it didn't happen for whatever reason. V5 stated R1 was sent back to his previous placement. V5 stated R1 had been known to have behaviors including hitting staff. Interventions were to keep them separated, they told R2 to stay away from R1 but he is low functioning and doesn't always understand. On 6/11/26 at 9:10am, V4, Social Services Designee, stated R1 had been aggressive with staff, struck R2, and verbally threatened him. V4 stated she talked to R1 and R2 about avoiding each other.On 6/11/26 at 10:15am, R2 was alert and oriented to person, place, and time, but not purpose. R2 stated R1 threatened, hit him, would shake his fist at him, flipped him off, threw water on him, and tried to run over his toes with R1's wheelchair although he did not make contact. R2 stated R1 also yelled at and hit staff and yelled at other residents if he felt like they were in his personal space. R2 stated staff told him to try to stay away from R1, and this upset R2 because he couldn't do things stuff he normally liked to do, such as clearing off the dining room tables, because R1 was always around. R2 stated the police never questioned him about R1's behavior toward him. On 6/12/26 at 9:00am, V6, Registered Nurse, stated on 5/24/26, V5 notified her of the altercation between R1 and R2. V6 stated she immediately notified V1 as she is the Abuse Coordinator. V6 stated V1 told V6 to, Keep them separated, that's about all she said. V6 stated she thought that R1 may have already been on 15 minute checks at that point. V6 stated R1 self-propelled throughout the facility, and was alert with periods of extreme confusion. V6 stated staff had talked to R2 about staying away from R1, but as R2 was developmentally delayed, he might not have understood why he needed to stay away.On 6/12/26 at 10:15am, V1 stated she was notified about the incident between R1 and R2 immediately after it happened, and she began an investigation. V1 stated she told staff to make sure R1 and R2 stay separated and to do 15-minute checks, which V1 stated in retrospect R1 might have already been on. V1 stated she was unaware of dietary staff asking for R1 to be removed from the dining room earlier in the evening. V1 stated at no time did she consider placing R1 on one-to-one supervision as they do not have enough staff. V1 stated she did not notify the police of the physical assault. On 6/12/26 at 11:10am, V7, Dietary Aid, stated she did not witness the incident with R1 and R2, but earlier in the evening, she saw R1 with his finger in R2's face, with a mean look on R1's face, and she asked CNA staff to remove R1. V7 stated R1 obviously didn't stay out of the dining room, and he was always pretty much all over the place in his wheelchair.On 6/12/26 at 12:25pm, V9 (CNA) stated R1 was sitting in his wheelchair, and was kind of in the way of traffic. V9 stated R2 was trying to be helpful and pushed R1's wheelchair out of the way and tried to remove R1's clothing protector when R1 hit R2 in the face. V9 stated she notified R2's nurse, V5, who said to keep them separated, and she told R2 to stay away from R1. V9 stated later on she heard that dietary staff heard R1 threaten R2, but she had no firsthand knowledge of that. V9 stated she was not sure if R1 was put on 15 minute checks at that point or if he was already on them, and there were no further incidents that night. On 6/12/26 at 12:35pm, V1 stated she did not notify law enforcement of R1 hitting R2. On 6/16/26 at 11:0pm, V1 stated she was not aware of R1 throwing water on R2 as referenced above. V1 stated she did not therefore begin an abuse investigation.On 6/17/26 at 8:50am, V2 stated R1 was started on every 15-minute checks on 5/24/26 around 7-730pm after he hit R2. V2 stated prior to that R1 had been on, High frequency checks, which meant all staff are keeping eyes on him, because he was never in his room unless he was in bed asleep. V2 stated R1 remained on 15-minute checks until he was discharged . V2 stated she had been notified of the incident where R1 threw water on R2. V2 stated staff had reported to her that R1 ran over R2's toes with R1's wheelchair, but when she interviewed R2 he said R1 almost ran over his toes, and when she examined his feet there were no injuries. V2 stated she was, Upset at staff for not keeping them apart. V2 stated R2 had difficulty staying away from R1 as R2 had an intellectual disability and wanted everybody to be his friend. V2 stated one to one monitoring for R1 was never considered because they don't have enough staff, and even if overtime was offered, staff would not be willing to come in. V2 stated when residents require one to one monitoring, the family will be notified and asked to provide it. V2 stated she did not think R1's family had been asked to provide one on one, and both R1's sons were difficult to get hold of.The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure dated 2026 documented, in part, Purpose: To ensure that all of (the facility's) residents are free from abuse, neglect, misappropriation of their property, and exploitation. Procedure: 3. The facility shall review altercations from resident to resident as a potential situation of abuse. A. Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to: Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, (or intimidating); Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. 4. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility will increase enforcement action, including, but not limited to: A. Taking steps to prevent further potential abuse; Reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations. See CCG 00309 Elder Justice Act Policy and Procedure; Conducting a thorough investigation of the alleged violation; (and) Taking appropriate corrective action. 9. The facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property. 12. The facility will ensure compliance with the Elder Justice Act Policy and Procedure. (See CCG 00309). 13. Response: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall; A. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper time frame pursuant to this policy; B. Have evidence that all alleged violations are thoroughly investigated; C. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress; (and) D. Report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with state law, including to the state survey agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on observation, interview and record review the facility failed to ensure that the dish machine and 3 compartment sink were effectively sanitizing the dishes and stationary equipment. This has the potential to affect all 59 residents residing in the facility.The Findings Include: During the initial tour of the kitchen on 11/18/25 at 9:45am, V4 (Cook) measured the sanitizer levels of dish machine with a quaternary sanitizer test strip. The strip measured 0 part per million (ppm). V4 then retrieved chlorine test strips and tested the dish machine again with a 0 ppm reading. A bucket of sanitizer was then tested with the quaternary test strip and a 0 ppm reading was obtained. A dishwasher Temperature Log and Temp/Chemical Sanitizing Machine dated November 2025 was provided and was filled out through the current day 11/18/2025. The log documented that the sanitizer level for the dish machine should be 50 ppm chlorine. This log documented that the sanitizer level was checked for the breakfast shift and V4 (Cook) stated that she was the employee to fill out the log for the breakfast meal this morning. It was marked at being 50 ppm chlorine. V4 stated that the sanitizer level is always ok. When asked if she used a strip and checked the sanitizer level this morning V4 again stated, I don't know, the sanitizer level is always ok. The log further documented for the month of November that all breakfast, lunch and supper meals on the log have a 50 PPM (Parts Per Million) reading listed as the sanitizer level logged for every meal. On 11/18/2025 at 10:00 AM, V5 (Dietary Manger) stated at this time that they have recently switched companies who delivers and maintains their dish machine, and she will have to find their contact information to have them come out and service the dish machine. V5 stated that the sanitizer bucket used to clean stationary equipment is made from a premixing system located at their 3-compartment sink, and that is maintained from the same company. V5 stated that she expects the staff to check the levels of sanitizer before each meals dishes are washed in the dish machine and when the fresh buckets of sanitizer are made. V5 stated that she will switch to disposable products at this time and revert to the emergency plan of using the 3-compartment sink and manually mix the sanitizer in the sink. On 11/19/2025 at 9:30 AM, V6 (Cook) stated that they fixed the dish machine sanitizer and it is at the proper level. The level of sanitizer when checked with a chlorine test strip was at 200 PPM, which is indicating over the recommended level of chlorine sanitizer. V6 stated that she would call maintenance and have them adjust the machine to lower the amount of sanitizer the machine is using. At the same time, the bucket sanitizer was checked with a quaternary test trip, and no sanitizer was present in the bucket. V6 made a fresh bucket of sanitizer and checked the level, and again it was not registering sanitizer. V6 stated that maintenance would check this as well and possibly adjust the hose. A policy and procedure for Dish Machine Use dated 12/30/24 documents: Food Service staff required to operate the dish machine will be trained in all steps of the dish machine use by the supervisor or designee proficient in all aspects of proper use in sanitation .4. Dish machines that use bleach for sanitation are to be tested prior to dishes entering the machine. The correct solution is 50-100 ppm with the chlorine test strips. A policy and procedure for pot and pan washing with a date of 12/30/24 documents, All pots and pans that are hand washed will be done in a three-compartment sink. A wash-rinse-sanitize procedure will be followed 3. the third sink will be filled to a designated water line with warm water (not less than 75 degrees) and two pumps (2 ounces) of sanitizer from the dispenser over the sink. A solution of sanitizer at the rate of 200 PPM is necessary.The Long-Term Care Facility Application for Medicare and Medicaid dated and signed on 11/19/25 documents 59 residents reside in the facility.

Based on observation, interview and record review the facility failed to follow policy and procedure for infection control practices for 4 of 16 residents (R13, R54, R57, and R59) reviewed for infection control in the sample of 35. The Findings Include:1. R54's admission Record documented an Initial admission Date of 11/12/2024. R54's admission Record documents the following diagnoses: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, polyosteoarthritis, neuromuscular dysfunction of bladder, pain in right knee, major depressive disorder, hypotension, and acute kidney failure. R54's Order Summary Report dated 11/20/2025 documented an order for suprapubic catheter change monthly on the 7th - urologist to change. The order summary goes on to document an order for infection precautions - enhanced barrier - staff will wear gown and gloves when in direct resident contact.R57's admission Record documented an Initial admission Date of 10/23/2025. R57's admission Record documents the following diagnoses: unspecified fracture of third lumbar vertebra, iron deficiency anemia, acute posthemorrhagic anemia, type 2 diabetes mellitus, essential hypertension, hypertensive heart disease, atrial fibrillation, postlaminectomy syndrome, and discitis. R57's Order Summary Report dated 11/20/2025 documented an order for daptomycin intravenous daily until 11/27/2025. On initial tour of the facility on 11/18/2025 beginning at 9:30 A.M., R54 and R57 had no isolation precaution signs outside their room. R54 and R57 did not have an isolation station for personal protective equipment outside their rooms. On 11/18/2025 a Matrix for Providers (form CMS 802) was provided by the facility. R54 and R57 do not have a check mark in the column for transmission-based precautions.On 11/19/2025 at 2:40 P.M. V8 (Infection Preventionist Nurse) stated she is not sure why R54 and R57 do not have isolation precautions on their doors. V8 stated that both R54 and R57 should have isolation precautions and it will be put in place immediately.On 11/19/2025 at 3:05 P.M. V1 (Administrator) stated the facility is doing an audit to ensure all residents who require isolation precautions are on them.On 11/20/2025 at 9:00 A.M. R54 and R57's rooms were observed with isolation signs on the outside of the doors and personal protective equipment carts outside of their rooms.On 11/21/2025 at 10:52 A.M. V8 stated when a resident is admitted , she tells the nursing staff that the resident needs isolation precautions and what the isolation is for. V8 stated it is perplexing that R54 didn't have signs and personal protective equipment stations because R54 has been in that room for months. V8 stated R54 had isolation trash cans in his room and she is certain that R54 had isolation signs on his door. V8 stated she is not sure how or when it was taken down. V8 stated it is her expectation that the isolation precautions be put up and utilized until she takes them down. V8 stated she does not double check the residents after they are admitted to make sure the isolation precautions are put into place. V8 stated that R57's isolation precautions for having a mid line just must have been missed. V57 stated she is responsible for making sure that residents are placed on precautions per the facility protocol. On 11/21/2025 at 10:58 A.M. V3 (Registered Nurse / Assistant Director of Nursing) stated she realized after starting R57's antibiotic and leaving the room she did not gown up. V3 stated she knew R57 was supposed to be on enhanced barrier precautions because he has a mid-line.On 11/21/2025 at 11:01 A.M. V2 (Director of Nursing) stated it is her expectation that the infection preventionist nurse communicate isolation precautions for all residents. V2 stated it is also her expectation that the infection preventionist nurse follow up to ensure the residents who require isolation are on isolation. V2 stated that in daily morning meetings it is discussed who is on isolation and why. V2 stated there is no reason R54 and R57 were not on isolation precautions.A facility policy titled Enhanced Barrier Precautions with a date of 10/28/2024 documented It is this facilities policy that Enhanced Barrier Precautions (EBP) are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. EBP is used during high-contact care activities for residents with chronic wounds or indwelling medical device. 2. On 11/20/2025 at 11:00 AM, V7 (Registered Nurse) completed a blood glucose check on R59. V7 pulled the test strip out of the machine and discarded it then placed the blood glucose monitoring machine in a basket with lancets and alcohol prep pads. V7 then left R59's room and pushed R59 to the dining room and placed the clipboard with the basket containing the blood glucose machine and blood glucose monitoring supplies on the medication cart. At 11:06 A.M. V7 walked to medication cart, sanitized hands, picked up clipboard with the basket containing the blood glucose machine and blood glucose monitoring supplies and went to the dining room to get a blood pressure on R59. At 11:13 A.M. V7 went in R13's room and sat clipboard with blood glucose monitoring supplies on the bed side table. V7 came out of the room and placed a gown and gloves on. V7 then went to R13 and obtained his vital signs. At 11:17 A.M. V7 took blood glucose machine out of basket and obtained glucose reading. V7 then took the test strip out of machine and discarded it. V7 placed glucometer back in basket with supplies and left R13's room. On 11/20/2025 at 11:20 A.M. V7 stated she uses one blood glucose machine and disinfects it after she has gotten all of her resident's blood glucoses. V7 stated she did not clean the machine in between each resident use. On 11/20/2025 at 11:25 A.M. V2 stated there are two blood glucose machines. V2 stated the nurse is supposed to use one and clean it. V2 stated while that one is drying the nurse is supposed to use the other blood glucose machine. V2 stated that the blood glucose machine should be cleaned after each use. V2 stated it is her expectation that all nurses in the facility know the policy and to disinfect the blood glucose machine between uses. A facility policy titled Cleaning and Disinfection of Glucometer with a date of 10/28/2024 documented under section titled Guidelines: . All glucometers that are shared among multiple residents will be thoroughly wiped with the disinfectant and allowed to air dry after every use and between each resident.

