Every finding on record at Ryze at Homewood

Based on observation, interview, and record review, the facility failed to have fall interventions in place for residents at risk for falls. This applies to 6 out of 8 residents (R2, R4, R5, R6, R7 and R8) reviewed for falls in a sample of 8. The findings include:1. On 8/1/26 at 10:22 am, R2, who was alert and oriented, said she fell a few months ago. R2 said her bed had been left in a high position. R2 said she does not know who left it in a high position. R2 said she fell out of bed. R2 did not have a gold star on her name plate outside of her room next to her door. R2 did not have a bolster on her bed at this time. On 8/2/26 at 2:37 pm, R2 was in bed. There was no bolster in her bed. R2 said she has never had a bolster in her bed. R2's 7/28/26 MDS (Minimum Data Set) showed her cognition is intact. R2's 5/26/26 Post Fall Assessment showed R2 was yelling for help at 4:50 am and was found on the floor with the mattress flipped on top of her. The assessment showed the action taken was assisted the resident back in bed and lowered the bed to the lowest position. R2's 7/25/26 care plan showed R2 was a high risk for falls with interventions for a bolster on bed for repositioning. 2. On 8/1/26 at 10:35 am, R4 was in her bed. There was no golden star on her name plate outside her room next to her door. R4, who was alert and oriented, said she had a fall recently while a staff was trying to transfer her. R4's 7/29/26 MDS showed R4's cognition is intact. A record review on 8/1/26 and 8/2/26 of R4's 7/21/26 care plan showed R4 was a high risk for falls but there were no interventions listed in the care plan. R4's 7/25/26 Post Fall Assessment showed R4 with a score of 19, indicating R4 is at high risk for falls. 3. On 8/1/26 at 11:14 am, R5 was in her room in her wheelchair with her bedside table in front of her with her breakfast tray on it. R5 was not wearing anything on her feet. R5 said she was blind and she was listening to the TV. There was no gold star on her name plate outside of her door. On 8/2/26 at 8:25 am, there was no gold star on R5's name plate outside of her door. R5's 6/22/26 MDS shows R5's cognition is moderately impaired. R5's 6/18/26 care plan showed R5 was at risk for falls. R5's 6/19/26 Restorative Comprehensive Assessment showed a fall risk score of 15, indicating R5's is at a high risk for falls. 4. On 8/1/26 at 11:18 am, R6 was in her room in her wheelchair. R6, who was alert and oriented, said she had a fall a few months ago. There was no gold star on R6's name plate. R6's 6/16/26 MDS showed her cognition is intact. R6's 2/8/26 Post Fall Assessment showed she was found on the floor in the bathroom. The document showed R6 felt like she was going to throw up and reached for the garbage can, lost her balance and fell. The assessment showed a score of 15. R6's 2/18/26 care plan showed R6 was a high risk for falls. 5. On 8/1/26 at 3:14 pm, R7 was observed in her room in bed. The call light string was short and hanging from the wall out of R7's reach. The floor around R7's bed had pieces of food and rolled up food wrappers. There was no gold star on R7's name plate outside of her door. R7's 6/15/26 MDS showed R7's cognition is severely impaired. R7's 3/30/26 care plan showed R7 is at a high risk for falls with interventions including, resident needs a safe environment free from spills and/or clutter and a reachable call light. 6. On 8/2/26 at 8:42 am, R8 was in the dining room eating breakfast. R8 only had athletic socks on his feet, and they were not non-skid. At 8:56 am, R8's name plate did not have a gold star on it and on R8's floor was a yellow liquid and potato chips on the floor. At 8:48 am, V11, CNA (Certified Nurse's Assistant), said she dressed R8 that morning and put the athletic socks on him and she did not put shoes on him because he did not have any shoes. On 8/3/26 at 9:07 am, R8 was in his bed and on his floor was potato chips. R8's 7/1/26 MDS showed R8's cognition is severely impaired. R8's 7/28/26 Post Fall Evaluation showed he was found on the floor in his room with the floor wet under him and his clothes were wet on him. R8's 7/12/26 care plan showed R8 is a high risk for falls with interventions including the resident needs a safe environment with a clutter free room. On 8/3/26 at 11:29 am V2, Director of Nursing/DON, said the beds should not be in a high position because it makes it a greater risk for injury if the resident falls out of bed. V2 said the gold star on the name plate is used for staff to identify and know that the resident is at a high risk for falls so the staff will provide fall interventions to prevent falls. V2 said all residents should have non-skid socks or non-skid shoes on to help ambulate and help to prevent slipping and falling. V2 said call lights should be within the residents' reach. V2 said the residents' environment should be clean, clutter free, and the floor should be dry. V2 said if not, it becomes a safety, tripping, or a fall hazard.On 8/3/26 at 10:49 am, V1 (Administrator) said the residents' beds should always be in a low position so the severity of a injury is lessened. V1 said the golden star is to alert the staff that the resident is at high risk for falls and to be aware of their interventions. V1 said all residents that are at risk for falls should have interventions in place in their care plan. V1 said all residents should have non-skid shoes or non-skid socks to provide traction to prevent falls. The facility's Fall Prevention and Management policy (revision date 5/27/2026) showed residents identified as high risk for falls will have a star icon on the door. The policy showed that after a fall incident the fall risk evaluation is completed by the nurses, score of 10 or greater indicates the resident is at high risk for falls. Residents at high risk for falls will have a star icon on the door. Care plans are to be updated with new interventions based on root cause analysis after each fall occurrence.

Based on observation, interview and record review, the facility failed to have sufficient staff to provide nursing and related services as determined by assessments, individual plan of care, number of residents, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. This failure has the potential to affect all 131 residents currently at the facility.The 1/12/26 facility census includes 73 (2nd floor) residents. 1.R1 resides on the 2nd floor. On 1/12/26 at 10:17 AM, R1 was lying atop of a LALM (Low Air Loss Mattress), however, the setting was on static (firm) mode (the setting should be on alternate mode - while lying in bed). Several large white clumps of food were observed on R1's chest. R1 affirmed he was served Grits for breakfast. R1 also affirmed he was unable to move the right upper extremity. R1's indwelling urinary catheter tubing was notably cloudy with chunks of purulent substance floating in the urine and heavy sediment. On 1/12/26 at 10:22 AM, V14, Licensed Practical Nurse, was asked if R1 has any wounds. V14 (LPN/Licensed Practical Nurse) stated, He does have wounds. R1 responded, On my legs. V14 was asked about R1's LALM settings. V14 stated, Wound Care handles the settings. I guess they base it on his (R1's) weight. V14 was asked what static mode indicates on R1's LALM. V14 responded, I'm assuming it alternates the pressure for him. V14 was asked if V14 knows when the LALM static mode should be used. V14 stated, No, I don't and failed to change R1's LALM settings to alternate mode. V14 was asked about the white clumps of food observed on R1's chest. V14 responded, I see he dropped some food on his shirt. R1 replied, I ate some grits today and it fell out the bowl. V14 made no effort to remove the food off R1's chest and/or change his shirt. V14 was asked about the appearance of R1's indwelling urinary catheter and contents in the bag. V14 responded, I see his discoloration, sediment. V14 was asked if R1's catheter bag was dated. V14 removed the bag from the bed rail, raised it above R1's bladder and replied, It's not. V14 was asked if V14 notified the doctor regarding R1's abnormal urine. V14 stated, I haven't, no I didn't call the doctor about that. V14 was asked where catheter/bag changes are documented. V14 responded, Probably under his profile in the progress notes. V14 was asked when R1's urinary catheter was placed and/or bag changed. V14 reviewed R1's EMAR (Electronic Medical Records) to no avail and affirmed he was unsure. 2.R13 resides on the 2nd floor. On 1/12/26 at 10:37 AM, R13 was wearing a black shirt which was notably covered in white debris. R13's beard and mustache were long. R13 was asked if R13 prefers to be shaved. R13 stated, I gotta (sic) get that done but the barber only comes once a month and affirmed he requires assistance with shaving. R13's nails were long and broken. R13 was asked who cuts R13's nails. R13 responded, Nobody. R13 was asked how frequent staff change R13's indwelling urinary catheter bag. R13 stated, It's supposed to be once a week. R13 was asked when R13's catheter bag was changed. R13 responded, When they decide to change it. R13's (January 2026) Medication Administration Record includes change urinary bag as needed when clinically appropriate, however, nothing is documented. At 10:47 AM, V13, Wound Care Coordinator, was asked about the appearance of R13's shirt. V13 (Wound Care Coordinator) stated, There's white specs that I see all over his shirt. 3.R11 resides on the 2nd floor. On 1/12/26 at 10:52 AM, R11's curtain was noted to be dangling from the track with 23 hooks not attached. R11 was asked about the curtain. R11 stated, The curtains are falling off. I old 'em (sic) about a week ago to fix the curtains. One of the staff pulled it and the hooks came off. 4.On 1/12/26 at 11:20 AM, the 2nd floor 700 unit shower was inspected with V21 (Health Information Manager). The beige double sinks were notably soiled with a white substance. The countertop had a spilled orange substance that appeared somewhat dry and food debris was present. V21 was asked what was on the countertop. V21 stated, It looks like soap and food. V21 was asked what was in the sinks. V21 responded, White residue. A large pile of soiled toilet paper with a brown smeared substance was observed on the floor next to the toilet. V21 was asked what was on the toiled toilet paper. V21 replied, The tissue in the corner? It looks like poop. V21 was asked if staff are supposed to monitor residents while in the shower room. V21 stated, They should, yes ma am. The ceramic tiles around the shower drain were notably broken in multiple pieces, some of which were missing, creating a safety hazard. V21 was asked about concerns with the shower tile. V21 responded, There's little broken pieces at the drain. V21 was asked why the shower head was missing in one of the showers. V21 replied, I don't know, its broken. A wet, soiled washcloth was observed dangling from the shower chair. V21 was asked about the washcloth on the shower chair. V21 stated, It looks used. A razor was also observed on the tub. V21 was asked if razors are allowed to be used by residents unsupervised. V21 responded, No. 5.R32 resides on the 2nd floor. On 1/12/26 at 11:27 AM, R32 was lying in bed (on the mattress) and the fitted sheet was at the foot of the bed. R32's modified call light was dangling from a rack and out of reach. R32 reached for the call light to no avail and was unable to reach it. On 1/12/26 at 11:36 AM, V14, Licensed Practical Nurse/LPN, was asked about the location of R32's bed sheet. V14 (LPN) stated Well, he moves a lot, so it doesn't stay on his bed. I don't know what they have to rectify that, but it continually comes off the bed. V14 subsequently left R32's room without addressing concerns with R32's sheet and/or providing the call light. 