Based on interview, observation, and record review the facility failed to provide supervision and implement effective interventions to prevent falls for 1 (R1) of 3 residents reviewed for falls in the sample of 12. This failure resulted in R1 sustaining a fall that caused a fracture of left knee and large hematoma of scalp and a right parietal subarachnoid hemorrhage. This past non-compliance occurred on from [DATE] to [DATE].Findings Include:R1's face sheet documents an original admission date of [DATE]. R1 has diagnoses in her electronic health record including, but not limited to dementia, dorsalgia, history of falling, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, and difficulty in walking.R1's non-medication related physician orders include but are not limited to order dated [DATE] for monitoring and prevention of adverse effects of opioid medications including, but not limited to falls, disorientation, dizziness, vertigo, and lightheadedness.R1's most recent minimum data set (MDS) dated [DATE] documents R1 has a brief interview for mental status (BIMS) score of 2 indicating R1 is not cognitively intact indicating R1 is unaware of her own safety. In section GG of same MDS it is documented R1 is dependent for all activities of daily living including transfers and mobility except eating. Section I of the same MDS documents diagnoses including, but not limited to non-Alzheimer's dementia, history of falling, muscle weakness, and abnormalities of gait and mobility.R1's most recent care plan (CP) dated [DATE] documents R1 has a focus area dated [DATE] indicating R1 is at risk for falls. Interventions related to this focus area include but are not limited to assisting R1 to always keep non-skid footwear on while R1 is up, dated [DATE]; intervention dated [DATE] documents to make sure R1's call light is always within reach; and a third intervention, undated in current care plan is to place a fall mat beside the bed to decrease the impact of falls. Another focus area on R1's CP dated [DATE] documents R1 has an alteration in her ability to care for self and needs assistance due to cognitive impairment and weakness. Interventions for this focus area include but are not limited to R1 requiring mechanical lift transfer with assist of two staff for transfers dated [DATE].R1's Final Serious Injury Incident Report date [DATE] documents on [DATE] at 11:30 am R1 was being prepared for transfer from bed to chair. Staff member stepped out into the hall to obtain the lift and resident rolled out of bed onto the floor. Resident was in the center of the bed when staff member stepped out to the lift. Resident obtained a left subtle non-displaced fracture of the medial femoral condyle as well as a right parietal subarachnoid hemorrhage. Bed was in low position when resident rolled out. Resident to return to this nursing facility today [DATE]. R1's hospital records dated [DATE] documents a computed tomography scan reading of R1's left knee showing a subtle nondisplaced fracture of the medial femoral condyle with moderate suprapatellar lipohemarthrosis. A computed tomography scan reading dated same as first, of R1's skull documents a large left frontal scalp hematoma and an equivocal right parietal subarachnoid hemorrhage.On [DATE] at 11:07 AM, R1 was located in the therapy room receiving therapy. R1 had a very large hematoma noted to left of midline of forehead that extended into the scalp. There was dried blood noted to the center of the hematoma. There were also sutures present but unable to determine how many due to the dried blood. R1 had yellow, purple and blue bruising extending all the way down her face into her neck. R1 was not interviewable at that time.On [DATE] at 11:58 AM, V10, (Certified Nurse's Aide/CNA) stated on [DATE] while she was assisting R1 to get ready for lunch R1 was lying in bed. V10 stated she had left the mechanical lift outside the door of R1's room until R1 was readied for transfer from bed to wheelchair. V10 stated she left R1's bedside unattended to retrieve the mechanical lift outside R1's door of room. V10 stated when she left R1's bedside unattended R1's bed was in the lowest position and R1's side rails were up, but R1's fall mat was not placed back in the proper position of R1's bedside. V10 stated when she walked out of the room, she then heard V11(CNA) yell for her to get back in the room. V10 stated when she rushed back into R1's room she observed R1 lying on her left side next to her bed with bleeding coming from her head. V10 stated in looking back she believed she did not leave R1 in the safest possible position before leaving the bedside because she did not place R1's fall mat back at side of bed. V10 stated the protocol for getting R1 ready to transfer via use of the mechanical lift is one staff member stays at bedside while the other retrieves the mechanical lift. V10 stated she simply was not thinking, leaving R1 unattended and fall mat removed from bedside while retrieving the mechanical lift. V10 stated she believes R1's fall could have been prevented if the other staff member, V11 had been at bedside to prevent R1 from rolling out of bed, or at the least R1's injuries from the fall could have been less severe if fall mat had been in place according to R1's fall precautions. On [DATE] at 9:52 AM, V11, CNA stated on [DATE] she had initially walked in R1's room by herself to ready R1's roommate for transfer from bed to wheelchair. V11 stated soon after she saw V10 step into the room and go to R1's bedside to assist R1 in getting ready to transfer from bed to wheelchair via mechanical lift; she pulled the privacy curtain between the two residents. V11 stated the next thing she knew, she heard an awful noise and asked V10 if she was ok. V11 stated she didn't get a response and stepped around the curtain to check on V10. V11 stated at that time she observed V10 had left the room and R1 was lying on the floor beside the bed on her left side with active bleeding coming from somewhere on her head. V11 stated immediately after R1's fall she noted R1's fall mat was not in place and R1's bed was not in the lowest position. V11 stated she would describe the bed height at approximately waist height for most people. V11 stated she did know R1 had a history of falls and was at risk for further falls. V11 stated she did not believe the safest practice of having R1's bed in the lowest position and fall mat placed back at bedside was followed for R1's safety. V11 stated she believed R1's injury could have been prevented if V10 had not left R1 unattended or at the least R1's injuries could have been less severe if all fall precautions had been put back into place before V10 left the room. V11 stated she always does R1's transfers and care with a second staff member because she is a two-assist resident.On [DATE] at 4:14 PM, V15 (Medical Doctor/MD) stated R1's injuries could possibly have been less severe if the fall mat had been placed back at bedside before V10 stepped away from the bedside to retrieve the mechanical lift.On [DATE] at 1:08 PM, V14 (CNA) stated the safest way to leave a resident who is at risk for falls is to place all their fall precautions back into place including the fall mat back into correct position at bedside. V14 also stated she believed R1's fall could have been completely prevented if V10 had waited for a second staff member to assist her in getting R1 ready for transfer, or at least R1's injuries could have been less severe if V10 had placed R1's fall mat back into proper position at bedside before stepping out of the room leaving R1 unattended.On [DATE] at 1:22 PM, V12 (CNA) stated the safest way to leave a resident unattended including R1 is to place resident's bed into the lowest position and put all their fall precautions back into place including their fall mat.On [DATE] at 10:51 AM, V9 (Registered Nurse/RN) stated the safest practice when leaving a resident unattended to retrieve the mechanical lift for transfer is to place all fall precautions back into place including the resident's fall mat if has the mat listed as an intervention. V9 stated regarding R1's fall, they were unsure if it could have been completely prevented but does believe R1's injuries could possibly have been less severe if all fall precautions had been put back into place including her fall mat before V10 had left R1's room.On [DATE] at 2:00 PM, V2 (Director of Nurses/DON) stated she was here on [DATE] and assisted with first aid for R1 after her fall until emergency medical technicians arrived on grounds. V2 stated she believed V10 should have placed R1's fall mat back at bedside before stepping out of the room to retrieve the mechanical lift. V2 stated re-education of all CNA staff regarding transfers and fall prevention/safety was conducted with all CNA staff within twenty-four hours after R1's fall.On [DATE] at 1:16 PM, V1 (Administrator) stated after the fall of R1 re-education on transfers and fall prevention/safety was conducted for all CNA staff within twenty-four hours after R1's fall. V1 stated she was unsure if R1's fall could have been completely prevented or that R1's injuries could have been less severe but did believe V10 should have placed R1's fall mat back at bedside before stepping out of the room to retrieve the mechanical lift.Facility's fall policy revised [DATE] document in part, Purpose: . to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to minimize fall related injuries.Prior to the survey date, the facility took the following actions to correct the noncompliance:1. V1 stated in-servicing on safe transfers using mechanical lifts and placing fall precautions back into place before leaving residents was completed with all CNA's within twenty-four hours of the incident involving R1. V1 stated there was a Quality Assurance and Performance Improvement plan put into place on [DATE]. V1 stated facility monitored safe transfers using mechanical lifts and residents having fall precautions in place over for four days up until [DATE] with a one hundred percent success rate. V1 stated they will monitor over the next quarter using surprise inspections conducted by V1 to make sure mechanical lift transfers are being conducted safely and fall precautions are in place.2. Facility's Quality Assurance and Performance Improvement report dated [DATE] documents a sample of six residents was reviewed from [DATE]-[DATE] for safe transfers using a mechanical lift and fall precautions were in place for those six residents. The report documents the success rate as one hundred percent at that time. The same report documents these two aspects will be monitored using a larger sample size over the next quarter and monitored. 3. Inservice documentation for CNA staff with a start date of [DATE] with a Topic/Subject: Transferring with mechanical lift/fall intervention, safety shows all CNA staff signed off on completing the training. Included with the documentation was a document titled Transferring with Mechanical Lift Education and the facility's policy titled Using Mechanical Lift dated [DATE] indicating CNA staff were trained on safe transfers of residents using mechanical lifts and importance of fall precautions.