6.R79 resides on the 2nd floor. On 1/12/26 at 11:38 AM, the front of R79's incontinence brief appeared to be saturated and the lines on the front of the brief were dark blue. V14 was asked about R79's brief. V14 (LPN) untaped the brief, lowered it and stated, It looks like he's wet. I'm going to have to send somebody in here to change you, then taped the brief back on the resident and left the room. V14 was asked why R79's diaper was saturated. V14 responded The CNA (Certified Nursing Assistant) is probably in another person's room doing patient care. R79's g (gastrostomy) tube feeding (Jevity 1.5 Cal) was infusing at 50 ml (milliliters) per hour. R79's Jevity bottle was hung at 12:30am (per container), however, roughly 1300ml were still in the 1500ml container, therefore, only 200ml was infused over the past 11 hours. V14 was asked about R79's Jevity orders. V14 (Licensed Practical Nurse) stated, I'm going to have to look at that. V14 was asked if V14 hung R79's Jevity. V14 responded, No, I didn't. V14 inspected R79's Jevity container and stated, I guess they hung it at midnight, the time they have on the bottle. V14 was asked how many milliliters were left in R79's Jevity container. V14 responded, 1275 to 1250. V14 was asked how roughly 1300mls remained in R79's Jevity container if the infusion rate is set at 50ml/hour, and the container was hung 11 hours ago. V14 replied, That's a good question. 7.R56 and R69 reside on the 2nd floor. On 1/12/26 at 12:10 PM, a large brown spill was observed on the table where R56 and R69 were seated (some of which appeared dried), however, there was no food and/or drinks on the table. V10 (Housekeeping Manager) attempted to clean the table, however, had to scrub it to remove the substance because it was partially adhered to the table. A light stain (where the substance was spilled) was also noted on the table. V10 stated, It don't wanna come out (sic) while trying to remove the stain.V10 was asked what was on R56 & R69's table. V10 stated, It looked like coffee. On 1/12/26 at 12:24 PM, V17, Licensed Practical Nurse/LPN was asked about the current 2nd floor staffing. V17 (LPN) stated, We have two Nurses; one on 5/6 (500/600 units) and a Nurse on 7/8 (700/800 units) and one 4-hour Nurse, and affirmed there are 5 CNAS (Certified Nursing Assistants) on dayshift due to 800 unit currently closed. V17 was asked how many (2nd floor) residents require mechanical lift transfer. V17 responded 5 or 6. V17 was asked how many 2nd floor residents require assistance. V17 replied, Most of the residents require assist. Surveyor reviewed the 1/12/26 (500/600) dayshift daily assignment sheet, V17 affirmed one of five CNAs were crossed off, therefore, only 4 were assigned to those units. 8.On 1/12/26 at 12:37 PM, a brown smeared substance was observed on the wall, the floor, and dresser in R11's room. V19, CNA, was asked about the substance on the wall, floor, and dresser in R11's room. V19 (CNA/Certified Nursing Assistant) inspected the substance and stated, It look like poop or food or something on the wall, the floor and this dresser. 9.On 1/12/26 at 12:44 PM, V16 (CNA) served R1's lunch in the room and stated, Your lunch is here. I'm going to put it in front of you so he you can eat, then exited the room. V16 was asked if R1 can feed himself. V16 responded, Yes, he feeds himself. R1 attempted to eat carrots with a spoon without assistance and accidentally pushed them off the plate onto the tray. R1 had difficulty feeding himself due to flaccid right upper extremity and inability to use both hands. 10.On 01/12/2026 11:10AM, R29 was in her room with family members, alert and oriented, and stated she is concerned with sitting on her urine for an extended period, especially on night shift. R29 said the night staff usually comes in around 11PM, will change residents once, and then again around 4am. R29 does not think that the facility has enough staff. 11.On 1/12/2026 at 10:19AM, V33 (Registered Nurse/RN) was observed in the 100/200 unit of the facility passing medication. V33 said she is the only nurse scheduled for the 2 units, with 2 Certified nursing assistants (CNAs). Facility rosters indicate there are 25 residents on both floors. Review of daily schedule for 1/12/2026 provided by the facility showed 2 nurses on that floor, one full time and one part time that will start at 11:00AM. On 1/12/2026 at 3:10PM, surveyor asked V33 (RN) if any other nurse came in at 11:00AM on her unit and she said no, she was the only nurse on day shift for both units. V33 added she has been assigned to 25 to 28 residents in the past and that is standard for the facility. On 1/12/2026 at 3:46PM, V2 (DON) said it was only one nurse on the 100 and 200 unit; the other nurse on the schedule was a mistake because she took over from another staff in the 500 unit that went home at 11:00AM. V2 added having one nurse for 25 residents is their normal scheduling, they only have 2 nurses in the 100/200 unit when it is full and that has not happened since she started here in July of 2025. 12.On 01/12/2026 10:55AM, R78 was observed in his room, awake and alert, and stated he is doing okay. R78 added he has an issue with getting his showers; they told him that he is scheduled on Thursday and Fridays, but staff does not give it to him. R78 thinks the facility is short of staff. 13.On 01/12/2026 3:10PM, R54 was observed in her room up in wheelchair. R54 stated she has been waiting to be changed since after lunch. Staff kept on telling her to wait, they are looking for someone to help them, and they never came back. R54 said she is wet and had a bowel movement, they do this to her all the time. She sits in her waste for an extended period and that is not right. R54 has left sided weakness and is supposed to be on restorative care but stated no one is providing her with any restorative care and her left hand is painful. 14.On 01/13/2026 8:36 AM, R121 was in her room awake and alert and stated she is doing okay. R121 was observed eating breakfast and said that breakfast is okay today. R121 said she sometimes she sits in her urine and feces for hours before being changed. On night shift they have one C.N.A for both the 100 and 200 units; they are supposed to have 2 but will pull one to another unit when they are short During this survey, concerns were identified with accommodation of needs, activities of daily living care, housekeeping, restorative care, safety, medication storage/labeling, and significant weight loss due to prescribed enteral feedings not received and/or 1:1 feeding assistance not provided. On 1/14/2026 at 1:17PM, V2 (DON) said the facility only has 2 restorative aides. They used to have 3 but one left. The DON is also the restorative nurse; the facility does not have any restorative nurse currently. V2 is not sure if anyone has provided restorative care for R54. On 01/13/2026 11:15 AM, V12 (Staffing Coordinator) said she has been doing staffing for the facility since February 2025 and generally depends on the census to determine staffing. If the census is 145, she will schedule 5 nurses on day shift and evening shift and 4 nurses for 3rd shift. Certified Nurses Assistants will be 12 on morning and afternoon shifts and 9 on night shift. The staffing breakdown according to units is as follows: 100/200 units- 1 Nurse and 2 CNAs for all three shifts (Census 1/12/2026 26 residents) 300/400 units- 1 Nurse and 2 CNAs for all three shifts. (Census 1/12/2026- 32 residents). 500/600 units -2 Nurses and 3 CNAs for morning and afternoon shifts and 1 Nurse and 3 CNAs for night shift. Census 1/12/2026 (50 residents) 700 unit- 1 Nurse and 2 CNAs all three shifts, one CNA slits between the 700 unit and 600 unit. (Census on 1/12/2026 23 residents) The 800 unit is closed currently. V12 said, Census of 145 is considered a full house. I have never scheduled more than 1 nurse on the 100/200 unit. I was not aware that one CNA is pulled from that unit on night shift. If there is a call off, they should pull from the 500/600 unit with 3 CNAs. V12 stated V12 has never received any concerns regarding staffing, the facility is currently hiring, does not use any agency. Facility assessment, dated 12/2025, documented under staffing plan the total number of licensed nurses providing direct care, including wound care nurses and nursing supervisors is 20 to 25 per day. Nurse aides including restorative aides is 35 to 35 per day, other nursing personnel (MDS nurses, Wound Care Coordinator, Restorative Nurse, infection prevention Nurse) will be 4-6 per day. In addition to nursing staff, other staff needed for behavioral healthcare and services (list other positions/roles), Social workers, Activity Director/aides, Director of Customer Experience, Psychologist (s), Psychiatrist, LCSW. The facility assessments also listed the following staffing ratios: For Nurses, post-acute unit is 1:20 all sifts. Long term care units 1:25 all shifts. For CNAs, the ratio for both post-acute and long term is 1:12 all shifts. Facility schedule provided during the survey and staffing coordinator's interview indicates te facility is not scheduling enough staff to provide care to residents according to facility assessment. The staffing policy (reviewed 5/2025) states staffing is based on the IDPH (Illinois Department of Public Health) formula for determining numbers and levels of staff. Staffing is then increased based on the needs of the resident population. Staffing is supplemented as needed by outside entities

Based on observation, interview, and record review, the facility failed to ensure food items in the walk-in cooler were labeled and dated; failed to ensure sanitizing compartment sink and sanitizing bucket had the correct concentration of sanitizer to wipe food preparation surfaces; failed to ensure food carts were free of dried food spills; and failed to ensure the floor of the kitchen and dry storage room were kept clean and free of visible dirt. These failures have the potential to affect all 127 residents that receive oral foods from the facility's kitchen.Findings include:On 1/12/26, V1(Administrator) presented the facility census as 131. 4 residents receive nothing by mouth (NPO status), totaling 127 residents who eat oral foods prepared in the kitchen.On 1/12/26 between 9:35 AM and 10:00 AM during observation of the kitchen with V7(Dietary Manager) and V22(Cook), the following food items were observed in the walk-in cooler, without label or dates:Small pan of half-full barbecue sauce, small pan of half-full chocolate pudding, large pan of three-quarter full Turkey-pot pie (V7 stated that this potpie was prepared on the previous Thursday, 4 days ago). V7 added all foods should be labeled with the dates and the(V7) would do in-service to remind staff.V22, Cook, dipped quat (quaternary ammonia) test strip for more than 10 seconds into both the sanitizing sink solution and the sanitizing bucket solution and found it to be between 0-150 parts per million(ppm). V22 tested it the second and the third time but the test strips still did not change color. V22 stated the sanitizing solution should show color between 200-400ppm. The surveyor observed the quat chemical container was empty, and staff tried to replace the chemical container. V22 stated the test strip did not change because the container that dispensed the chemical was empty and now it will dispense from the full chemical container.The floor of the Dry Storage Area of the kitchen was observed with visible accumulated dust, and visible dirt; the floor of the whole kitchen showed visible dirt. V7 stated the floor of the whole kitchen is supposed to be cleaned daily.In addition, two kitchen carts were observed with dried food spills; V7 stated the carts should be cleaned daily.Facility's Dietary Policy on Compartment sink dated 1/2023 and revised on 1/2026 and On Tray Dietary Policies and Procedures state: Sanitizing solutions shall be tested by a test kit or device that accurately measures the concentration. This policy states that the quat concentration for the test strip shall be 200 to 400 PPM. On Tray Dietary policies and Procedures #10 states: Date, label and properly secure all products removed from original containers with all items labeled, stating the contents inside, the dates opened and the appropriate use by date. #11 states: Store cold food and beverages until their used by date/ expiration date.Facility's Kitchen Cleaning Schedule D3 Daily Duties states: Sweep/mop kitchen including fridge, freezer, and storage room. Clean hydration carts, juice machine, and coffee machine.