Based on interview and record review, the facility failed to respond to residents' requests for assistance in a timely manner to promote dignity and respect for 1 (R1) of 4 residents reviewed for call light response in the sample of 4. This failure resulted in R1 having to urinate on herself, causing her feelings of discomfort, anxiety, humiliation, and embarrassment.Findings Include: R1's admission Record documented an admission date of 4/27/25 and included diagnoses of morbid (severe) obesity due to excess calories, spinal stenosis, need for assistance with personal care, presence of right artificial hip joint, pain in right hip, presence of artificial knee joint, bilateral, essential tremor, anxiety, and muscle weakness. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. This MDS also documents under Functional Abilities and Goals, R1 is dependent for toileting hygiene, shower/bathe self, upper body dressing, and putting on/taking off footwear. R1's current Care Plan included a focus area of I currently have an alteration to my ability to care for self and need assistance d/t (due to) Anxiety, Cognitive impairment, Weakness initiated on 1/31/25. Corresponding interventions include: encourage resident to participate to the fullest extent possible with each interaction, encourage resident to use bell to call for assistance, praise all efforts at self care, PT (physical therapy), OT (occupational therapy) and ST (speech therapy) evaluation and treatment. R1 also has a focus area of I am currently able to perform mobility with 2 assist, gait belt and walker initiated on 5/7/25 with corresponding interventions of: encourage (R1) to use bell to call for assistance if needed and monitor/document ability to perform ADLs (activities of daily living).Facility Resident Council meeting minutes dated 7/18/25 document under 4. New Business: (R1) says only one CNA (Certified Nurse Assistant) at night needs more. A facility Resident/Family Concern/Grievance Form dated 07/18/2025 documented Resident Council by the Resident Name. Under Section 1, the Nature of Concern documented Resident states not enough CNA's on the floor at night. Says she needs things like ice water and there is no one to get it. In Section 2 under Review and Action Taken, V2 (Director of Nursing/DON) documented Nurse managers come in to assist as needed, assured resident council that there is always at least 3 CNAs overnight. Staff more assist b/t (between) 6 - 10p and 4-6a to help during busy X's (times). Facility Resident Council meeting minutes dated 8/15/25 under #4, New Business documented Still not enough CNAs at night.On 08/29/2025 at 10:53 AM, R1 stated she sometimes has trouble getting her call light answered. R1 stated on night shift, there is one CNA per hall. R1 stated that she has been told staff have been hired but she has yet to see any new faces. R1 stated that she has peed on herself waiting for her call light to be answered. R1 stated she knows of three times that this has happened and added that this has only occurred on weekends. R1 stated it's embarrassing when she's in the hall and has to pee on herself. R1 said she does not like that she had to pee on herself, but she had to wait too long. R1 stated there isn't a problem on day shift, that shift always has plenty staff. R1 said on weekends the staff number is much lower than during the week. R1 stated she has complained about staffing in resident council meetings and has even sent a text message to V7 (Assistant Director of Nursing/Licensed Practical Nurse - ADON/LPN) on 08/22/2025 and told her that she has had her call light on for over an hour. R1 stated the staff that work here are really good, there just isn't always enough staff to take care of all the residents. On 08/29/2025 at 11:09 AM, V3 (Family Member) stated that R1 called him about 6 weeks to 2 months ago crying and upset. V3 couldn't recall the exact date, but stated R1 told him her call light had been on for 2 hours and no one was answering. V3 stated he told R1 that if she had an accident that was ok, she couldn't help that no one was answering. V3 said he told R1 if you go in the hallway and have pee on yourself then maybe they will help you. V3 stated he hated to tell R1 that, but he did not know what else to do. V3 stated that he was furious, so he called the facility and sternly told them to go take care of R1. V3 stated the nurse who answered the phone told him if you think you can do it better then you need to come here and help. V3 stated he then got on social media and found V7 (ADON/LPN) and explained to her what happened. V3 stated V7 said she would take care of the problem. V3 stated he had no issues with this until last weekend 08/23/2025 and 08/24/2025. V3 stated on 08/23/2025 around 8:00 PM, R1 called because her call light had been on since she came back from the dining room after supper. V3 stated R1 said she told the staff member pushing her that she needed to use the restroom but R1 ended up having to relieve herself and was incontinent. V3 said R1 didn't say who the staff member was. V3 stated he checked with R1 on 08/24/2025 and R1 had no complaints at that time, but R1 called V3 later that night on 08/24/2025 around 8:30 PM and told V3 that R1's call light had been on for over an hour, and no one had answered it. V3 stated that R1 is very proper and that it is degrading that the facility does not have enough help to the point R1 is having to urinate on herself. V3 stated he told R1 that he will notify the proper people and will get this handled. V3 stated on the weekends, the staffing is much lower than during the week. V3 stated if it is happening to R1 who is alert and with it, it is happening to other residents who cannot speak. On 08/29/2025 at 11:35 AM, V7 (ADON/LPN) stated she was contacted by V3 (Family Member) months ago about an issue and it was addressed. V7 stated that R1 sent her a text and told her R1's call light had been on for over an hour, and no one was answering it. V7 stated that it was between 6:00 and 7:00 PM and that time frame is very busy for the staff. V7 stated as soon as staff was available, they went in the room and took care of R1. V7 stated they try to keep a staff member on the hall during meals, but it is hard to meet all the needs after supper. V7 stated they try to schedule enough staff and sometimes if a call in occurs, it doesn't pan out. On 08/29/2025 at 11:39 AM, V2 (DON) stated when R1 was incontinent a couple months ago, she couldn't remember exactly when but she was aware of it as she was working as a CNA that night. V2 stated she went and toileted/cleaned R1, changed her clothes, and placed her in bed. V2 stated they educate the staff all the time about answering call lights promptly. V2 stated she was not aware of any issues that occurred over the weekend with R1. V2 stated call lights should be answered within 10-15 minutes. V2 stated for the weekend of 08/23/2025 and 08/24/2025, there were 3 or 4 CNA's scheduled to work. V2 stated she thinks that one called in and was not replaced. V2 stated in those situations, they try to have a CNA stay late until around 10 PM and then have a day shift person come in around 2:00 - 04:00 A.M. V2 stated they must have not found someone to come in. V2 stated that ideally, she would like to have 4 CNA's every night, but it does not matter what she thinks staffing should be. V2 stated there are two nurses on night shift. V2 stated there are 35 residents in the facility that require two staff assist. V2 stated that on evening/nights, the toughest time is from 6:00 PM to 10:00 PM. V2 stated they attempt to cover when needed but it doesn't always happen. V2 stated they are attempting to hire more staff and get them trained.On 08/29/2025 at 11:44 AM, V1 (Administrator) stated she was not made aware of the call light concerns regarding R1 on the weekend of 08/23/2025 and 08/24/2025 until now. V1 stated the call light does not have a report that can be viewed to see how long the call light was going off. V1 stated she has never been made aware of any resident complaining about call lights going off for an hour. On 08/29/2025 at 2:04 PM, V12 (CNA) stated at times I feel like we are understaffed. V12 stated it is hard to get to call lights on night shift because there are not a lot of staff working. V12 stated there are a lot of times there are only three CNA's in the building for the entire night. V12 stated lately when there are 4 scheduled and someone calls in, they are not replaced on the schedule. V12 stated she gets the bare basics done for the residents, but there are too many that require two-person assist and they have to wait for up to an hour.On 08/29/2025 at 3:21 PM, V11 (CNA) stated R1 had incontinent episodes over the weekend of 08/23/2025 - 08/24/2024. V11 stated that it is not typical for R1 to be incontinent. V11 stated we cannot get to all the residents after supper in a timely manner. V11 stated it happens more often than not. V11 stated a lot of residents have to wait when they shouldn't. V11 stated the staff try to get everyone out of the dining room, residents changed who are wet, the ones who want laid down, laid down and answer the call lights. V11 stated management is aware of the issues as the night shift staff have complained. V11 stated they are told to ask the other CNA's or the nurse for help. V11 stated that all the staff are busy including the nurses and it is hard to get the call lights answered. V11 stated the staff issues are mostly on the weekends. V11 stated she does not do as well as she could because it is impossible. V11 stated if I would have been able to get to R1 in time she would not have been incontinent. V11 stated if a resident is a two assist, they have to wait until there are two staff available and it can easily take an hour. V11 also stated that the weekend laundry staff recently quit so they have to do the laundry on night shift too.On 09/02/2025 at 2:21 PM, V15 (LPN) stated she was working and was R1's nurse the weekend of 8/23-8/24/25 when R1 had an incontinent episode. V15 stated R1 is normally continent, and she thought it was odd that this happened. V15 stated it wasn't until later in the shift, R1 told her that she was incontinent because the call light was on for over an hour. V15 stated that one nurse and one certified nurse assistant is not enough for the 30 residents that reside on R1's hall. V15 stated this last Saturday 08/30/2025 a CNA called in and the nurse on call (V7) did not find any coverage and did not come in to help. V15 stated it seems every weekend they are short staffed. V15 stated all the residents cannot receive the care they need with the current staffing they have.A facility provided census sheet documented there are 27 residents that reside on R1's hall. Of those 27 residents, V2 indicated by placing a dot beside resident names that there were 15 residents who require the assist of two staff for transfers and care, with R1 being one of those residents. V2 indicated by yellow highlight that 10 residents on that hall require the assist of one staff member for transfers and care. Facility policy titled Facility Resident Rights Policy and Procedure with no date documents under section V. Respect and dignity. Every resident has a right to be treated with respect and dignity.

Based on interview and record review, the facility failed to ensure sufficient staff were scheduled/available to provide timely care to meet residents' needs. This failure has the potential to affect all 60 residents residing in the facility. Findings Include:1. R1's admission Record documented an admission date of 4/27/25 and included diagnoses of morbid (severe) obesity due to excess calories, spinal stenosis, need for assistance with personal care, presence of right artificial hip joint, pain in right hip, presence of artificial knee joint, bilateral, essential tremor, anxiety, and muscle weakness. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. This MDS also documented under Functional Goals and Abilities R1 is dependent for toileting hygiene, shower/bathe self, upper body dressing, and putting on/taking off footwear.R1's current Care Plan included a focus area of I currently have an alteration to my ability to care for self and need assistance d/t (due to) Anxiety, Cognitive impairment, Weakness initiated on 1/31/25. Corresponding interventions include: encourage resident to participate to the fullest extent possible with each interaction, encourage resident to use bell to call for assistance, praise all efforts at self care, PT (physical therapy), OT (occupational therapy) and ST (speech therapy) evaluation and treatment. R1 also has a focus area of I am currently able to perform mobility with 2 assist, gait belt and walker initiated on 5/7/25 with corresponding interventions of: encourage (R1) to use bell to call for assistance if needed and monitor/document ability to perform ADLs (activities of daily living).On 08/29/2025 at 10:53 AM, R1 stated she sometimes has trouble getting her call light answered. R1 stated on night shift there is one certified nurse assistant (CNA) per hall. R1 stated on weekends the staff number is much lower than during the week. R1 stated she has complained about staffing in resident council meeting and even sent a text message to V7 (Assistant Director of Nursing/Licensed Practical Nurse - ADON/LPN) on 08/22/2025 telling V7 she had her call light on for over an hour. R1 stated the staff that work there are really good, there's just not enough staff to take care of all the residents.2. R2's admission Record documented an admission date of 10/13/2024 and included diagnoses of iron deficiency anemia, major depressive disorder, anemia, osteoarthritis of knee, morbid obesity, major depressive disorder, anxiety disorder, chronic pain syndrome, essential hypertension, unspecified atrial fibrillation, and unspecified systolic congestive heart failure. R2's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R2 is cognitively intact. The same MDS documented under Functional Abilities and Goals R2 is dependent for toileting hygiene and putting on/taking off footwear. The MDS also documented substantial maximum assist for shower/bathe self and lower body dressing.R2's current Care Plan included a focus area of I currently have an alteration to my ability to care for self and need assistance. The interventions listed are to encourage resident to participate to the fullest extent, encourage resident to use bell for assistance and praise all efforts.On 08/29/2025 at 11:27 AM, R2 stated that staffing on weekends is sparse. R2 stated she has to wait long periods of time on the weekends to get her call light answered. R2 stated the staff are all very helpful and can only do what they can. R2 stated that they do not have enough staff on night shift to take care of everyone.3. R3's admission Record documented an admission date of 12/11/2024 and included diagnoses of aftercare following joint replacement, pain in right knee, difficulty walking, morbid obesity, major depressive disorder, acute kidney failure, sleep apnea, essential hypertension, and chronic obstructive pulmonary disease.R3's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R3 is cognitively intact. This MDS documented under Functional Abilities and Goals R3 requires substantial/maximum assist for toileting, showering, dressing, and putting on/taking off footwear.R3's current Care Plan dated 05/22/2025 documents a focus area of I currently have an alteration in my ability to care for myself and need assistance. Interventions listed include encourage provide range of motion, praise all efforts, and therapy as ordered.On 08/29/2025 at 12:10 PM, R3 stated it takes up to an hour for call lights to be answered on weekends. R3 stated the facility does not have enough staff on nights.4. R4's admission Record documented an admission date of 11/08/2022 and included diagnoses of contracture of the left hip, major depressive disorder, atherosclerosis of native arteries, anemia, morbid obesity, essential hypertension, chronic atrial fibrillation, chronic systolic heart failure, and chronic obstructive pulmonary disease.R4's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R4 is cognitively intact. The MDS under Functional Abilities and Goals documented R4 requires substantial/maximum assist for toileting, shower/bathe self, dressing, and putting on/taking off footwear.R4's current Care Plan with a date of 10/21/2024 included a focus area of I currently have an alteration to my ability to care for self and need assistance. The interventions listed are encourage resident to participate to the fullest extent, encourage resident to use bell for assistance and praise all efforts.On 08/29/2025 at 1:42 PM, R4 stated staffing on the weekends is very slim. R4 stated that staff are running around sweating the entire shift because there are not enough staff. R4 stated that there's one CNA on each hall at nights. R4 stated there is not enough staff to cover the residents needs. R4 stated during the day it only takes 15 minutes or less for call lights to get answered but on evenings and weekends, it is 30 minutes to an hour. R4 stated at supper time, you cannot get a staff member to answer a call light. R4 stated that it is very difficult to get staff to help after supper. On 08/29/2025 at 2:04 PM, V12 (Certified Nurse Assistant/CNA) stated at times I feel like we are understaffed. V12 stated it is really hard to get to call lights on night shift because there are not a lot of staff working. V12 stated there are a lot of times there are only three CNA's in the building for the entire night. V12 stated lately when there are 4 scheduled and someone calls in, they are not replaced on the schedule. V12 stated she gets the bare basics done for the residents, but there are too many that require two-person assist and they have to wait for up to an hour.On 08/29/2025 at 2:11 PM, V2 (Director of Nursing/DON) stated for the weekend of 08/23/2025 and 08/24/2025, there were 3 or 4 CNA's scheduled to work. V2 stated she thinks that one called in and was not replaced. V2 stated in those situations, they try to have a CNA stay late until around 10 PM and then have a day shift CNA come in around 2:00 - 04:00 AM. V2 stated they must have not gotten someone to come in. V2 stated that ideally, she would like to have 4 CNA's every night, but it does not matter what she thinks staffing should be. V2 stated there are 35 residents in the facility that require two staff assist. V2 stated that on evening/nights, the toughest time is from 6:00 PM - 10:00 PM. V2 stated they attempt to cover when needed but it doesn't always happen. V2 stated they are attempting to hire more staff and get them trained.On 08/29/2025 at 3:21 PM, V11 (CNA) stated we cannot get to all the residents after supper in a timely manner. V11 stated it happens more often than not. V11 stated a lot of residents have to wait when they shouldn't. V11 stated the staff try to get everyone out of the dining room, residents changed who are wet, the ones who want laid down, laid down and answer the call lights. V11 stated management is aware of the issues as the night shift staff have complained. V11 stated they are told to ask the other CNA's or the nurse for help. V11 stated that all the staff are busy including the nurses and it is hard to get the call lights answered. V11 stated the staff issues are mostly on the weekends. V11 stated she does not do as well as she could because it is impossible. V11 stated if a resident is a two assist, they have to wait until there are two staff available and it can easily take an hour. V11 also stated that the weekend laundry staff recently quit so they have to do the laundry on night shift too. V11 stated she cannot even get her showers done when she works.On 09/02/2025 at 2:21 PM, V15 (LPN) stated that one nurse and one certified nurse assistant is not enough for the 30 residents that reside on the R1's hall. V15 stated this last Saturday 08/30/2025, a CNA called in and the nurse on call (V7, ADON/LPN) did not find any coverage and did not come in to help. V15 stated it seems every weekend they are short staffed. V15 stated all the residents cannot receive the care they need with the current staffing they have. The July 2025 Certified Nurse Assistant schedule documented on 07/04, 07/11, 07/18 and 07/19 there were only three certified nurse assistants scheduled to work.The August 2025 Certified Nurse Assistant schedule documented on 08/09, 08/15, 08/23, 08/24 there were only three certified nurse assistants scheduled to work.A facility provided census sheet documented there are 3 halls in the facility, one being East/Far East, one being West, and one being North. This document shows 60 residents reside in the facility, with V2 indicating 35 of those residents require two staff assist for care and transfers by placing a dot beside the resident names. V2 indicated by yellow highlight (without a dot) that 19 residents require the assist of one staff member for care and transfers. The East/Far East Hall denotes 27 residents reside on the hall, with 15 requiring the assist of two staff for transfers and care, and 10 requiring the assist of one staff member for transfers and care. The document shows 18 residents reside of the [NAME] Hall, with 11 requiring the assist of two staff for transfers and care and 4 requiring the assist of one staff for transfers and care. The North Hall notes 16 residents reside on the hall, with 9 residents requiring the assist of two staff for transfers and care and 5 residents requiring the assist of one staff for transfers and care. The facility's policy titled Staffing with a revision date of 02/20/2025 documented under section titled Procedure: The facility will provide sufficient staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident.A facility matrix dated 08/29/2025 documented a total of 60 residents residing at the facility.

Based on observation, interview and record review the facility failed to maintain air conditioning equipment and provide comfortable temperatures for 21 of 21 residents (R1-R21) reviewed for environment in the sample of 21. Findings Include: On 06/27/2025 at 11:30 A.M. while entering the building fans were observed in resident rooms, and lights were off in the dining room. On 06/27/2025 at 11:56 A.M. V1 (Administrator) stated that there was a recent problem with the air, but it was fixed yesterday 06/26/2025. On 06/27/2025 at 1:12 P.M. V3 (Agency Registered Nurse) stated that it is cooler in the facility. V3 stated that it was hot in the building but not unbearable. V3 stated there were fans in the hallway blowing air. V3 stated she is not aware of any residents that had heat related issues. On 06/27/2025 at 1:20 P.M. R3 stated that it has been miserable with the temperatures in the building. R3 stated she has two fans and is uncomfortable, but she was sure that everyone else is too. R3 stated that she did not complain to anyone about being hot because she figured everyone was hot. R3's MDS (Minimum Data Set), dated 03/08/2025, documents that R3 has a BIMS (Brief Interview for Mental Status) of 15, indicating R3 is cognitively intact. On 06/27/2025 at 1:23 P.M. R4 stated that it was really hot in the dining room, so they quit eating in it. R4 stated that he is still warm even though there is a fan in his room. R4 stated he had ice water and had no complaints about his care. R4 stated it has been toasty in the facility with the air braking and he is hot. R4's MDS (Minimum Data Set), dated 05/26/2025, documents that R5 has a BIMS (Brief Interview for Mental Status) of 15 indicating that R4 is cognitively intact. On 06/27/2025 at 1:25 P.M. V4 (Certified Nurse Assistant) stated it's hot in this building still. V4 stated, I am not sure if they fixed the problem or not. It is still hot. On 06/27/2025 at 1:27 P.M. a sign was observed posted on the activity calendar stating Bingo store postponed until 06/30/2025 due to temperature in the dining room. On 06/27/2025 at 1:36 P.M. [NAME] Hall thermostat temperature was reading 80 degrees. On 06/27/2025 at 1:38 P.M. North Hall thermostat temperature was reading 80 degrees. On 06/27/2025 at 1:40 P.M. V1 (Administrator) stated it was warmer in the building on Monday, 06/23/2025 than normal. V1 stated that it was just thought that it was hotter than normal outside, so she was not surprised that the building is warmer. V1 stated she monitored the temperatures but did not record anything because the temperatures were within the allotted range. V1 stated that on Tuesday, 06/24/2025, around 12:00 P.M. the east hall and the kitchen temperatures were ranging between 81 and 84 degrees. V1 stated she notified the home office at 3:30 P.M. on 06/24/2025 of the temperatures. V1 stated that the home office then reached out to a heating and air conditioning company to send them to the facility. V1 was told that the company would arrive on Wednesday, 06/25/2025 in the morning. V1 stated they did not come, and she reached out to the home office and was told they were running behind and would be there later Wednesday afternoon. V1 stated the heating and air conditioning company did not show up Wednesday. V1 was told by the home office that the company would be here first thing on Thursday. V1 stated at 3:00 P.M. on Thursday the heating and air company had still not arrived, so she decided to call someone else to come out. V1 stated at 5:00 P.M. she called a local heating and air company, and they came out Thursday 06/26/2025 to look at it. V1 stated she is not sure what was wrong with it but that it was fixed. V1 stated that when the issue first occurred, she was instructed by the home office to turn off the unit to east hall to prevent it from burning up. V1 stated the temperature in the building had been warmer than normal due to the higher temperatures outside. V1 stated they immediately put fans in the hallways to circulate air, and they offered popsicles and encouraged residents to consume extra fluids. V1 stated that no residents had any ill side effects from the heat in the building being higher than normal. V1 stated on Wednesday, the residents were encouraged to eat in their rooms due to the temperatures in the dining room. V1 stated that she checked a few resident rooms but did not document their temperatures. V1 stated that it was hotter in east hallway than in the resident rooms. V1 stated the temperature is better in the facility today than it was on Thursday but feels like it will take some time for the air to catch up since it is 95 degrees outside. On 06/27/2025 at 1:50 P.M. V2 (Director of Nursing) stated that she noticed on Monday, 06/23/2025, that it was warmer in the building than normal. V2 stated that V1 was observing the thermostats, and they were not noted to be above 81 degrees. V2 stated that they tried to get someone to come look at it, but that company was busy, so they had to wait. V2 stated they shut blinds, added fans to the hallways and tried to keep residents out of the dining room because that is where it seemed to be the warmest at. V2 stated the air was working on the far east so they placed fans to blow the air from the far east to the east hall. V2 stated that they had to completely turn off the air to the east hall. V2 stated that they offered a hydration station and passed extra ice water. V2 stated they also passed popsicles for a couple days. V2 stated that they also made activities have smaller groups so that there were no heat related issues. V2 stated that if a resident was observed to have a red face, the resident would get their temperature checked and would get offered a cool washcloth. V2 stated that any resident with a diagnosis with anything lung related was observed first. On 06/27/2025 at 2:30 P.M. a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit (F). On 06/27/2025 2:33 P.M. The following temperatures were taken: East Hall thermostat was registering 78 degrees F. Surveyor thermometer was displaying 79.1 degrees F. North Hall thermostat was registering 81 degrees F. Surveyor thermostat displaying 81.6 degrees F. [NAME] Hall thermostat was registering 80 degrees F. Surveyor's thermometer was displaying 79.9 degrees F. The lounge was 82.7 degrees F on the surveyor's thermometer. The sitting area by the nurse station was 82.4 degrees F on the surveyor's thermometer. At 2:55 P.M. room [ROOM NUMBER], 79.5 degrees F, at 2:57 P.M. room [ROOM NUMBER], 81.1 degrees F. At 2:58 P.M. room [ROOM NUMBER], 81.1 degrees F , at 2:59 P.M. room [ROOM NUMBER], 82 degrees F, at 3:01 P.M. room [ROOM NUMBER], 82 degrees F. On 07/01/2025 at 9:45 A.M. V5 (Certified Nurse Assistant) stated that when the air went down it was miserable on east hall. V5 stated the facility put fans in the hallways but it was still really hot. V5 stated that residents on east hall were complaining about the temperature of the building. V5 stated that everyone was complaining about how hot it was in here. V5 stated there were times when the air was down that she would have to go into the shower room and hose her head down with cold water because it was so hot. On 07/01/2025 at 9:54 A.M. V1 stated that the heating and air company came back out Friday evening to evaluate the units again. V1 stated the front air conditioner was noticed to be blowing warm air again and the heating and air company is here this morning working on it again. V1 stated they have diagnosed the problem as being a coil is out. V1 stated they have gone to get the part and it should be fixed when they get back. V1 stated there were no resident related issues this weekend due to the temperature of the building. On 07/01/2025 at 11:20 A.M. V6 (Registered Nurse) stated when the air was down, the facility put fans in the halls to help circulate air. V6 stated that staff passed extra ice water and would shut some lights off to help with the temperature. V6 stated that she was hot while she was working. On 07/01/2025 at 2:34 P.M. V8 (Maintenance Director) stated he can't remember when he was made aware of the air conditioner issue. V8 stated that when he was told he went out to the unit to look at it. V8 stated he wasn't sure what was wrong with it, but a company was called to come look at it. V8 stated that he was told a compositor was out and it was fixed. V8 stated that it was still warm in certain areas of the building, so they called the company to come back out. V8 stated there is now a coil out of another unit and the company is supposed to be here with the part today to fix it. Facility temperature logs document that on 06/24/2025 temperatures on east hall were at 3:00 P.M. 83 degrees F, at 4:00 P.M. 83 degrees F, at 6:00 P.M. 84 degrees F, at 8:00 P.M. 83 degrees F, and 10:00 P.M. 81 degrees F. Facility temperature logs document that on 06/25/2025 temperatures on east hall were at 7:00 A.M. 80 degrees F, at 9:00 A.M. 81 degrees F, at 11:00 A.M. 83 degrees F, at 1:00 P.M. 84 degrees F, at 3:00 P.M. 84 degrees F, at 5:00 P.M. 84 degrees F, at 7:00 P.M. 83 degrees F, and at 9:00 P.M. 82 degrees F. Facility temperature logs documents that on 06/26/2026 temperatures on the east hall were at 7:00 A.M. 81 degrees F, at 9:00 A.M. 82 degrees F, at 11:00 A.M. 84 degrees F, at 1:00 P.M. 84 degrees F, at 3:00 P.M. 84 degrees F, at 5:00 P.M. 84 degrees F, and at 7:00 P.M. 81 degrees F. Facility document titled Extreme Heat documents extreme heat events are defined as periods when the heat index is 100 degrees or higher for one or more days, or when the heat index is 95 degrees or higher for two or more consecutive days. Prolonged periods of this heat accompanied by high humidity create dangerous situation for vulnerable populations. Elderly residents and those with chronic medical conditions such as cardiopulmonary conditions, high blood pressure and residents with mental illness are at increased risk for heat exhaustion, heat stroke and heat cramps. According to historical climate data found on the website Weather Underground (https://www.wunderground.com/history/daily/us/il/), the highest temperature and humidity levels were recorded for the following dates: 06/24/2025 (Tuesday) at 2:15 PM a temperature of 94 degrees F and 42% humidity level, 6/25/2025 (Wednesday) at 2:53 PM a temperature of 94 degrees F and 49% humidity level, 6/26/25 (Thursday) at 4:53 PM a temperature of 96 degrees F and 46% humidity level, and 6/27/25 (Friday) at 12:53 PM a temperature of 96 degrees F and 41% humidity level. Based on the historical data provided from the Weather Underground website and National Weather Service Heat Index chart, the heat index for the following dates is: 6/24/25 97 degrees F, 6/25/25 97 degrees F, 6/26/25 104 degrees F, and 6/27/25 101 degrees F. The facility provided MDS (Minimum Data Set) Resident Matrix dated 06/27/2025 documented R1-R21 reside on the East Hall of the facility.