Based on observation, interview and record review, the facility failed to ensure that 2 of 3 outside dumpsters garbage disposal were covered with the lids, and failed to ensure that the floor around the dumpsters were free of spilled trash, thus creating an unsanitary environment. These failures have the potential to cause harboring of rodents which can affect all 131 residents in the facility.Findings include:On 1/12/26 at 9:15am, 2 of 3 outside dumpsters were observed to be open without lids, with trash on the floor around the dumpsters. Again on 1/12/26 at 10:20am after kitchen observation with V7(Dietary Manager), the surveyor and V7 observed the same dumpsters without covers. V7 stated that leaving dumpsters open could cause rodents to come around the building, and that he(V7) would notify the housekeeping and laundry departments. On 1/13/26 at 11:30am, V1(Administrator) stated that she(V1) would speak with the laundry and housekeeping staff regarding this.Facility's policy titled Disposal of Garbage and Refuse dated 1/2023 and revised 5/2025 states in #1: The facility will assure all garbage and refuse containers are in good condition (no leaks), and waste is properly contained in dumpsters or compactors with lids and covered. #3 states: Garbage storage areas are maintained in a sanitary condition to prevent the harborage and feeding of pests and rodents.

Based on observation, interview, and record review, the facility failed to store/transport clean clothing in a manner that prevents potential contamination. This failure has the potential to affect all 131 residents that reside within the facility.Findings include:Facility census (1/12/2026) documents 131 residents reside within the facility. On 1/5/2025 at 11:17 AM, observed a clothing rack with clean clothing hanging in the hallway. A sheet was located on top of the clothing rack that was pulled back, exposing approximately 75% of the clean clothing. Of the remaining 25% of clothing that the sheet was covering, 50% of the total surface area of the clothing was still exposed. V42 (Housekeeper) was observed passing the clean clothes from the rack and the sleeve of the shirt touched V42's clothing. V42 observed the clothing rack uncovered and stated, Sorry, I was just passing out the clothes. It should be covered; I didn't put the sheet back. V42 pulled the sheet back over the coat rack and the sheet was not long enough to cover all the clothes. 50% of the clothing was still exposed. V1 (Administrator) confirmed the observations and affirmed the sheet was not long enough to cover all the clothes. V1 told V42, The clothes have to be fully covered, that sheet isn't long enough. You need a bigger sheet or something to cover the clothes. V42 explained the clothing rack has clothes for all the units and V42 was going unit to unit to deliver them because the clothing was left over clothing that didn't get passed when the clean clothes were originally delivered.On 1/14/2025 at 3:40 PM, observed the linen cart uncovered with towels, wash clothes, sheets, blankets in the 100 unit. V12 (Staffing Coordinator) confirmed the linen cart was uncovered. V1 (Administrator) observed the linen cart and confirmed the linen cart was uncovered. V44 walked to the uncovered linen cart with another linen cart and began filling the linen cart with clean linen from the open cart. The clean linen touched V44's abdomen/chest multiple times while transferring from the uncovered cart to the new cart. V43 (Regional Nurse Consultant) observed the clothing items touch V44's clothing and V43 educated V44 that clothing cannot touch V44's own clothes, otherwise it would be considered contaminated.Record review of facility linen handling policy (1/2025) documents, .This facility promotes the control of infections through the use of Standard Precautions while handling linen. 7. Carry clean linen away from uniform to prevent contamination. 8. Clean linen is stored in a covered or closed area.

Based on observation, interview, and record review, the facility failed to ensure five residents (R5, R16, R58, R74, and R76), out of a sample of 54 residents reviewed for resident rights, were treated with dignity and respect.Findings include: Record review of facility mealtimes indicates the 300/400 dining room mealtime is 12:15 PM. 1.On 1/12/2025 at 12:45 PM, R71 was observed sitting in the 300/400 dining room watching other residents at R71's table eat. R71 was not served any lunch. All other residents in the dining room were served lunch and approximately 25% of the residents had finished eating. R71 affirmed R71 was hungry and didn't know why R71 was not served a lunch tray. V41 (Activity Aide) confirmed R71 did not receive a lunch tray, that all other residents were served/eating, and approximately 25% of the residents had already finished eating. V41 was unsure why R71 did not get lunch served to them, stating, I don't know what happened, I don't think a tray came down for (R71). Someone is looking into it and we're getting (R71) a tray. V41 affirmed R71 not getting a tray and having to watch other residents eat is a dignity concern and all residents should be served together. On 1/12/2026 at 12:50 PM, V7 (Dietary Manager) affirmed V7 was aware R71 did not get a lunch tray and the dietary staff were preparing a tray for R71. V7 stated, I don't think a meal ticket printed out for (R71). Everyone should be served lunch at the same time. V7 affirmed staff begin passing trays for lunch at 12:00 PM. 2.On 1/16/26 at 12:31 PM, R58 was observed, in the dining room, seated at a table with 4 (R5, R16, R74, and R76) other residents during lunch. Throughout the meal, R58 exhibited continuous drooling, which accumulated on the tabletop and on R58's clothing. The accumulation of R58's puddle of thick sputum on the table was approximately a 1/2 foot long and a foot wide. The drooling was clearly visible and persisted for an extended period of time. R58 appeared unaware or unable to manage the drooling independently and required staff support to maintain comfort and personal dignity. R5, R16, R74, and R76 at the table were visibly exposed to the situation, as the drooling remained on the shared dining surface during the meal. On 1/14/26 at 4:40 PM, V2 (Director of Nursing/DON) said, The situation (drooling during lunch) that was described to me was not acceptable. It's disgusting. The area was not cleaned immediately, and an odor could have been present. It's not fair to the other residents (residents sitting at the table during lunch). This should have been addressed promptly. Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure resident call lights were within reach, failed to ensure resident equipment was clean, failed to ensure equipment (in use) was in good condition, failed to ensure sheets covered the mattress while in use, failed to ensure soiled bed linens were changed, failed to ensure requested condiments were provided, and failed to ensure staff provided assistance when resident socks were wet and needed to be changed for six of 54 residents (R2, R13, R27, R32, R88, R94) in the sample. Findings include: 1.On 1/12/26 at 10:37AM, R13's wheelchair (including wheel spokes) was notably soiled with white debris and the arm rests were severely cracked (almost all the vinyl was missing). On 1/12/26 at 10:40 AM, V23 (Central Supply) was asked about the appearance of R13's wheelchair. V23 (Central Supply) stated, It's a little old. On 1/12/26 at 10:47 AM, V13 (Wound Care Coordinator) was asked if R13's wheelchair appeared clean. V13 (Wound Care Coordinator) responded, The wheels? No. V13 was asked about the appearance of R13's wheelchair arm rests. V13 replied, The vinyl or fake leather is peeling off. 2.On 1/12/26 at 11:02 AM, R2's fitted sheet was soiled with a dried spill and corn flakes. V20 (Maintenance) was asked about the appearance of R2's bed linens. V20 (Maintenance) stated, The CNA (Certified Nursing Assistant) hasn't come and change it yet; it's probably some waste food. 3.On 1/12/26 at 11:27 AM, R32 was lying in bed (on the mattress) and the fitted sheet was at the foot of the bed. R32's modified call light was dangling from a rack and out of reach. R32 was unable to reach the call light when asked. On 1/12/26 at 11:36 AM, V14 (Licensed Practical Nurse/LPN) was asked about the location of R32's bed sheet. V14 (Licensed Practical Nurse) entered the room and stated, Well, he moves a lot, so it doesn't stay on his bed. I don't know what they have to rectify that, but it continually comes off the bed. V14 left R32's room without addressing concerns with R32's sheet and/or providing the call light. 4.On 1/12/26 at 12:11 PM, R2 received two (2) hamburgers, however, condiments were not received. R2 requested ketchup and mayonnaise at this time. V21 (Health Information Manager) provided R2 with only one (1) ketchup packet. 5.R27's face sheet documents diagnoses that include but are not limited to morbid obesity, diabetes, and COPD (chronic obstructive pulmonary disease). R27's BIMS (Brief Interview for Mental Status) score, dated 12/31/25, is 13, which indicates R27 is cognitively intact. R27's care plan, dated 12/20/25, documents, ADL (Activities of Daily Living): (R27) requires assist with daily care needs, with interventions that document, in part, Assist with resident (R27) with ADLs; Call light within reach. R27's care plan, dated 12/20/25, documents, Bed mobility: has a self-care deficit in bed mobility r/t (related to) Decreased ability to position or reposition self in bed/ Turn from side to side/ Use side rails to move in bed/ Move from lying to sitting or sitting to lying position). On 1/12/26 at 10:30 AM, R27's call light was observed wrapped around R27's beside table, not within reach. R27 said, I don't know what the nurse did. I had it (call light) a certain way, but the nurse moved it and now I can't reach it. Of course I need help. On 1/12/26 at 10:55 AM, V28 (Licensed Practical Nurse/LPN) said, Oh, weird, the call light is like attached to the room light. No, she can't reach the call light; let me figure out what's going on here. 6.R88's face sheet documents diagnose that include but are not limited to dementia, cognitive impairment, and chronic kidney disease. R88's BIMS (brief interview mental status) score, dated 10/30/25, is 6 which indicates R6's cognition is severely impaired. R88's care plan, dated 7/3/25, documents, (R88) is at high risk for falls, with interventions that document, in part, Be sure the resident's (R88) call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 1/12/26 at 10:45 AM, R88's call light was observed behind R88's bed not within reach. On 1/12/26 at 10:47 AM, while in R88's room with V31 (Housekeeper), V31 said, I don't know why his call light is behind the bed. I just clean the rooms. 7.R94's face sheet documents diagnoses that include but are not limited to Alzheimer's, pain in right hip, and repeated falls. R94's BIMS (brief interview mental status) score, dated 10/30/25, is 3, which indicates R94's cognition is severely impaired. R94's care plan, dated 10/20/24, documents, The resident has an ADL (activities of daily living) deficit, with interventions that document R94 needs substantial assistance with bed mobility, dressing, personal hygiene, toilet use, transfer, and requires set up assistance with eating. On 1/12/26 at 12:16 PM, R94 was observed in the dining room with R94's right foot laying in puddle of water on the floor. R94 said, Can you get me some new socks. My feet are cold and wet. Someone said they are going to get new ones but never came back. On 1/12/2026 at 12:19 PM, V30 (Certified Nursing Assistant/CNA) said, That's water, not urine. (R94) sometimes drops the water when she's drinking. Yeah, that's a lot of water. No, not sure how long the water has been there. I'll take her to her room and change her socks. On 1/14/26 at 4:40 PM, V2 (Director of Nursing/DON) said call lights are expected to be within residents' reach at all times and answered timely. Review of facility policy titled, Call Light Response, dated 5/01/25, documents, 3. Ensure the call light is always within the resident's reach. 4. When the patient or resident is in bed or confined to a bed or chair, provide the call light within easy reach of the patient or resident. Record review of facility policy titled, Activities of Daily Living, dated 5/01/25, documents, A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. 2. A program of assistance and instructions in ADL skills is care planned and implemented. Grooming: c. Resident's facial hair should be shaved if necessary and appropriate per personal preference. Feeding: Adaptive equipment, assistance and instruction are given as required. Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care. The undated CNA job description states assist residents with dressing and ensure that dependent residents are dressed in clean clothing. Keep wheelchairs, and other resident equipment clean. Make beds and change bed linens when soiled.