Based on interview and record review, the facility failed to ensure quarterly assessments were completed within the required time frames for nine (R13, R16, R25, R27, R47, R48, R49, R52 and R54) of nine residents reviewed for quarterly assessments in a sample of 35. The Findings Include: R13's Face Sheet documented an admitted [DATE]. R13's most recent completed and submitted quarterly Minimum Data Set (MDS) Section A documented an Assessment Reference Date (ARD) of 4/27/24. The next quarterly MDS Section A was initiated with an ARD of 7/28/24 but had not been completed or submitted as of the date of this review on 08/16/24. This indicates more than 92 days between completion of assessments and shows R13's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/28/24. R16's Face Sheet documented an admitted [DATE]. R16's most recent completed and submitted quarterly MDS Section A documented an ARD of 4/16/24. The next quarterly MDS Section A was initiated with an ARD of 7/5/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R16's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/5/24. R25's Face Sheet documented an admitted [DATE]. R25's most recent completed and submitted quarterly MDS Section A documented an ARD of 4/12/24. The next quarterly MDS Section A was initiated with an ARD of 7/1/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R25's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/1/24. R27's Face Sheet documented an admitted [DATE]. R27's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/5/24. The next quarterly MDS Section A was initiated with an ARD of 7/4/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R27's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/4/24. R47's Face Sheet documented an admitted [DATE]. R47's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/9/24. The next quarterly MDS Section A was initiated with an ARD of 7/8/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R47's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/8/24. R48's Face Sheet documented an admitted [DATE]. R48's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/9/24. The next quarterly MDS Section A was initiated with an ARD of 7/8/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R48's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/8/24. R49's Face Sheet documented an admitted [DATE]. R49's most recent completed and submitted quarterly MDS Section A has an ARD date of 4/6/24. The next quarterly MDS Section A was initiated with an ARD of 7/5/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R49's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/5/24. R52's Face Sheet documented an admitted [DATE]. R52's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/7/24. The next quarterly MDS Section A was initiated with an ARD date of 7/6/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R52's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/6/24. R54's Face Sheet documented an admitted [DATE]. R54's most recent completed and submitted quarterly MDS Section A documented an ARD date of 4/19/24. The next quarterly MDS Section A was initiated with an ARD of 7/8/24 but had not been completed or submitted as of the date of this review on 8/16/24. This indicates more than 92 days between completion of assessments and shows R54's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/8/24. On 8/15/24 at 2:00 PM, V3 (MDS Coordinator) confirmed that R13, R16, R25, R27, R47, R48, R49, R52 and R54's MDS Assessments had not been submitted timely due to V3 being pulled to the floor to cover shifts due to staff illness and call-ins. V3 stated that the MDS's were created/initiated in July, but she is now currently working on catching up on these. The Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Chapter 2 documents the following: Assessment Schedule: An OBRA (Omnibus Budget Reconciliation Act) assessment (Comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. An OBRA comprehensive assessment is due every year unless the resident is no longer in the facility. There must be no more than 366 days between comprehensive assessments . According to the Center for Medicare and Medicaid Services (CMS) Resident assessment Instrument (RAI) Version 3.0 Manual Chapter 2: Assessments for the RAI .The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) .

Based on observation, interview and record review, the facility failed to maintain aseptic technique while performing urinary catheter care and implement transmission based precautions for two (R23, R47) of two residents reviewed for infection control in a sample of 35. Findings include: 1. R23's Face Sheet documented an admitted [DATE]. R23's Face Sheet included the following diagnoses: multiple sclerosis, neuromuscular dysfunction of bladder, unspecified, dementia, unspecified, cerebral infarction due to embolism of left middle cerebral artery. R23's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R23 had severe cognitive impairment. This same MDS documents under section H0100, Appliances yes for an indwelling catheter. R23's Physician Order Sheet (POS) documented an order dated 12/24/2022 Foley Catheter Care every shift. R23's Care Plan documented a focus area of an indwelling catheter related to neurogenic bladder with interventions to monitor for evidence of catheter blockage, signs and symptoms of urinary tract infection. On 8/15/2024 at 11:05 AM, V4 (Certified Nurse Assistant/CNA) provided indwelling urinary catheter care as well as incontinence/perineal care for R23. V4 set up on a clean surface with a water basin, washcloths, and a no rinse peri-wash. There was no hand sanitizer or extra gloves set up for care. V4 washed her hands prior to the procedure, donned gloves, gowns and proceeded to remove R23's brief that contained fecal matter. Once R23's dirty brief had been removed, V4 started cleaning the perineal area without donning new gloves or completing hand hygiene. After the procedure was completed, V4 applied a new brief to R23 without donning new gloves or completing hand hygiene. V4 was not observed to complete hand hygiene or gloves changed throughout the entire perineal/incontinence care procedure. On 8/15/2024 at 11:30 AM, V4 (CNA) stated she did not change her gloves during R23's perineal care. V4 stated she had not worked the floor as a certified nurse assistant for a while. V4 stated she was nervous and had forgotten to change her gloves. On 08/15/24 at 12:25 PM, V2 (Director of Nursing/DON) stated she would expect staff to follow the facility policy and procedure and use appropriate hand hygiene with donning and doffing gloves during incontinent/perineal care. V2 stated V4 did notify her that she did not change her gloves during the foley catheter procedure because she was nervous. On 8/15/2024 at 1:07 PM, V1 (Administrator) stated she would expect staff to use appropriate hand hygiene with donning and doffing gloves during incontinent/perineal care and follow the facility policy and procedure. The facility policy titled Perineal/Incontinence (revised 9/11/2020) documents under Procedure step 7 remove soiled brief/underpad from resident by rolling the brief/underpad to contain as much fecal matter as possible. If gloves visibly soiled or you touch stool, remove gloves, complete hand hygiene and don new gloves. Step 14 remove gloves and perform hand hygiene. Step 15 Apply clean brief and reapply clothing. 2. R29's Face Sheet documented an admitted [DATE] and included the following diagnoses: Alzheimer's disease, unspecified, altered mental status, and dementia. R29's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 2, indicating R29 had severe cognitive impairment. R29's Progress Note dated 8/12/2024 documented a positive coronavirus result reported to V6 (Physician). On 8/15/2024 at 11:15 AM, R29's door was closed with an isolation droplet precaution sign and report to nurse before entering sign on R29's door. There was a bin outside R29's door with personal protective equipment (PPE) that included gowns, gloves, mask, hand sanitizer, and disinfection wipes. V6 (Physician) observed walking into R29's room with no PPE on and left R29's door open while completing his assessment. On 8/15/2024 at 11:20 AM, V6 (Physician) stated, R29 was feeling better. V6 stated, the Coronavirus (Covid) is just a cold, and he does not believe residents should be isolated for it. V6 stated it affects the mental health of dementia residents to be isolated. On 8/15/2024 at 11:30 AM, V7 (Registered Nurse/RN) stated, she had requested V6 don PPE prior to entering R29's room and V6 declined. On 8/15/2024 at 12:25 PM, V2 (Director of Nursing/DON) stated, she would expect physicians to follow the Center for Disease Control (CDC) guidelines for Covid positive residents. V2 stated, V6 had been educated on wearing appropriate PPE in Covid positive rooms. On 8/15/2024 at 1:07 PM, V1 (Administrator) stated, V6 had been educated on wearing appropriate PPE in Covid positive resident rooms. V1 stated, she would expect physicians to follow the CDC guideline for Covid. R29's Physician Order Summary dated 8/12/2024 documented isolation droplet precaution related to covid. Every shift for isolation. The facility policy titled Coronavirus Disease (revised 9/26/2023) documented under section 11.6 Visitation of Residents on quarantine/Isolation: visitors should adhere to the core principles of infection prevention and control, which includes hand hygiene, well-fitting face covering, appropriate physical distancing and PPE. The Center for Disease Control (CDC) website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#r1, (updated 3/18/2024) documents, any health care provider who enters the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on observation, interview and record review, the facility failed to provide adaptive utensils for one (R21) of one resident reviewed for assistive devices in the sample of 35. Findings include: R21's Face Sheet documented an admitted [DATE] and includes the following diagnoses encephalopathy, unspecified, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery, and dysphagia, oropharyngeal phase. R21's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. This same MDS documents under section K0100-Swallowing Disorder, C. coughing or choking during meals or when swallowing medications. R21's Physicians Orders dated 8/14/2024 documented an order for, Low Concentrated Sweets, diet, dysphagia mechanical texture, regular/thin consistency (No bread, toast, buns, pancakes, french fries, banana bread, biscuits.) R21's Care Plan dated 5/21/2024 documents nosey cups for liquids. No bread, toast, buns, pancakes, french fries, banana bread, biscuits. On 08/13/24 at 12:00 PM, during lunch in the dining room, R21 was observed sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground pulled pork with gravy, creamed corn, baked beans-no bacon, soft chopped fruit, and cornbread/margarine with two beverages served in regular cups with straws. On 8/14/2024 at 12:07 PM during lunch in the dining room, R21 was observed sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground meatballs with mushroom gravy, mashed potatoes and gravy, frosted cake and bread/margarine with two beverages served in regular cups with straws. On 8/14/2024 at 12:09 PM, R21 stated he does use a nose out cup to drink from. R21 stated, they are in his room. On 8/14/2024 at 12:10 PM, V9 stated R21 had been using cups with straws to drink from but does use his nose out cups as well. On 8/14/2024 at 12:11 PM, V10 (Certified Nurse Assistant/CNA) stated she is not sure if R21 uses nose out cups but will check with dietary. On 8/14/2024 at 12:15 PM, V11 (Dietary Manager) stated R21 does use the nose out cups but is unable to find them. V11 stated he thought they got thrown away. On 8/15/2024 at 10:11 AM, V1 (Administrator) stated V11 ordered four nose out cups yesterday for R21 and they found two in his room for him to use. R21's menu ticket dated 8/13/2024 and 8/14/2024 documented Regular diet, mechanical soft with no breads. Adaptative Equipment: Nose Out Cup. On 8/16/2024 at 2:30 PM, V1 (Administrator) stated, the facility does not have a policy regarding adaptive utensils for residents, however, she would expect staff to follow physician orders and provide adaptive utensils.

Based on observation, interview and record review, the facility failed to provide therapeutic diets as ordered for 1 (R47) of 2 residents reviewed for dietary supplements in the sample of 35. Findings Include: R47's Face Sheet documented an admitted [DATE] and included the following diagnoses of unspecified protein-calorie malnutrition, dysphagia, oropharyngeal phase. R47's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. This same MDS documents under section I Active Diagnoses, a diagnosis of I5600 Malnutrition (protein, calorie) risk of malnutrition. R47's Physician Order Summary dated 5/13/2024 documented high protein pudding. On 8/13/2024 at 12:05 PM, R47 was sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground pulled pork with gravy, creamed corn, baked beans-no bacon, soft chopped fruit, and cornbread/margarine. R47's meal tray did not include high protein pudding. On 8/14/2024 at 12:05 PM, R47 was sitting with V9 (Speech Language Pathologist/SLP) being served a regular mechanical diet of ground meatballs with mushroom gravy, mashed potatoes and gravy, soft chopped California blend vegetables, frosted cake and bread/margarine. R47's meal tray did not include high protein pudding. On 8/14/2024 at 12:10 PM, V9 stated, R47 should have a high protein pudding with lunch and supper meals. On 8/14/2024 at 12:11 PM, V10 (Certified Nurse Assistant/CNA) stated she wasn't sure if R47 was supposed to have high protein pudding, but she would check with dietary. On 8/14/2024 at 12:15 PM, V11 (Dietary Manager) stated R47 should have high protein pudding with her lunch and dinner. V11 stated it was a dietary oversite that she did not get it the last two days. On 8/16/2024 at 11:32 AM, V1 (Administrator) stated she would expect dietary staff to follow physician orders and provide nutritional supplements. R47's menu ticket dated 8/13/2024 and 8/14/2024 documented Regular diet, mechanical soft texture diet. The following is documented under the Notes section: high protein pudding at lunch and supper.

Based on interview and record review the facility failed to ensure comprehensive assessments were completed in accordance with required time frames for two (R12, R44) of two residents reviewed for comprehensive assessments and timing in the sample of 35. The Findings Include: R12's Face Sheet documented an admitted [DATE]. R12's previous Comprehensive Minimum Data Set (MDS) assessment documented an Assessment Reference Date (ARD) of 7/4/23. R12's most recent completed and submitted Quarterly MDS assessment, Section A documented an Assessment Reference Date (ARD) of 4/7/24. R12's current Comprehensive MDS assessment Section A documented it had been initiated with an ARD of 7/2/24 but documents no completion date as of the date of this review on 08/16/24. This indicates more than 92 days between quarterly completion of assessments, more than 366 days between completion of comprehensive assessments, and shows R12's comprehensive assessment had not been completed/submitted within 14 days after the ARD of 7/2/24. R44's Face Sheet documented an admitted [DATE]. R44's previous Comprehensive MDS assessment documented an ARD of 7/12/23. R44's most recent completed and submitted Quarterly MDS assessment, Section A documented an ARD of 4/7/24. R44's current Comprehensive MDS assessment Section A documented it had been initiated with an ARD of 7/6/24, but documents no completion date as of the date of this review on 08/16/24. This indicates more than 92 days between quarterly completion of assessments, more than 366 days between completion of comprehensive annual assessments, and shows R44's comprehensive assessment had not been completed/submitted within 14 days after the ARD of 7/6/24. On 8/15/24 at 2:00 PM, V3 (MDS Coordinator) confirmed that R12 and R44's MDS Assessments had not been submitted timely due to V3 being pulled to the floor to cover shifts due to staff illness and call-ins. V3 stated that the MDS's were created/initiated in July, but she is now currently working on catching up on these. The Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Chapter 2 documents the following: Assessment Schedule: An OBRA (Omnibus Budget Reconciliation Act) assessment (Comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. An OBRA comprehensive assessment is due every year unless the resident is no longer in the facility. There must be no more than 366 days between comprehensive assessments . According to the Center for Medicare and Medicaid Services (CMS) Resident assessment Instrument (RAI) Version 3.0 Manual Chapter 2: Assessments for the RAI .The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) .

Based on observation, interview and record review, the facility failed to implement progressive person centered interventions for fall prevention for 1 (R1) of 3 residents reviewed for falls in the sample of 3. This failure resulted in R1 experiencing 4 falls between 2/20/24 and 3/3/24 which required emergency room evaluation and/or treatment for injuries that included skin tears to right arm, a right orbital fracture, head lacerations, and baseball size hematoma to the head. Findings Include: R1's Admission Record documented an initial admitted to the facility as 9/22/23. R1 is documented on this same record as being [AGE] years old with diagnoses including but not limited to: Unspecified Dementia, unspecified severity, with agitation; Type 2 Diabetes Mellitus; Major Depressive Disorder; Insomnia; Muscle Weakness; and Cognitive Communication Deficit. V9 (Physician) is documented as being R1's Primary Care Physician. R1 was observed as being alert to person only during this survey. Review of R1's Progress Notes in her Electronic Health Record documented falls most recently occurred on 2/20/24, 2/23/24, 2/29/24, 3/3/24, 3/13/23, and 3/27/24. R1's Electronic Health Record included the following documentation in relation to these falls: 1. A Nursing Progress Note documented on 2/20/24 at 11:02 AM that at 6:00 AM that day, R1 was found in her room lying on the floor following an apparent fall. Resident was lying flat on her back and clearly had a laceration to her right orbital. The fall was not witnessed and resident was not able to provide any information otherthan (sic) she had fallen. Pressure was applied to the laceration until EMS (Emergency Service Personnel) arrived, resident was encouraged to stay in place The local hospital Discharge Instructions dated 2/20/24 documented the diagnosis of Blow-out fracture of orbital floor; Facial laceration. A Nursing Progress Note documented on 2/20/24 at 7:24 PM, that R1 returned to the facility from the local hospital with x-ray's to R1's right wrist and shoulder being normal, but a CT (Computed Tomography) of her head revealing a FX (fracture) to right orbital. 4 sutures are documented as being in place to right orbital laceration. R1's current Plan of Care documented a focus area of being at high risk for falls, initiated on 9/26/23. Interventions listed following this fall include: hipsters with a date initiated of 2/21/24, and Therapy to screen with a date initiated of 2/20/24. On 3/27/24 at 10:13 AM, V1 (Administrator) confirmed the accuracy of the documented interventions. 2. A Nursing Progress Note documented on 2/23/24 at 8:23 PM that R1 experienced unwitnessed fall. States hit their head. Has two skin tears 2 in. (inches) in length and 0.5 in. diameter to the right forearm. C/o (complains of) shoulder and arm pain. No visible injuries to the head V9 (Physician) is documented as being notified with orders to send to ER (emergency room ) for evaluation and treatment. The local hospital Discharge Instructions dated 2/23/24 documented the diagnosis of, Carotid artery calcification; Closed head injury; fall. Major Tests and Procedures documented as being completed on this same form include a CT of head or brain without contrast and CT of spine cervical without contrast. No findings of significance were discovered in relation to the fall. Review of R1's current Plan of Care documented no new interventions were implemented following this fall. On 3/27/24 at 10:13 AM, V1 confirmed R1's Plan of Care was reviewed, and no new interventions were implemented following this fall as she stated new interventions had just been implemented following her previous fall and not had time to show their effectiveness yet. 3. A Nursing Progress Note dated 2/29/24 at 9:38 AM documented R1, Found on the floor, yelling help. Unwitnessed fall. Resident states they hit their head trying to walk. Notable laceration to the R (right) temple. R (right) temple bleeding. Resident denies hitting any other part of body. Alert to person only. Resident follows commands, and eyes can track movement. V9 is documented as being notified with orders to send to the ER for head trauma. 911 was called for transport. This note also documents Chair next to residents bed knocked over. The local hospital ED (Emergency Department) Note - Physician dated 2/29/24, documented a chief complaint of, fell this am, 3rd fall in 1 week, opened old wounds to right eye brow. 1 3 cm (centimeter) laceration and 1 1 cm to right eye brow. History of Present Illness includes the following notation, Differential includes intercranial hemorrhage, skull fracture, laceration. CT scan obtained and independently interpreted by myself. Is negative for internal injuries Given that the wound is old and now reopened, there is no indication to close it. This will have to heal by secondary intent . R1's current Plan of Care documented a focus area of being at high risk for falls. Therapy screenings were documented as being completed on 2/27/24, with services now being provided. The plan documented a new intervention of Resident to wear soft helmet for head protection 2/29/2024. If resident takes off or refuses to wear. Staff is to chart behavior. Soft helmet use following this fall with date of initiation documented as 2/29/24. On 3/27/24 at 10:13 AM, V1 confirmed the accuracy of R1's documented interventions and confirmed the soft helmet use was to be implemented at all times, removed only for bathing. 4. A Nursing Progress Note dated 3/3/24 at 9:26 AM documented .CNA (Certified Nurse Assistant) called for help. This nurse went to resident's room. Resident was laying on her back. She was next to the sink. Her walker was turned over and laying above her head. An additional note made on 3/3/24 at 9:27 AM documented, .Resident did c/o (complain of) head pain. Nurse assessed a significant size hematoma to the parietal area on the back of the head .MD notified. NO (new order) to send to ER for eval and treat . The local hospital ED Note - Physician dated 3/3/24 documented a chief complaint of, .unwitnessed fall this am. Per report from (V2's name-Registered Nurse/ RN), patient has frequent falls and old laceration and bruising above right eye and old fx (fracture) to right wrist. Today, baseball size hematoma to right occipital area . A CT scan of R1's head is documented as being obtained, demonstrating a scalp hematoma. R1's current Plan of Care documented no new interventions implemented after this fall. The care plan documents Continue with therapy for balance and strengthening with a date initiated of 3/3/2024. In addition, therapy services are documented as being continued for balance and strengthening on the Intervention Timeline 2024 provided by V1. On 3/27/24 at 10:13 AM, V1 confirmed the accuracy of R1's documented interventions. On 3/26/24 at 1:32 PM, V2 (RN) stated that R1's normal status is confused and forgetful. V2 stated that staff are to document if R1 refused to utilize equipment such as her helmet. V2 stated she cannot recall who the CNA (Certified Nurse Assistant) was that called for help during R1's fall on 3/3/24. V2 stated that she recalled R1 was lying in front of the sink on the floor, in her room. V2 stated R1's helmet was not in place at the time of the fall. V2 stated the fall occurred in the morning and she had not yet seen R1 yet that day. V2 stated R1 had a large knot to the back part of her head. V2 stated that if R1 is refusing to comply with fall interventions, such as wearing her helmet, staff should re-approach later to offer interventions and document the refusal if that is still the case after later failed attempts. On 3/27/24 at 9:13 AM, V14 (CNA) stated she was the staff member working on 3/3/24 when she observed R1 lying on her back in front of the sink in her room. V14 stated she had heard something, and when she went to check, found R1 on the floor. V14 stated R1 didn't have her helmet on and isn't sure if it had even been implemented yet at the time of this fall. V14 stated once the helmet was implemented, it was to be worn at all times. V14 stated she doesn't know if R1 can remove the helmet herself. V14 stated R1 seems to leave the helmet on as far as she knows and has observed, at the times she's worked with R1. V14 stated at the time of R1's fall, R1 was complaining of her head hurting. V14 stated that R1 is not supposed to walk by herself but is very confused and does. R1's Electronic Health Record documented no refusal notation regarding R1's soft helmet on 3/3/24. An Orders - Administration Note dated 3/3/24 at 8:55 AM, entered by V2 (RN) stated Note Text as, Ensure frequent rounding is being done by staff and ensure soft helmet and hipsters are in place. Chart any non-compliance. Every shift for MONITORING. Resident non-compliant with soft helmet. On 3/27/24 at 11:35 AM, V16 (Director of Nursing/DON) stated that she does recognize R1's Clinical Record lacks documentation regarding any refusal of services R1 has had or different interventions the facility staff may have attempted in an effort for fall prevention. V16 stated that she would expect staff to document any refusal of care or interventions such as the helmet in her record. V16 stated that R1 was not always compliant with wearing her helmet and did have some refusals at the start of its initiation, but is doing better now. In reference to the Administration Note documented above, V16 stated she views non-compliant and refusal as having two separate meanings. V16 stated non-compliant would mean that redirection is needed to fulfill the intended task. Such as if R1 would allow her helmet to be on, but needed frequent reminders to leave it in place, or re-apply the helmet .the desired outcome could be reached with the task being re-attempted, etc. V16 stated refusal of a service would be that despite redirection and interventions, R1 would not allow the service or intervention to be provided. V16 stated there is no official program or direction in place to deal with R1 being non-compliant or refusals. V16 stated if R1 was refusing to wear her helmet, there was no alternative intervention in place to implement. V16 stated that the Administration Note (referenced above) in R1's Progress Notes stems from entries staff have made in the Medication or Treatment Administration Record (MAR/TAR) that automatically transcribe over into the progress notes then. V16 stated that she had put entries on R1's Treatment Administration Record to remind staff of interventions in place for R1's falls. V16 confirmed for example, the Administration Note made in R1's record at 8:55 AM on 3/3/24 of R1 being non-compliant with her soft helmet, does not mean R1 was refusing to wear her helmet at that time, or was even being viewed at that time, but is a general entry statement for the shift that day. V16 stated if R1's status was to change where she was actually refusing, a progress note should have been made to document that status. On 3/27/24 at 11:57 AM, V2 stated she does not recall the circumstances that triggered the entry that R1 was being non-compliant with her soft helmet on 3/3/24, as she had not seen her that morning prior to her fall. V2 stated she does not recall anything being reported to her regarding any non-compliance or refusal of services with R1 that morning. V2 stated usually what she does, is if it is reported to her that a resident is refusing a service, she will make a progress note in the record. For entries on the TAR reminding staff to ensure interventions, she makes the TAR entry at the time she is initially viewing the resident for that shift. On 3/27/24 at 10:13 AM, V1 confirmed that R1 was to wear her helmet at all times. V1 stated that in the beginning of the helmet being implemented, R1 would refuse to wear it, and she would expect those refusals to be documented. V1 acknowledged R1's record contains a lack of documentation which would have reflected more frequent refusals of wearing the helmet, should they have existed. V1 acknowledges the need for revision of a residents person centered care plan and documentation of interventions being implemented to add in addition to or replace ineffective interventions for effective fall prevention. On 3/27/24 at 9:33 AM, V13 (Nurse Practitioner) stated that she has seen R1, but mainly just for continued evaluation for therapy progress. V13 stated she believes overall, R1 did pretty well with therapy, but just has a lot of confusion which results in behaviors and contributes to her falls. V13 stated V9 is R1's primary caregiver and would be the staff who receive the day to day calls of events. V13 stated she would expect the facility to revise a resident's Plan of Care to fit the resident needs for fall prevention. On 3/27/24 at 10:53 AM, V9 confirmed he is the Primary Care Provider for R1. V9 stated that R1's mental status has recently suffered a significant decline due to her progressing dementia. V9 stated that the facility does a good job of notifying him of any changes in a resident's status. V9 stated he would expect a resident's plan of care to be revised to fit their specific person centered needs and does acknowledge that should R1 have been wearing her helmet during a fall, it could potentially lessen or negate a head injury. V9 stated that R1 has sustained a facial fracture from a fall in the past, so protecting her head is important. 5. A Nursing Progress Note dated 3/13/24 at 9:51 AM documented, R1 observed on floor in doorway by this nurse. Stated she just fell down. No injuries . R1's current Plan of Care documented a focus area of being at high risk for falls. A new intervention following this fall with an initiation date of 3/13/24 is documented as Refer resident to (name of outside acute psychiatric care hospital) for increased behaviors 3/13/2024. Another intervention listed as being initiated on 3/21/24 documents Resident often leaves walker away from her and walks without it. Remind resident that she needs to have her walker with her and someone with her when ambulating. On 3/26/24 at 12:38 PM, V1 stated that the facility received no response from (name of outside acute psychiatric care hospital) following the referral made. On 3/27/24 at 10:13 AM, V1 confirmed the accuracy of R1's documented intervention of a (name of outside acute psychiatric care hospital) behavioral service referral following her 3/13/24 fall with no contact made with them as of 3/27/24. 6. A Nursing Progress Note dated 3/27/24 at 2:20 PM documented, This nurse was outside the dining room and heard a noise, resident observed on the floor with chair turned on its side. Resident wearing soft helmet, and hipsters. CNA in the dining room witnessed event. Resident was assessed, neuro checks initiated, ROM (range of motion) performed. Resident denied any pain or injuries. No visible injuries were noted R1's Fall Risk Assess. (Assessment) dated 9/24/23, documented a score of 12, indicating she was assessed as being at high risk for falls. The Fall Reduction Policy with a revision date of June 17, 2022 documented the purpose of the policy included, .To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. To promote a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk. The same policy also documented under the section of Prevention and Treatment Guidelines, .12. The care plan should be reviewed after every fall and updated with a new intervention, when applicable.