Based upon observation, interview, and record review, the facility failed to ensure esident curtains were hung properly, failed to ensure dining room tables/resident rooms are cleaned timely for four (R11, R56, R69, R88) residents, failed to ensure the 700 unit shower room was clean, failed to discard soiled toilet paper, failed to replace the shower head, failed to repair broken floor tiles in the shower, and failed to ensure soiled linen was placed in the laundry for 23 residents residing on the 700 unit in a total sample of 54 reviewed for homelike environment. Findings include: The 1/12/26 census includes 23 residents residing on the 700 unit. 1.On 1/12/26 at 10:52 AM, R11's curtain was noted to be dangling from the track with 23 hooks not attached. R11 stated, The curtains are falling off. I told 'em (sic) about a week ago to fix the curtains. One of the staff pulled it and the hooks came off. 2.On 1/12/26 at 11:20 AM, the 2nd 700 unit shower was inspected with V21 (Health Information Manager). The beige double sinks were notably soiled with a white substance. The countertop had a spilled orange substance that appeared somewhat dry, and food debris was present. V21 was asked what was on the countertop. V21 stated, It looks like soap and food. V21 was asked what was in the sinks. V21 responded, White residue. A large pile of soiled toilet paper with a brown smeared substance was observed on the floor next to the toilet. V21 was asked what was on the toiled toilet paper. V21 replied, The tissue in the corner? It looks like poop. V21 was asked if staff are supposed to monitor residents while in the shower room. V21 stated, They (staff) should, yes ma am. The ceramic tiles around the shower drain were notably broken in multiple pieces, some of which were missing, creating a safety hazard. V21 was asked about concerns with the shower tile. V21 responded, There's little broken pieces at the drain. V21 was asked why the shower head was missing in one of the showers. V21 replied, I don't know, its broken. A wet, soiled washcloth was observed dangling from the shower chair. V21 was asked about the washcloth on the shower chair. V21 stated, It looks used. A razor was also observed on the tub. V21 was asked if razors are allowed to be used by residents unsupervised. V21 responded, No. 3.On 1/12/26 at 12:10 PM, a large brown spill was observed on the table where R56 and R69 were seated (some of which appeared dried), however, there was no food and/or drinks on the table. V10 (Housekeeping Manager) attempted to clean the table, however, V10 had to scrub it to remove the substance because it was partially adhered to the table. A light stain (where the substance was spilled) was also noted on the table. V10 stated, It don't wanna come out (sic) while trying to remove the stain. V10 was asked what was on R56 & R69's table. V10 stated, It looked like coffee. 4.On 1/12/26 at 12:37 PM, a brown smeared substance was observed on the wall, the floor, and dresser in R11's room. V19 (Certified Nursing Assistant) inspected the substance and stated, It looks like poop or food or something on the wall, the floor and this dresser. 5.R88 was unable to be interviewed due to altered mental status. R88's face sheet documents diagnose that include but are not limited to dementia and cognitive impairment. R88's BIMS (Brief Interview for Mental Status) score, dated 10/30/25, is 6, which indicates R88's cognition is severely impaired. On 1/12/26 at 10:45 AM, human feces were observed on the floor in R88's room, next to R88's bed. On 1/12/26 at 10:47 AM, V31 (Housekeeper) said, I haven't gotten to this room (R88's) yet. I don't know what that is. Maybe it's food or something. I don't know if it's poop. I'll clean it up though. Record review of facility job description titled, Housekeeping Aide, undated, documents, Provides a clean and sanitary environment for staff and residents using proper policies and procedures. 1. Wet mops resident rooms and bathrooms daily. The safe and homelike environment policy (reviewed 1/14/25) states in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. This includes ensuring that the resident can receive care and services safely. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Report any unresolved environmental concerns to the administrator. Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based upon observation, interview, and record review, the facility failed to ensure that ADL (Activities of Daily Living) care was provided to 10 of 54 dependent residents (R1, R2, R3, R13, R27, R29, R54, R78, R79, R121) in the sample reviewed for ADL care.Findings include: 1.R1's 8/15/24 care plan states resident has an ADL self-care performance deficit related to hemiplegia/hemiparesis. R1's 12/13/25 functional assessment affirms resident is dependent on staff for dressing. R1's 12/13/25 BIMS (Brief Interview Mental Status) determined a score of 7 (severe impairment). On 1/12/26 at 10:17 AM, several large white clumps of food were observed on R1's chest. R1 affirmed he was served Grits for breakfast. R1 also affirmed he was unable to move the right upper and lower extremities. On 1/12/26 at 10:22 AM, V14 (LPN/Licensed Practical Nurse) stated, I see he dropped some food on his shirt. R1 replied, I ate some grits today and it fell out the bowl. V14 made no effort to remove the food off R1's chest and/or change his shirt. 2.R13's 7/30/24 care plan states resident has an ADL self-care performance deficit related to intervertebral disc disorders with myelopathy, lumbar region. R13's 11/19/25 functional assessment affirms resident requires partial/moderate assistance with dressing and substantial/maximal assistance with personal hygiene. R13's 11/19/25 BIMS determined a score of 13 (cognition intact). On 1/12/26 at 10:37 AM, R13 was wearing a black shirt which was notably covered in white debris. R13's beard and mustache were long, R13 was asked if R13 prefers to be shaved. R13 stated, I gotta (sic) get that done but the barber only comes once a month and affirmed he requires assistance with shaving. R13's nails were long and broken. R13 was asked who cuts R13's nails. R13 responded, Nobody. On 1/12/26 at 10:47 AM, V13 (Wound Care Coordinator) stated, There's white specs that I see all over his shirt. 3.R2's 7/30/24 care plan states resident has an ADL self-care performance deficit related to lack of coordination. R2's 12/3/25 functional assessment affirms resident requires partial/moderate assistance for personal hygiene. R2's 12/3/25 BIMS determined a score of 14 (cognition intact) On 1/12/26 at 11:07AM, R2's fingernails were long and broken. R2 was asked about R2's fingernails. R2 stated, I pick at 'em. (sic) R2 was asked if R2 can cut his own nails. R2 responded, No, I just pick at 'em. (sic) 4.R79's 7/31/24 care plan states resident has an ADL self-care deficit related to stroke. R79's 12/8/25 functional assessment affirms resident is dependent on staff for toileting. R79's 12/8/25 BIMS determined a score of 15 (cognition intact). On 1/12/26 at 11:38 AM, the front of R79's incontinence brief appeared to be saturated and the lines on the front of the brief were dark blue (indicating the diaper was wet). V14 (Licensed Practical Nurse/LPN) untaped the brief, lowered it, and stated, It looks like he's wet. I'm going to have to send somebody in here to change you then taped the diaper back on the resident and left the room. V14 was asked why R79's diaper was saturated. V14 responded, The CNA (Certified Nursing Assistant) is probably in another person's room doing patient care. 5.R1's 12/13/25 functional assessment affirms resident requires partial/moderate assistance with eating. On 1/12/26 at 12:44 PM, V16 (CNA) served R1's lunch (in the room) and stated, Your lunch is here. I'm going to put it in front of you so he you can eat then exited the room. V16 was asked if R1 can feed himself. V16 responded, Yes, he feeds himself. R1 attempted to eat carrots with a spoon without assistance and accidentally pushed them off the plate onto the tray. R1 had difficulty feeding himself due to flaccid right upper extremity and inability to use both hands. On 1/14/26 at 12:49 PM V35 (Registered Dietician) was asked if R1 can feed himself. V35 (Registered Dietician) responded, It depends on the day. I do believe he should be a 1:1 feed though. 6.R29 is [AGE] years old, admitted [DATE], with a past medical history including chronic obstructive pulmonary disease, muscle wasting, unspecified lack of coordination, obesity class 3, type 2 diabetes, syncope, and collapse. Minimum Data Set (MS) assessment, dated 12/16/2025, indicated R29 is cognitively intact and requires partial/moderate to substantial t/maximal assistance for most Activities of daily Living (ADL) needs. Section H (bowel and bladder) of the same assessment documented R20 is frequently incontinent of bowel and bladder. Care plan initiated 12/11/2025 stated resident requires assist with daily care needs. Interventions include assist with ADL needs, keep clean and dry after each incontinent episode, etc. On 01/12/2026 11:10 AM, R29 was in a room with family members, alert and oriented, and stated she is concerned with sitting in her urine for an extended period, especially on night shift. R29 said the night staff usually comes in around 11PM, will change residents once, and then again around 4 AM. R29 said she knows how to use her call light, but no one answers the light. She does not know her shower days, and the Certified Nurse Assistants (CNAs) give millions of excuses when a resident requests a shower. R29 added she has not received a shower since last week. R29 is scheduled for showers on Tuesdays and Friday, the last documented shower for R29 is on January 6, 2026. 7.R78 is [AGE] years old, admitted on [DATE], with a medical history including other acute osteomyelitis, left ankle and foot, muscle wasting and atrophy, sepsis unspecified organism, type 2 diabetes, mixed hyperlipidemia, and peripheral vascular disease. MDS (Minimum Data Set) assessment, dated 12/18/2025, section C (cognitive) indicated R78 is cognately intact, Section GG (functional) indicated R78 requires partial/moderate assistance with ADL needs, section H bowel and bladder) documented R78 is occasionally/frequently incontinent of bowel and bladder. Care plan, revised 12/25/2025, stated R78 requires assist with daily care needs. Interventions include assist resident with ADLs, goal: staff will anticipate and meet all of resident's needs daily. Interventions: assist resident with ADLs, keep clean and dry after each incontinent episode, etc. On 01/12/2026 10:55AM, R78 was observed in his room, awake and alert, and stated he is doing okay. R78 added he has an issue with getting his showers. The facility told him he is scheduled on Thursday and Fridays, but staff does not give one to him. R78 is scheduled for showers on Tuesdays and Fridays. R78 received two showers, on 12/26/2025 and 1/6/2026, since admission, as documented in shower sheets provided by facility. 