Based on observation, interview, and record review the facility failed ensure a functioning or equivalent notification call system was available for resident use. This failure has the potential to effect all 60 residents residing in the facility. Findings Include: On 10/17/23 at 10:00 AM, V1 (Administrator) stated that the electronic call light system is not working. V1 stated after ordering new parts which failed to correct the problem, a whole new call light system has been ordered. The current plan is that they are telling residents to ring their hand bell, along with using the call light. V1 stated that the call light system will light up, but it doesn't make a sound. Residents are told to use both the call light and the bell, or just the bell. The staff then go down the hall to find who's bell it is, and if they use the call light it helps them respond quicker. The system will take a couple weeks to install once it comes in. There is not a definite date on when this will occur due to waiting on the system to be delivered. 1. On 10/19/23 at 10:35 AM, R3 was observed lying in bed, sleeping, rolled on her side, with her side of face in direct contact with the side rail. R3's call light button was observed in her reach, attached to the side rail. A bell was also observed on her bedside table, which was out of R3's reach. R3's call light was pushed, attempting to be activated, with no light illuminating in the hall, above the resident's door. Staff were observed walking by the room for 5 minutes as evidence by watching a clock, with none stopping to assist R3. On 10/19/23 at 10:58 AM, V1 confirmed that R3's call light was not functioning and the bell was out of her reach. V1 acknowledges that R3's cognition is not such that she could potentially utilize a call light consistency, but despite a resident's cognition status, a functioning call system should be available for resident use. V1 stated that she would expect staff to check on R3 more frequently to ensure her well being. V1 confirms that R3's call light was not properly functioning. 2. On 10/18/23 at 10:36 AM, R12 stated the bell call system is not always effective in providing timely assistance, especially when the door to his room is closed. R12 stated that at times he has had to wait longer than 30 minutes for staff to answer his call bell request. R12 stated that staff do apologize and express they were busy assisting other residents. R12 stated he is able to state the 30 minute response time, by evidence of watching the clock in his room. R12 stated that he uses just the bell, and not light system as it does not function properly. R12 confirms that the facility has attempted to make repairs and is awaiting installation of a new call light system. R12 was alert and oriented to person, place and time during this interview. 3. On 10/17/23 at 1:45 PM, R40 was in her room lying in bed. R40 who was alert and oriented stated call lights routinely take up to 45 minutes to be answered. R40 activated her call light, which was answered by staff 21 minutes and 29 seconds later. R40 stated some of the call light system on that hall has been inoperable for over a month. R40 stated sometimes staff do not hear the residents bells ringing so she has to go get staff herself to go help them. Grievance Logs documented the following: 9/15/23: Call lights (not) fixed. 8/18/23: Call lights. 5/19/23: Too long to answer call lights. 4/21/23: Too long for call lights. Review of the facility policy with a revision date of November 5, 2020 documents, The facility will be adequately equipped to allow resident to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet and bathing facilities. Calls for assistance shall be answered timely. The same policy goes on to state, .2. A tap bell supply/hand bell will be available to be used in the case of a communication system malfunction. In the event the primary communication system malfunctions, a tap/hand bell shall be issued to each resident to call for assistance with and shall serve as the new communication system until the primary communication system is functioning again. Review of the Resident Matrix dated 10/17/23 documents 60 residents reside in the facility.

Based on interview and record review the facility failed to provide timely staff response to call lights for five residents of five residents (R12, R40, R45, R46, R53) reviewed for call lights in the sample of 34. Findings include: 1. On 10/17/23 at 10:48 am, R45, who is alert and oriented, stated call lights take a long time, too long, but could not indicate how long. R45's Face Sheet documented an admitted [DATE] and diagnoses including Hemiplegia and Hemiparesis of the Right Dominant Side and Epilepsy. 2. On 10/18/23 at 9:45 am, R46 was alert and oriented. R46 stated call lights often take up to 40 minutes to be answered. R46's Face Sheet documented an admitted [DATE] and diagnoses including Polyneuropathy, Hypertension, Chronic Pain, and Chronic Non Pressure Ulcers of the Lower Extremities. 3. On 10/17/23 at 12:53 pm, V5 (family member of R53) was observed ambulating R53 out of the bathroom. R53 was alert but oriented only to self. V5 stated she had been trying for 45 minutes to get staff to help her take R53 to the bathroom, but, They kept saying they would but they never did, so I decided to take him myself. V5 stated she visits R53 daily from early in the morning until bedtime, and waiting 45 minutes or more for staff assistance is an ongoing problem. V5 stated because of this issue, at the end of October 2023 she plans to take R53 back home. R53's Face Sheet documented an admitted [DATE] and diagnoses including Parkinsons Disease, Hypertension, and Unspecified Dementia. 4. On 10/17/23 at 1:45 pm, R40 was in her room lying in bed. R40 who was alert and oriented stated call lights routinely take up to 45 minutes to be answered. R40 activated her call light, which was answered by staff 21 minutes and 29 seconds later. R40 stated some of the call light system on that hall has been inoperable for over a month. R40 stated sometimes staff do not hear the residents bells ringing so she has to go get staff herself to go help them. R40's Face Sheet documented an admitted [DATE] and diagnoses including Hypertension, Diabetes Type 2, Major Depressive Disorder, and Difficulty Walking. 36969 5. On 10/18/23 at 10:36 AM, R12 stated the bell call system is not always effective in providing timely assistance, especially when the door to his room is closed. R12 stated that at times he has had to wait longer than 30 minutes for staff to answer his call bell request. R12 stated that staff do apologize and express they were busy assisting other residents. R12 stated he is able to state the 30 minute response time, by evidence of watching the clock in his room. R12 stated that he uses just the hand bell, and not the electronic call light system as it does not function properly. R12 confirms that the facility has attempted to make repairs and is awaiting installation of a new call light system. R12 was alert and oriented to person, place and time during this interview. Grievance Logs documented the following: 9/15/23: Call lights (not) fixed. 8/18/23: Call lights. 5/19/23: Too long to answer call lights. 4/21/23: Too long for call lights. A Resident Call Bells Policy dated 11/5/20 stated, The facility will be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each residents bedside, toilet, and bathing facilities. Calls for assistance shall be answered timely.

Based on interview and record review, the facility failed to ensure a residents medication regimen was free from unnecessary medications for one of five residents (R33) reviewed for unnecessary medications in the sample of 34. Findings include: R33's Face Sheet documented an admitted [DATE] and diagnoses including Alzheimer's Dementia and Unspecified Psychosis. R33's Physicians Orders documented an order for Risperdal 0.25mg (milligrams) one tablet at bedtime with a start date of 9/11/23. R33's Psychopharmacological Medication Flow Sheet documented an entry dated 6/23/21,Risperdal 0.5mg give one at bedtime, and the next entry dated 9/11/23, (decrease) Risperdal to 0.25mg. at bedtime. A 9/11/23 Medication Review Request documented,Risperdal 0.5mg Can we possibly do a GDR (Gradual Dose Reduction) or place her on a different medication?, with the Physicians response,Decrease Risperdal to 0.25mg. daily. There was no documentation in R33's chart to indicate a GDR was attempted between 6/23/21 and 9/11/23. On 10/20/23 at 09:32 am, V2 (Director of Nurses) confirmed that R33 did not receive a GDR for R33's Risperdal between 6/23/21 and 9/11/23. V2 stated the interdisciplinary committee meets usually once per month to discuss resident GDRs. V2 stated residents on psychotropic medications should be reviewed for a possible GDR at least quarterly. V2 stated after the committee meets and a GDR is recommended, a GDR Review Request is sent to the prescribing MD (Medical Doctor). V2 stated they have had difficulty with getting the Review Requests back from the doctor so V2 recently submitted a Quality Assurance plan to address this issue. An Unnecessary Medications Policy dated 11/9/19 stated,The purpose of this procedure is to ensure the resident is free from unnecessary medications. An unnecessary medication is an excessive dose, for excessive duration, without adequate monitoring, (or) without adequate indications for use.

Based on record review and interview the facility failed to update the comprehensive care plan with new focus areas and interventions for 1 of 15 residents (R47) reviewed for care plans in a sample of 34. The Findings Include: R47's admission record documents an admitted [DATE]. This same document includes the following diagnosis: Alzheimer disease, anxiety, and depression. On 9/24/23 a dietary recommendation note for R47 written by V6 (Registered Dietitian) documents r/t (related to) wt (weight loss) and current intakes , rec (recommend) mighty shakes bid (twice daily). R47's current physician order sheet has an order for mighty shakes with meals twice a day with a start date of 9/25/23. On 10/19/23 at 12:30 PM, V4 (Minimum Data Set Coordinator/Care Plan Coordinator) verified that R47's weight loss and mighty shake were not on the comprehensive care plan and stated that she will speak with the Dietary Manager to see about updating the care plan to ensure all problem areas are included. The Comprehensive Care Plan Policy dated 6/25/20 states that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident 5. Care Plans are revised as changes in the resident dictate. Care Plans are reviewed at least quarterly.

Based on record review, observation and interview the facility failed to ensure that call bells are placed within reach of residents for 2 of 15 residents (R3 and R25) reviewed for call lights in a sample of 34. The Findings Include: 1. R25's admission record documents an admitted [DATE]. This record also lists medical diagnosis that include: paralytic gait, anxiety disorder, contracture of the left and right hand and hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side. R25's Quarterly Minimum Data Set, dated dated dated [DATE] documents that R25's Brief Interview for Mental Status score is a 9 indicating he has a moderate impairment of cognition. This same document in Section G indicates that R25 requires extensive assistance of two persons for: bed mobility, transfers, toilet use, persona hygiene, and dressing. On 10/17/23 at 10:30 AM, R25 was observed in bed watching television and his call bell was over on a bedside dresser not within reach. When asked how he notifies staff of his needs, R25 stated that the call lights don't work and that 'little bell' is of no use that far away. R25 stated that he will just have to yell when he needs something, and that happens frequently because they forget to move the bell close to him. 36969 2. On 10/19/23 at 10:35 AM, R3 was observed lying in bed, sleeping, rolled on her side, with the side of face in direct contact with the partial side rail. R3's call light button was observed in her reach, attached to the partial side rail. A bell was also observed on her bedside table, which was out of R3's reach. R3's call light was pushed by surveyor, attempting to be activated, with no light illuminating in the hall above the resident's door or sounding. Staff were observed walking by the room for 5 minutes as evidence by watching a clock and continuous observation, with none stopping to assist R3 away from the rail. On 10/19/23 at 10:48 AM, R3 was observed as being repositioned in bed, still sleeping, with her face off of the bed rail. R3's call light button as well as the bell were observed out of her reach. On 10/19/23 at 10:58 AM, V1 (Administrator) confirms that R3's call light was not functioning and the bell was out of her reach. V1 acknowledges that R3's cognition is not such that she could potentially utilize a call light consistently, but despite a resident's cognition status, a functioning call system should be available for resident use. V1 stated that she would expect staff to check on R3 more frequently due to her low cognition to ensure her well being. Review of R3's Minimum Data Set (MDS) dated [DATE] documented as Brief Interview for Mental Status (BIMS) score of 7, indicating she is cognitively impaired. Review of this same MDS documents in section G0110 for bed mobility that R3 requires extensive assistance of 2 plus persons physical assistance. Review of the facility policy titled, Policy & Procedure Resident Call Bells with a revised date of 11/5/20 documents, .5. If a resident is unable to utilize the communication system, it should still remain within reach of resident however staff will check resident at an increased frequency which will be based on nursing's assessment of the residents needs.