8.R54 is [AGE] years old, admitted on [DATE]. R54's face sheet listed the following medical history: metabolic encephalopathy, other lack of coordination, cognitive communication deficit, aphasia following cerebrovascular disease, systemic lupus, type 2 diabetes, and repeated falls. R54 is assessed as being cognitively intact, requires substantial/maximal assistance for toileting, dressing and personal hygiene, and dependent on staff for shower/bathing, toileting and transfers. R54 is also assessed as being frequently incontinent if bowel and bladder. Incontinence care plan, revised 12/25/2025, stated R54 requires staff assistance with toileting and toileting hygiene. Interventions include monitor toileting hygiene and assist as needed, help with toileting hygiene at routine intervals, keep skin clean, dry and moisturized, etc. On 01/12/2026 3:10PM, R54 was observed in her room, up in wheelchair. R54 stated she has been waiting to be changed since after lunch. R54 stated staff kept on telling her to wait, they are looking for someone to help them, and they never came back. R54 said she is wet and had a bowel movement. R54 stated they do this to her all the time; she sits in her waste for an extended period and that is not right. 01/12/2026 3:15PM, V33 (Registered Nurse/RN) stated the morning CNA for the resident left already, but she will find someone to help the resident. 9.R121 is [AGE] years old, admitted on [DATE], with a medical history including: chronic obstructive pulmonary disease, with acute exacerbation, morbid (severe) obesity due to excess calories, hyperlipidemia, major depressive disorder, and blindness one eye. MDS assessment, dated 1/6/2026, indicated R121 is cognitively intact and dependent on staff for most ADL care needs. Care plan, revised 10/23/2024, stated R121 has functional urinary and bowel incontinence related to impaired mobility, interventions include check for incontinent episode regularly throughout the shifts, provide incontinent care after each incontinent episode, report any signs of skin breakdown, etc. On 01/13/2026 8:36 AM, R121 was in her room awake and alert, and stated she is doing okay. R121 was observed eating breakfast and said breakfast is okay today. R121 said she sometimes sits in her urine and feces for hours before being changed. On night shift they have one CNA (Certified Nursing Assistant) for both the 100 and 200 units. They are supposed to have 2 but will pull one to another unit when they are short. R121 said she is very upset about that; no one should sit in their waste waiting to be changed for hours. On 1/13/2025 at 2:45PM, V2 (DON) said showers are scheduled two times a week are supposed to be provided as scheduled. Staff are supposed to document if a shower or bed bath is provided on the shower sheet. 10.On 1/12/26 at 10:30 AM, R27 was observed with visible facial hair along R27's chin area. The hair appeared as a small cluster of dark, coarse strands extending a few millimeters in length, noticeable at conversational distance. R27 said, You think I haven't asked to get rid of these hairs on my face? I even told the nurse the other day just get me the pink bucket thingy and a razor, and I'll try to do it (shave). As you can see, I still haven't gotten these hairs removed. On 1/13/26 at 8:35 AM, V3 (Assistant director of Nursing/ADON) and V33 (Registered Nurse/RN), V3 said, (R27) we'll get you shaved and cleaned up after you receive your meds if you'd like. R27 replied, I've been asking for a razor for my face, even asked for that pink thing to do it myself. 11.R3's face sheet documents an admission date of 9/08/2025, and diagnoses that include but are not limited to dysphagia, chronic atrial fibrillation, constipation, hypertension, and chronic pulmonary artery disease. R3's BIMS (Brief Interview for Mental Status) score, dated 12/15/2025, is 3, which indicates R3's cognition is severely impaired. R3 unable to be interviewed due to altered mental status. R3's care plan, dated 9/08/25, documents, Nutritional Status at risk for weight loss due to mech (mechanical) altered diet, dysphagia, decreased po (by mouth) intakes, skin alterations, dementia, current sig (significant) weight loss. R3's care plan does not identify that R3's weight loss was unavoidable. R3's care plan, dated 9/12/25, documents, (R3) has been observed experiencing the following depressive symptoms (Little interest in once pleasurable things, Tired, fluctuation in sleep patterns, little to no appetite). R3's active physician order, order date 12/04/25; end date indefinite, documents, 1:1 assistance while eating or drinking with meals. On 1/12/2026 at 12:23 PM, R3 was observed receiving her lunch tray. From 12:23 PM to 12:47 PM, there was no staff member observed providing one-to-one feeding assistance to R3. Staff were observed assisting other residents in the dining room; however, no staff member was observed assisting R3 to provide continuous feeding assistance as ordered. R3 did not receive prompts, physical assistance, or supervision consistent with one-to-one feeding during the observation period. No staff member returned to provide the ordered assistance prior to the end of the observation. On 1/12/2026 at 12:47 PM, V30 (Certified Nursing Assistant/CNA) said, (R3) does not require 1:1 feeding. No, she eats fine, just like the rest of us. On 1/13/26 at 12:26 PM, V35 (Registered Dietician) said R3 is a 1:1 feed. On 1/14/26 at 4:40 PM, V2 (Director of Nursing/DON) said staff are expected to follow physician orders and care plans. V2 affirmed if it's not charted, it's not done. R3 is a 1:1 feed and that is provided by the wound care tech. V2 sated V2 was unaware R3 did not have a 1:1 during lunch on Monday (1/12/26) and V2 stated V2 would find out what happened. The undated CNA job description states assist residents with dressing and ensure that dependent residents are dressed in clean clothing. Keep resident's finger and toenails clean and trimmed. Activities of Daily Living policy, revised 5/1/2025, stated in general: a program of activities of daily living is provided to prevent disability and return or maintain residents at their level of functioning based on their diagnosis. Guideline: 1 The ability of each resident to meet the demands of daily living is determined by a licensed nurse.2. A program of assistance and instructions in ADL skills is care planned and implemented. Under procedure (f): Showers and baths are scheduled, and assistance is provided when required. Incontinence care policy, revised 05/2025, states incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown Record review of facility policy titled, Baseline Care Plan, dated 1/2023, documents, To provide the staff with guidance on completion of comprehensive person-centered care baseline care planning. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will include at a minimum the following necessary information to properly care for a resident: Supervision needs, activities of daily living needs, dietary orders. Record review of facility policy titled, Activities of Daily Living, dated 5/01/25, documents, A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. Grooming: c. Resident's facial hair should be shaved if necessary and appropriate per personal preference. Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure medications were not left at bedside and failed to date opened multidose medications for four of 54 residents (R27, R112, R122, R127) in the sample.Findings include: 1.R122's [DATE] BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On [DATE] at 11:42 AM, an Albuterol Sulfate inhaler was observed on R122's bedside table. R122 was asked why R122's inhaler was on the table. R122 stated. I keep it in case I have to use it. R122's Physician Orders as of [DATE] documents Albuterol Sulfate Inhalation Aerosol Solution was prescribed on [DATE], however, orders to keep medication at bedside was excluded. 2.R27's face sheet documents diagnose that include but are not limited to diabetes and dysphagia. R27's physician order, ordered date [DATE], documents Albuterol Sulfate: 2 puff inhale orally every 6 hours as needed for SOB. On [DATE] at 10:30am, R27's Albuterol Sulfate inhaler was in R27's bedside table. R27 said, That's my inhaler. I need it because I get short of breath. On [DATE] at 10:55 AM, V28 (Licensed Practical Nurse/LPN) said, I administered it to her (R27) it earlier. No, (R27) does not self-administer the inhaler. Let me put this back in the med cart. 3.On [DATE] at 12:46 PM, with V33 (Registered Nurse/RN), during observation of medication storage, the following was observed in the medication cart for units 300 and 400: R27's albuterol sulfate inhaler opened with no open date labeled. R112's Symbicort inhaler opened with no open date labeledR127's albuterol sulfate inhaler opened with no open date labeled. R112's face sheet documents diagnoses that include but are not limited to COPD (chronic obstructive pulmonary disease) and tobacco use. R112's physician order, ordered date [DATE], documents, Symbicort: inhale orally every 12 hours for COPD. R127's face sheet documents diagnosis that include but are not limited to COPD (chronic obstructive pulmonary disease). R127's physician order, ordered date [DATE], documents Albuterol Sulfate: 1 puff inhale orally every 6 hours as needed for SOB (shortness of breath). On [DATE] at 12:46 PM, V33 (Registered Nurse/RN) said, Oh no. I'll have to throw these out and order new ones. There should be a date on the inhalers once they are opened because they expire before the date that is on the inhaler. The medication might not work. On [DATE] at 4:40 PM, V2 (Director of Nursing/DON) said multi-dose vials are labeled with an open date to prevent using expired products. Record review of facility policy titled, Medication Storage In The Facility, dated 5/2025, documents, Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 18. Facility staff will ensure that the multi-dose vial is stored following the manufacturer's suggested storage conditions. Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure the multi-use vial of blood glucose test strips was labeled with the date opened and remained closed when not in use. These failures have the potential to affect six residents (R5, R27, R74, R91, R123, and R127) who receive blood glucose monitoring tests residing on units 300 and 400, reviewed for laboratory storage in the sample of 54 residents.Findings include:Facility provided document titled, 300/400 Unit Accu-Check's, undated, documents R5, R27, R74, R91, R123, and R127 receiving blood glucose testing on Units 300 and 400.On [DATE] at 12:46 PM, V33 (Registered Nurse/RN), an opened vial of the multi blood glucose strips with no open date was observed, with top of bottle open, in the medication cart for Units 300 and 400. V33 said, This cart is for all the residents on unit 300 and unit 400. I didn't know that the strips expire at an earlier date once the bottle is opened. If expired strips are used the results might be wrong. I'll throw this one out and get another one.On [DATE] at 4:40 PM, V2 (Director of Nursing/DON) said multi-dose vials are labeled with an open date to prevent using expired products.Record review of manufacturing manual inside the container of multi blood glucose test strips titled, (Name of Brand) Blood Glucose Test Strips, revision date of 7/22, documents, Storage and Handling: 1. Always close the vial tightly after removing a test strip. This avoids moisture and direct sunlight. 5. Use within 6 months after opening.Record review of facility policy titled, Medication Storage In The Facility, dated 5/2025, documents, 18. Facility staff will ensure that the multi-dose vial is stored following the manufacturer's suggested storage conditions.Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure cold foods were stored properly and failed to ensure food was maintained within the required temperature range to prevent food borne illness. These failures have the potential to affect 73 (2nd floor) residents. Findings include:The 1/12/26 facility census includes 73 (2nd floor) residents.On 1/12/26 at 11:50 AM, lunch was delivered to the 2nd floor dining room via steam table, however, the substitute meal (turkey/cheese sandwich) was placed directly on the table and not contained or refrigerated. On 1/12/26 at 12:01 PM, V22 (Cook) placed a turkey/cheese sandwich on R73's tray. A temperature of that sandwich was requested. V7 (Dietary Manager) obtained the temperature of R73's sandwich and stated, It's 70.3. V7 was asked at what temperature should cold foods be maintained. V7 responded, Its' supposed to be 41 (Fahrenheit degrees). V7 was asked if turkey/cheese sandwiches should be placed directly on a table. V7 replied, They should be on a tray with ice, the deli sandwich. The dietary policy (reviewed 1/2026) states it is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. Place cold menu items such as ham salad or egg salad over an ice bath in a pan. Food temperatures will be verified using a thermometer.

Based on observation, interview and record review, the facility failed to ensure corridors have firmly secured handrails. This failure has the potential to affect all 32 residents that reside on the 300 and 400 units. Findings include: Facility census documents 12 residents reside on the 300 unit, and 20 residents reside on the 400 unit. On 1/12/2026 at 10:56 AM, observed the handrails loose (unsecured) and able to shift approximately 2 inches up or down outside room [ROOM NUMBER], 310, 311, and 312. The handrail outside room [ROOM NUMBER] was able to shift approximately 4 inches up or down, and all screws were visible loose coming out of the brackets. When light pulling pressure was applied to the handrail, the handrail began to disconnect from the wall. V8 (Maintenance Director) observed the handrails and confirmed the observations. V8 affirmed handrails should be tightly secured to the walls. V8 stated residents use the handrails for balance, safety, and to propel themselves down the hallway when in a wheelchair. On 1/14/2026 at 3:17 PM, observed the handrails loose (unsecured) outside room [ROOM NUMBER] across from the nurse's station, the rails by room [ROOM NUMBER]/412, 409/410, 407/408, between room [ROOM NUMBER] and the janitor closet. The handrails were also not secured between 405/406 and a hole approximately 5 inches tall by 3 inches wide was observed where the bracket to the handrail is secured to the wall. Additionally, screws could be seen approximately 1 inch from the wall that attached the bracket to the wall. V1 (Administrator) and V8 observed the handrails and confirmed the observations. V1 asked if V8 checked all the handrails after V8 was aware the handrails in the 300 were loose, and V8 replied V8 only checked and fixed the 300 unit handrails. Record review of the facility preventative maintenance policy (5/2025) does not document inspections of the facility's handrails are to be completed as part of the preventative maintenance in the facility.

Based on observation, interview, and record review, the facility failed to ensure the LALM (Low Air Loss Mattress) was on the correct setting while in use and failed to ensure all nursing staff were aware of required LALM settings for one of 54 residents (R1) in the sample. Findings include:R1's diagnoses include hemiplegia and hemiparesis.R1's 8/27/24 care plan states resident has actual impairment to skin integrity at right and left leg due to venous ulcers, intervention: therapeutic mattress in bed.On 1/12/26 at 10:17 AM, R1 was lying on top of a LALM alone in the room, however, the LALM was on static mode (firm setting). On 1/12/26 at 10:22 AM, V14 (Licensed Practical Nurse/LPN) was asked if R1 has any wounds. V14 (LPN) stated, He does have wounds. R1 responded, On my legs. V14 was asked about R1's LALM settings. V14 stated, Wound Care handles the settings. I guess they base it on his weight. V14 was asked what static mode indicates on R1's LALM. V14 responded, I'm assuming it alternates the pressure for him. V14 was asked if V14 knows when the LALM static mode should be used. V14 stated, No, I don't. V14 failed to change R1's LALM settings to alternate mode.On 1/12/26 at 10:45 AM, V14 (Wound Care Coordinator) was asked hat the LALM static mode indicates. V13 (Wound Care Coordinator) replied, The air flow is not there. V13 was asked why R1's LALM was on static mode while lying in bed. V13 stated, It's not supposed to be on static. On 1/14/26 at 10:08 AM, V13 reviewed R1's risk for skin breakdown assessments and stated, Based on the (12/29/25) score he's high risk. V13 was asked why R1 was provided a LALM. V13 responded, Cause (sic) he has history of pressure and because of his risk assessment. He does not have any wounds as of now. The skin care prevention policy (reviewed 6/2025) states all residents will receive appropriate care to decrease the risk of skin breakdown. For residents who are bed or chair bound, a chair cushion and pressure reducing mattress is needed. The (undated) LALM operation manual states press ON to set the air mattress to static mode or OFF to set to alternating pressure mode. NOTE! In static mode, the mattress provides a firm surface.

Based on observation, interview, and record review, the facility failed to assess the restorative needs and failed to provide restorative services for residents with mild hand contractures to prevent further decline. These failures affected two residents (R6 and R12) of three residents, reviewed for restorative care, in a total sample of 54 residents.Findings include:1.R6's Face sheet shows R6 was admitted to the facility on [DATE], with diagnoses which include but are not limited to Cerebral Infarction, Hemiplegia, and Hemiparesis following Cerebral Infarction affecting Right Dominant Side.Physician Order Sheet, dated 1/13/26, states: Patient should wear right hand comfy splint at all times for contracture management; Right hand Comfy splint should be removed for skin check and hygiene.Occupational therapy evaluation and plan of treatment, dated 1/13/26, under Assessment Summary, states: Continue use of right-hand comfy splint and Restorative Nursing Program for PROM.Care Plan, dated 1/13/26, states: (R6) requires the use of splint related to Cerebral Infarction, Hemiplegia and Hemiparesis. Goal states Patient should wear right comfy splint at all times for contracture management.2.R12's.Face sheet shows R12 was admitted to the facility on [DATE] with diagnoses which include but are not limited to Cerebral Infarction, Multiple Sclerosis, and Dementia.Physician Order Sheet, dated 1/13/26, states: Patient should wear right hand comfy splint at all times for contracture management; Right hand Comfy splint should be removed for skin check and hygiene.Occupational therapy evaluation and plan of treatment, dated 1/13/26, under Assessment Summary, states: Continue use of right-hand comfy splint and Restorative Nursing Program for PROM.Restorative Care Plan, dated 9/9/24 and revised 1/12/26, states: (R12) requires the use of splint related to Cerebral Infarction, Hemiplegia and Hemiparesis. Goal states Patient should wear bilateral palm guard at all times for contracture management.On 1/12/26 between 10:55 AM and 11:15 AM, R6 was observed in the room with right hand fingers slightly contracted and, in a fist, but without any device. R12 was observed in her room with right hand in a fist, without any device to prevent further contractures.Again on 1/12/26 at 12:20 PM, both residents' hands were still in the same condition.On 1/12/26 at 12:25 PM, V2 (Director of Nursing/Restorative Nurse) stated, (V24, Restorative Aide) is supposed to apply splints and do other restorative work today.On 1/12/26 at 1:20 PM, V24 (Restorative Aide) stated Actually, today is my day-off but I came in around 10 AM to help because someone called off. When I got here, I did the fall prevention first, and then started to help with feeding, and changing people. I did not have time to put splints on or do range of motion.On 1/12/26 at 2:30 PM, V34(Director of Therapy) stated, (R12) should have a palm protector on, maybe they left it in the drawer, or they forgot. For (R6), I will ask the OT (Occupational Therapist) to assess her and put in an order. Usually, the nurses or restorative nurse/aide or anyone, will let therapy know which residents need assessment, and therapy will do an assessment. Facility's Restorative Nursing Program Policy, dated 2/2025, states in #1: Each resident will be screened for restorative programs by the restorative nurse upon admission, quarterly, and with any significant change in function.Facility's document Restorative Nurse Job Description states: #8 - Performs rehabilitation assessments upon all new admissions, quarterly, and as needed, for existing residents throughout the facility.Facility's document Restorative Aide Job Description states: Assists with implementation of nursing restorative interventions as directed by the restorative nurse including but not limited to range of motion .splints, etc.

Based on observation, interview, and record review, the facility failed to implement fall prevention interventions and failed to provide supervision to one of 54 residents (R140); failed to ensure the 300 unit emergency exit door (egress) was able to be opened; and failed to ensure the 300 unit emergency exit door alarmed when opened affecting twelve 300 unit residents. Findings include: 1.R140 was [AGE] years old admitted to the facility on [DATE], with diagnoses which include but not limited to dementia, metabolic encephalopathy, adult failure to thrive, muscle wasting/atrophy, lack of coordination, and repeated falls. R140 was transferred to the hospital on 9/23/25 post fall(s) and did not return to the facility. R140's (8/28/25) admission evaluation includes a fall risk score of 21 (high risk). R140's (9/8/25) BIMS (Brief Interview Mental Status) determined a score of 7 (severe impairment). R140's (9/8/25) functional assessment affirms resident required substantial/maximal assistance with chair/bed to chair transfer. Walking was not attempted. R140's (8/29/25) care plan includes but not limited to; resident is at high risk for falls, interventions: move resident to room with optimal visual access from the nurse's station. Staff to assist as needed. R140's (9/23/25) progress notes document, 5:24 PM, the resident was observed on the floor on the right side of the bed in a prone position. The resident was assisted off the floor and assessment done. Resident has a raised area to the left forehead. Safety precaution is maintained. (Ambulance) notified of resident condition eta (estimated time of arrival) 45 minutes. 5:54pm (30 minutes later), The resident was in bed and rolled out. The resident is unable to recall what happened related to cognitive state. LOC (Level of Consciousness) remains the same alert x1 with confusion. Raised area noted to the left side of the forehead, no bleeding or bruising noted. The resident was assisted off the floor by staff and placed in the bed. Family notified. MD (Medical Doctor) made aware received new order to send to ER (Emergency Room) for evaluation. 6:31pm, (Ambulance) arrived resident transferred to hospital. (9/24/25) The resident was admitted to hospital, diagnoses: systemic Inflammatory Response Syndrome, dehydration, elevated liver enzymes, fall and contusion (bruise) of the head. R140's (9/23/25) 5:30pm, incident report affirms staff entered the room and the resident was observed laying on the floor. Resident unable to give description [Witnesses are excluded]. Predisposing factors: confused, impaired memory, and antipsychotic use. R140's (9/23/25) EMS (Emergency Medical Service) Patient Care Report states ambulance was dispatched to the scene for a [AGE] year-old who suffered from an (unwitnessed) fall. Patient does take 5 milligrams of Eliquis (blood thinner). Upon arrival, patient presented with a 3-inch hematoma on the left forehead. R140's (9/23/25) History & Physical states, patient is a [AGE] year-old female who presented to the ED (Emergency Department) status/post fall at nursing home. Patient is unable to provide any history, moans when touched but non-verbal. Head CT (Computed Tomography) with 1. moderate left frontal scalp hematoma without underlying calvarial fracture. 2. Asymmetric trace thickening of the left cerebellar tentorial leaflet, which is favored to represent [NAME] calcification, less likely trace subdural hemorrhage. No associated mass effect. On 1/13/26 at 10:58 AM, V2 (Director of Nursing) stated, Her (R140) score was 21 (8/28/25) so she's high risk for falls. On 1/13/26 at 9:25 AM, V32 (Nurse Consultant) stated, She (R140) didn't have any major injury; she had a scalp hematoma. On 1/14/26 at 12:59 PM, surveyor attempted to reach V39 (LPN/Licensed Practical Nurse) assigned to R140 (9/23/25) via phone to no avail. On 1/14/26 at 2:02 PM, surveyor attempted to reach V39 (again) via phone to no avail. On 1/14/26 at 4:30 PM, V2 (Director of Nursing) stated, There's no open area, the CT was negative for any fracture. On 1/15/26 at 10:01 AM, surveyor attempted to reach V39 (LPN) a third time via phone to no avail. On 1/15/26 at 11:08 AM, V45 (CNA/Certified Nursing Assistant/ R140's 9/23/25 assigned CNA) stated, I don't work there, I don't want to work there and hung the phone up. On 1/15/26 at 11:20 AM, surveyor attempted to reach V46 (CNA) assigned to R140's unit on 9/23/25 via phone; the line was busy. At 11:23 AM, surveyor attempted to reach V46 again, however, the line was still busy. On 1/15/26 at 11:30 AM, surveyor attempted to reach V47 (CNA) assigned to R140's unit on 9/23/25 via phone, however, the phone rang several times then disconnected. R140's (10/5/25) Certificate of Death states Cause of Death: Cerebrovascular Disease with Dementia. Manner of Death: Natural, The fall prevention policy (reviewed 7/2025) states while preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. A fall risk evaluation is completed by the Nurse. A score of 10 or greater indicates the resident is at high risk for falls. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. 2.Facility census for 1/12/2025 documents in part that 12 residents reside on the 300 unit. On 1/12/2025 at 10:58 AM, observed the emergency door alarm light at the top of the door not illuminated. A notice was posted on the door that indicates the door will alarm and the locking mechanism will be disengaged after holding the push bar of the door for 15 seconds. V8 (Maintenance Director) observed the alarm light and stated, We have been having issues with this door and the alarm sensitivity. V8 held the push bar of the door and no alarm sounded, and after 20 seconds, the door was still locked. V8 leaned V8's shoulder and applied full body weight to the door in attempt to open the door and the bottom of the door opened approximately 12 inches, but the door remained locked and unable to be opened. On V8's final attempt of getting the door open, an alarm sounded but the door did not unlock. V8 affirmed when the push bar is applied, the alarm should sound, and the lock should disengage after 15 seconds. V8 explained the 300 unit is a dementia care unit and the purpose of the alarm is to prevent elopement. V8 added the purpose of the door disengaging is that so staff and residents can escape if there was an emergency. Facility preventative maintenance policy (5/2025) documents in V8 is responsible for checking the operations of fire doors.

Based on observation, interview, and record review, failed to implement care plan interventions, failed to follow physician orders, failed to notify the physician of abnormal urine, failed to document abnormal urine, failed to obtain orders for urinalysis/culture, failed to ensure urinary catheter bags remain below the bladder level to prevent backflow and potential UTI (Urinary Tract Infection), and failed to ensure a nephrostomy tube drainage bag was placed below the kidney level to prevent backflow of urine into the kidney and the potential for kidney infection. These failures affected three residents (R1, R4, R13) in the sample of 54 residents. Findings include: 1.R1's diagnoses include (6/7/25) UTI. R1's 12/7/25 Physician Order Sheets state change urinary bag as needed when clinically appropriate every 8 hours as needed. R1's 6/5/25 care plan states resident requires use of an indwelling catheter related to diagnosis of neuromuscular dysfunction of bladder. Intervention: keep drainage bag lower than level of bladder. Monitor for signs/symptoms of UTI. Notify medical doctor of abnormal findings. Change catheter as needed. On 1/12/26 at 10:17 AM, R1's indwelling urinary catheter tubing was notably cloudy with chunks of purulent substance floating in the urine and heavy sediment. R1's urinary catheter bag was undated. Surveyor inquired when R1's catheter and/or bag were last changed; R1 was unsure. R1's (January 2026) MAR (Medication Administration Record) states change urinary bag as needed when clinically appropriate every 8 hours as needed however nothing was documented. On 1/12/26 at 10:22 AM, R1 was lying in bed. V14 (Licensed Practical Nurse/LPN) was asked about the appearance of R1's indwelling urinary catheter and contents in the bag. V14 (Licensed Practical Nurse) responded, I see his discoloration, sediment. V14 was asked if R1's catheter bag was dated. V14 removed the bag from the bed rail, raised it above R1's bladder and replied, It's not. V14 was asked if V14 notified the doctor regarding R1's abnormal urine. V14 stated, I haven't, no, I didn't call the doctor about that. V14 was asked where catheter/bag changes were documented. V14 responded, Probably under his profile in the progress notes. V14 reviewed R1's EMAR (Electronic Medical Records) stated he was unsure when the catheter bag was placed/changed. On 1/14/26 at 1:16 PM, V2 Director of Nursing/DON, was asked if orders were obtained for urinalysis and urine culture (on 1/12/26) for R1's abnormal urine. V2 (DON) stated, That I'm not sure about, I would have to check. On 1/14/26 at 3:20 PM, V40, Medical Director, was asked what cloudy urine with sediment and chunks of purulent drainage floating in a catheter is indicative of. V40 (Medical Director) stated, It can be many things. We would want to rule out UTI. If they see a change in the color or the sediment, nursing staff should bring it up with the DON (Director of Nursing) or the provider for sure. V40 was asked what should be ordered if urine appears abnormal. V40 replied, Urinalysis but also a culture. On 1/14/26 at 4:43 PM V36, Nurse Practitioner, was asked if V36 was notified of R1's abnormal urine. V36 stated, (R1's) a hospice patient. I was asked to look at a urinary catheter, but it was already changed before I looked at it. The DON called and said it was sediment or something in the urinary catheter. V36 was asled if a urinalysis or urine culture was ordered for R1 on 1/12/26. V36 responded, No ma am, this is a hospice patient. I refer them back to hospice. I reminded the nurse to call the hospice. R1's progress note on 1/12/26 at 12:14 PM states, called hospice, got order to change (urinary catheter). 