Based on observation, interview and record review the facility failed to follow the restorative plan of care when transferring one of three residents (R2) reviewed for transfer procedures in the sample of 10. This failure resulted in R2 sustaining a bruise to the inner aspect of her right arm, a bruise to her right torso and a knot to her right anterior axillary area from an improper transfer and later being sent to the emergency room and requiring outpatient surgery to evacuate an organized hematoma from the subcutaneous space of the right axillary area and repair an avulsion/laceration of the subscapularis muscle. The findings include: R2's Occurrence Report, dated 4/8/15, documents that E4, Certified Nurse Aide (CNA) noted a large swollen area which was "purple and puffy" to R2's right inner arm and reported this to E3, Registered Nurse (RN) on 4/8/15 at 5:30AM as an injury of unknown origin. R2's Nurses Notes document in part the following: On 4/8/15 at 5:30AM, a large bruise was noted to the inner aspect of R2's right arm. This bruise was 8 centimeter (cm) long and was dark purple in color with a slight blue color on the outer edge and had a faint red streak that extended up towards R2's shoulder. R2 did not show any signs of pain when being assessed and it is unknown how R2 obtained the bruise. On 4/9/15 at 2:15PM, Z4, Physician for R2, was notified of a bruise of unknown origin to R2's right upper arm. On 4/9/15 at 7:02PM, Z5, Power of Attorney (POA) for R2, is aware of the bruise discovered to R2's right upper arm. and aware of x-ray order and results. On 4/21/15 at 8:02PM, a 2.5 cm long by 1.5 cm wide lesion discovered on R2's right anterior axillary area, where bruising/hematoma area of unknown origin was previously discovered. The area ranges from purple to yellow in color with various stages of bruise healing. The tissue in the affected area has continued to be firm to touch and appears that with pressure the tissue has split open. Z5, POA for R2, is aware of this change and corresponding treatment order to keep steri strips intact. and wash with wound cleanser daily and cover with a sterile pad as needed for drainage. Nurses will monitor for signs and symptoms of infection. On 4/22/15 at 8:57AM, Z4, Physician for R2 was paged at 6:26AM due to R2's anterior axillary lesion was bleeding. Z4, Physician for R2 returned call at 7:14AM and gave orders to transport R2 to the hospital. Z5, POA for R2 was notified at 7:30AM and an ambulance was summoned via "911" dispatch at 7:41AM. The ambulance arrived at 8:05AM and departed with R2 on stretcher at 8:10AM. R2's Hospital Operative Report, dated 4/22/15, documents the surgical procedure as; 1. Right Axillary Exploration. 2. Evacuation of Right Axillary Hemotoma. experience of Traumatic Right Axillary Laceration. 4. Partial Excision/Debridement of Avulsed Segments of the Subscapularis Muscle. This same Hospital Report documents that R2 tolerated the procedure well with no apparent complications. R2's Nurses Notes of 4/22/15 at 6:16PM document in part that R2 arrived back at the facility at 4:30PM via ambulance with a 4 by 4 dressing in place and the dressing is dry, clean and intact with no drainage. On 4/30/15 at 12:40PM, Z3, Surgeon for R2, stated that he could not say what caused R2's injury but that is was a bruise that turned into a hematoma. Z3 went on to say that it is possible, in the length of time from 4/8/15 to 4/21/15, for the injury/bruise to advance as it did. Z3 said he looked at the muscle in surgery and then saw that it was torn. On 4/30/15 at 2:45PM, E8, Registered Nurse/Restorative Aide (RN/RA) stated that she does the facility's investigations of injuries of unknown origin regarding bruises and falls. E8, RN/RA went on to say that she saw R2's bruise for the first time on 4/9/15 in the early afternoon along with E2, Director of Nursing (DON), E5, Licensed Practical Nurse (LPN), and E11, Registered Nurse (RN). E8, RN/RA continued to say that R2's bruise at that time was purple and covered an area from R2's right shoulder to her right upper arm, that R2 also had a swollen area to her right axillary region and also had a purple, "linear bruise, approximately the width of a gait belt on the right side of her torso, on her ribs". E8, RN/RA went on to say that she was concerned about R2's bruises and the swollen area and started her investigation in the afternoon of 4/9/15. R2's Occurrence Report, dated 4/8/15, documents the investigative interviews regarding transfers as follows: On 4/9/15 at 3:00PM, E7, CNA stated that she had transferred R2 with 2 assist, gait belt and lifting some weight under R2's arms. On 4/9/15 at 3:10PM, E19, CNA stated the she has two assisted R2 with E6, CNA and that they are not always able to use a gait belt because R2 becomes combative during transfers so they lift under R2's arms. On 4/9/15 at 3:20PM, E20, CNA stated that she transfers R2 with 2 assist and a gait belt but that they do lift some weight under her arms. On 4/9/15 at 3:25PM, E21, CNA stated that she uses 2 assist for transfers and no gait belt and that R2 is not easy to transfer. On 4/9/15 at 3:35PM, E18, CNA stated that she uses 2 assist and no gait belt because it is hard to get on and that she lifts some weight under R2's arms. The facility's April 2015 Schedule was reviewed and the following staff were interviewed by this surveyor. These staff were caring for R2 at sometime during the three days prior to her bruise being noted: On 4/30/15 at 9:55AM, E6, CNA stated that R2 can get combative and that he transfers R2 with 1 assist and a gait belt. On 5/4/15 at 1:30PM, E7, CNA stated that if she transferred R2 by herself, she would lift R2 under her arms. E7, CNA continued to say if she and E17, CNA would transfer R2 together, then they would still lift R2 under her arms. E7, CNA went on to say that she knew she was not supposed to transfer R2 that way but it was easier because R2 was so tiny and R2 would put her feet on the floor and pivot. E7, CNA also said that R2 could get aggressive. On 5/1/15 at 4:40PM, E14, CNA stated that she would transfer R2 by putting her arms around R2's waist and pivoting her to her wheelchair. On 4/30/15 at 5:00PM, E16, CNA stated that she would transfer R2 with 2 assists and a gait belt but that R2 would get combative when staff would get her up out of bed. E16, CNA said that R2 would hit, punch and bite. On 4/30/15 at 10:20AM, E4, CNA stated that he would transfer R2 with 1 assist and a gait belt. E18 CNA, E7 CNA, E6 CNA and E19 CNA all cared for R2 at sometime during the time frame of 4/8/15 at 5:30AM, when R2's bruise was first noted, to 4/9/15 in the afternoon, when R2's transfer status was changed. All 4 of these CNAs indicated in their interviews that they were not adhering to R2's required transfer protocol. E6, E7 E19 and E16 all indicated in their interviews that R2 would become aggressive at times. R2 had behavior tracking for a target behavior of reduced episodes of being combative with staff. According to R2's April, 2015 behavior tracking for this target behavior, R2 did not have any episodes of this behavior. R2's 4/8/15 Occurrence Report documents a follow up report written by E8, RN/RA which documents in part: R2 is alert and oriented times one. R2 is often combative with care and depends on staff for all Activities of Daily Living and mobility. Staff propels her in her wheelchair. R2 is currently seeing occupational therapy for left upper extremity contracture. Root cause analysis; R2 received bruise from inappropriate transfers. Interventions: R2 is now a mechanical lift for transfers, staff is to be inserviced on proper transfer techniques, verbal warning is given for inappropriate transfers. R2's April, 2015 physician's orders [REDACTED]. R2's Restorative Care Plan, with an initiated date of 4/21/14 and a last review date of 1/22/15, documents that R2 will transfer with a gait belt and two assist by next review date of 4/22/15. This Restorative Care Plan was discontinued on 4/9/15 when R2 was changed to a mechanical lift transfer with 2 assist. R2's Minimum Data Set, dated dated [DATE], documents under Section G Functional Status, that R2's Transfer Status is Extensive Assistance with two person assist. The facility's Resident Handling Policy "Limited Lift", with a revised date of 11/22/11, states gait belt usage is mandatory for all resident handling with the exception of bed mobility and medical contraindications. The gait belt will be considered a part of the certified nursing assistant's uniform. A facility In-Service Attendance Sign In Sheet is dated 4/10/15 documenting the topic as Transfers and the content of the program as Proper Lifting of Residents. On page 2 of this same form it is written: "This is a facility wide verbal warning. If you are observed improperly transferring residents, this includes the lifts, you will be immediately written up." On 4/29/15 at 3:30PM, R2 was lying in her bed and had a light tan/yellow bruise to her right forearm, a clean, dry dressing to her right axillary region and a blue bruise approximately 2.5 centimeter by 1.5 centimeters above the dressing.

Based on record review and interview the facility failed to suspend the administration of an anticoagulant, with an elevated International Ratio (INR) of 4.12 for 1 of 5 residents (R3) reviewed for INR laboratory testing and [MEDICATION NAME] therapy in the sample 6. This failure resulted in R3 developing Hematuria and a continued elevation of the INR to 5.84 with a resulting hospital admission. Findings include: The physician's orders [REDACTED]. A laboratory report dated 09/24/13 states R3's INR was "4.12 #H (High)" with a reference range of 0.86-1.14 INR. The report also states: "INR Usual anticoagulated therapeutic range: 2.0 - 3.0" "More intensive anticoagulated therapeutic range: 2.5 - 3.5" The report has a stamp stating, "Faxed 09/24/13" and "AV to Dr (Doctor)" The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E2 (Director of Nurses) stated on 10/09/13 at 11:30AM that R3 did have an elevated INR of 4.12 on 09/24/13 and it was faxed to Z1. E2 stated E6 (Registered Nurse) works the 2PM-2AM shift and when she came to work she did not see R3's INR results and administered the [MEDICATION NAME] 6mg. (E2 stated E6 is currently not working due to a family illness.) E2 stated the lab usually calls with abnormal lab values and they did not call on R3's INR on 09/24/13. E2 stated if the lab does call with an abnormal lab value the nurse is to "pick up the phone and call the physician immediately" and "if you don't get a call from the lab, the lab is ok." E4 (Registered Nurse) stated on 10/09/13 at 1:30PM that she faxed R3's 09/24/13 INR report to the physician. E4 stated that she is sure she faxed the report before 2PM because her shift ends at 2PM. E4 stated she never cared for R3 personally, but she did get this lab off the fax machine and showed it to E3 (Registered Nurse) who was caring for him that day as she works that hall (West). E4 further stated she is not aware of what happened after she faxed the lab. E3 stated on 10/09/13 at 1:35PM that R3 did have an INR that came back "4 something" on 09/24/13 and it was faxed to the physician before 2PM. E3 stated the lab did not call the facility with the elevated INR on 09/24/13, but they do at times call the facility with abnormal lab values. E3 further stated she did not call Z1 on the "4 something" INR on 09/24/13. E3 stated she worked on 09/26/13 and a Certified Nurse Aide (CNA) reported to her that R3 had blood in his urine. E3 stated she called Z1 (physician) at that time and reported the blood in the urine and also informed Z1 that the INR had been drawn early that am as previously ordered. E3 stated orders were received to transfer R3 to the hospital. R3's physician's orders [REDACTED]. The physician's orders [REDACTED]. Z1 stated on 10/10/13 at 12:30PM that he did receive a call from E3 on 09/25/13 regarding R3 and he gave an order to hold the [MEDICATION NAME] and recheck the INR on 09/26/13. Z1 stated that R3 had an INR of 4.2 on 09/24/13 and he did not receive a call from the facility regarding these results. Z1 stated that if a facility does not call him or put a "red flag" on the lab, "I may not get it that day." Z1 further stated, "they should have a policy to call on an elevated lab such as this." "Every nurse should know with a drug like [MEDICATION NAME] that if an INR is elevated like that you don't give that medication. And, if you can't get ahold of me then you can call the on-call physician." "It should be understood by any nursing facility if a lab such as this is elevated, they should not give the drug until the physician is notified." The "Discharge Summary Observation/Short Stay Summary" dated 09/27/13 states, R3 "developed hematuria secondary to supra therapeutic INR of 5.84. His [MEDICATION NAME] was above 4 on 09/24 but no intervention was done." E2 stated on 10/10/13 at 2:00PM there was no follow up made on R3's INR results and a new policy has been put in place regarding physician notification of lab values.