2.R13's diagnoses include obstructive and reflux uropathy. R13's 7/25/25 physician orders state change urinary bag as needed when clinically appropriate. R13's (11/19/25) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). On 1/12/26 at 10:37 AM, R13 was asked how frequent staff change R13's indwelling urinary catheter bag. R13 stated, It's supposed to be once a week. R13 was asked when R13's catheter bag is changed. R13 responded, When they decide to change it. R13's (January 2026) MAR includes change urinary bag as needed when clinically appropriate, however, nothing is documented. On 1/12/26 at 10:45 AM, V13, Wound Care Coordinator, was asked about the appearance if R1's indwelling urinary catheter. V13 responded, It's white residue. V13 was asked what white residue is indicative of. V13 didn't respond. V13 then asked V14 (LPN) How often the order is to be changed? 3.R4's care plan, dated 12/19/25, states R4 has a nephrostomy bag; intervention states to observe for signs of skin irritation, keep skin clean, dry, and moisturized. On 1/12/26 at 10:40 AM, R4 was observed awake in bed with the nephrostomy drainage bag on top of her abdomen, showing only about one tablespoon of urine in the drainage bag. At 10:55 AM, R4's nephrostomy drainage bag was still in the same position. At this time, V26 (CNA/Certified nurse assistant) she did not know what kind of urine bag it was, but that it should be hanging down on the side of the bed to allow proper drainage. Immediately, V26 brought the drainage bag below R4, about 200 ml(milliliters) of the urine came out into the drainage bag. V27 (LPN/Licensed Practical Nurse) stated she was not sure what kind of catheter it was and she would go back and check. V27 came back and stated R4 has nephrostomy catheter that is connected directly to the kidney. V27 stated the drainage bag should be placed below the resident to allow gravity drainage and she would educate the CNA to be sure the drainage bag is placed below the level of the kidneys. On 1/12/26 at 12:55 PM, V2(Director of Nursing) stated V27 should have been given shift report that R4 has a nephrostomy tube. V2 added backflow of urine could cause kidney infection, and staff would be re-educated about this. Facility's Policy titled Nephrostomy Management, dated 1/2025, states: Residents with Nephrostomy will receive care consistent with professional standards of practice.#4b: Keep the drainage bag below the level of the kidney at all times. The indwelling catheter care policy (revised 5/2025) states daily and PRN (as needed) catheter care will be done to promote comfort and cleanliness. Catheter bag to be emptied at the end of every shift, and PRN. Record output and catheter care in POC (Plan of Care)

Based on observation, interview, and record review, the facility failed to execute physician orders and failed to implement care plan interventions for one resident (R3) in a sample of 54 residents reviewed for nutrition. These failures resulted in R3 sustaining a significant weight loss of -15.06% in less than 3 months (2 months and 13 days) and -7.04% in less than 1 month (17 days).Findings include:R3's face sheet documents an admission date of 9/08/2025, and diagnoses that include but are not limited to dysphagia, chronic atrial fibrillation, constipation, hypertension, and chronic pulmonary artery disease. R3's BIMS (Brief Interview for Mental Status) score, dated 12/15/2025, is 3, which indicates R3's cognition is severely impaired.R3's care plan, dated 9/08/25, documents, Nutritional Status at risk for weight loss due to mech (mechanical) altered diet, dysphagia, decreased po (by mouth) intakes, skin alterations, dementia, current sig (significant) weight loss. R3's care plan does not identify that R3's weight loss was unavoidable.R3's care plan, dated 9/12/25, documents, (R3) has been observed experiencing the following depressive symptoms (Little interest in once pleasurable things, Tired, fluctuation in sleep patterns, little to no appetite).R3's active physician order, order date 12/04/25; end date indefinite, documents, 1:1 assistance while eating or drinking with meals. Record review of R3's ADL (activities of daily living) Eating, documents on 12/19/25 (dinner), 12/26/25 (breakfast, lunch, and dinner), 1/02/26 (dinner), 1/9/26 (dinner), 1/10/26 (dinner), and 1/11/26 (dinner) R3 ate Independent: No help or staff oversight at any time. Record review of R3's MAR (medication administration record) shows R3 did not receive the 1:1 feed as ordered on 12/05/25 and 1/12/26.R3's physician order, ordered date 9/09/25; discontinued date: 11/24/2025, documents, Active Liquid Protein: Give 30mls BID two times a day. Review of R3's MAR (medication administration record) shows R3 did not receive the ordered liquid protein on 9/12/25.R3's physician order, ordered date 9/11/2025, documents, 2 calorie per ml supplement (ex. Med Pass) three times a day 120ml. Review of R3's MAR (medication administration record) shows R3 did not receive the ordered 2 calorie per ml supplement on 1/12/26.R3's physician order, ordered date 11/04/2025, documents, Proheal Sugar Free Critical Care AWC two times a day 90ml. Review of R3's MAR (medication administration record) shows R3 did not receive the ordered Proheal Sugar Free Critical Care on 11/06/25 and 1/12/26.Record review of physician's progress notes August of 2025 through January of 2026 documents no identification of the physician progress notes stating R3's weight loss was unavoidable, as well as no other interventions regarding R3's weight loss other than continue to monitor weights and adjust diuretic therapy as needed.R3's progress note, dated 12/5/2025 at 12:15p PM, per V35 (Registered Dietician), documents, Nutrition: Weight Warning & Pressure Wound: Weights: December 4 (2025): 125.6 pounds; 1 month ago: 135.6 pounds; 3 months ago: 134.2 pounds; BMI (Body Mass Index): 19.1 (underweight); Weight Changes: 10.0. Review: Resident (R3) triggered for significant weight loss x1 month; undesirable r/t (related to) underweight status. Re-weight shows true weight loss. No edema noted to BLLEs independent at meals - could benefit from 1:1 feeding assistance to help achieve adequate intake to maintain weight. Recommend: 1. Provide 1:1 feeding assistance at meals. 4. Encourage PO intakes at meals. 5. Encourage fluid consumption throughout the day.R3's progress note, dated 1/14/2026 at 4:11 PM, per V35 (Registered Dietician), documents, Nutrition: Weight Warning & Pressure Wound: Weights: BMI (Body Mass Index): 17.0 (underweight) Weight Changes: -13.4 pounds (10.7%) sig loss x1 month. 1:1 feeding assist. Has hx (history) of edema, none currently noted. Resident (R3) is malnourished r/t sig weight loss & low BMI/body weight. Recommends reaching out to family to schedule care plan for hospice care or G-tube placement.R3's weight record documents the following: 10/20/2025: 136.8 pounds; 12/16/25: 125.0 pounds; and 1/02/26: 116.2 pounds. R3 sustained a significant weight loss of -15.06% in less than 3 months (2 months and 13 days) and -7.04% in less than 1 month (17 days).On 1/12/2026 at 12:23 PM, R3 was observed receiving her lunch tray. From 12:23 PM to 12:47PM, there was no staff member observed providing one-to-one feeding assistance to R3. Staff were observed assisting other residents in the dining room; however, no staff member was observed assisting R3 to provide continuous feeding assistance as ordered. R3 did not receive prompts, physical assistance, or supervision consistent with one-to-one feeding during the observation period. No staff member returned to provide the ordered assistance prior to the end of the observation.On 1/12/2026 at 12:47 PM, V30 (Certified Nursing Assistant/CNA) said, (R3) does not require 1:1 feeding. No, she eats fine, just like the rest of us.On 1/13/26 at 12:26 PM, V35 (Registered Dietician) said, I identified several contributing factors to (R3's) weight loss. (R3) is a 1:1 feed, and (R3's) oral intake had generally been good, which raised questions regarding the amount of weight loss. (R3) had edema and (R3) experienced an 18-pound weight loss in one month, and this amount of loss cannot be attributed solely to the reduction of edema. (R3's) weight change from 125 pounds to 116 pounds was questioned and during that time period, the facility did not have a restorative nurse, and weights were obtained by different staff members. When variations such as this are identified, the recommendation is to obtain a reweigh for accuracy. (R3) was reweighed and there still was a noticeable significant weight loss.On 1/14/26 at 12:39 PM, V35 (Registered Dietician) said, (R3) has a one-to-one feeding order. Last month we noticed (R3) had a decrease in oral intake. As an intervention, assistance with meals was implemented. The need for one-to-one feeding was related primarily to (R3's) dementia and not due to dysphagia. 1:1 feeding was put in place to ensure (R3) was receiving adequate nutrition. If (R3) was not provided 1:1 assistance on Monday (1/12/26), that would be considered a deficiency. Yes, I do believe that failure to provide one-to-one feeding can affect the resident's weight loss. If staff are expected to feed a resident and do not provide the ordered assistance, then the weight loss would be considered avoidable.On 1/14/26 at 3:07 PM, V40 (Medical Director) said, There is potential harm to a resident if they require feeding assistance and are not provided that assistance. If a resident doesn't have the full ability to eat but needs assistance to do so, and that assistance is not provided, the result is inadequate nutritional support. Residents must be monitored closely, especially in the presence of overall health conditions and chronic medical conditions. Failure to provide feeding assistance can lead to nutritional decline and associated complications. If a resident does not eat at all due to lack of assistance, the outcome would be malnutrition, including severe malnutrition. If a resident eats only a portion of their meal because they require feeding assistance that is not provided, the impact is still significant. While this may not immediately jeopardize the resident's life or create an immediate danger, it represents a progressive, long-term decline. This can include nutritional deterioration, dehydration, and worsening of existing medical conditions. Regarding a resident who loses 15 percent of their body weight in less than 3 months, this would be considered harm to the resident if the weight loss is not clinically justified or unavoidable.On 1/14/26 at 4:40 PM, V2 (Director of Nursing/DON) said, Staff are expected to follow physician orders and care plans. If it's not charted, it's not done. Regarding (R3's) weight loss, ongoing monitoring has occurred, and there have been discussions with her (R3's) daughter. (R3) used to live in Texas and was followed by a cardiologist there. (R3) had fluid retention, which has since improved. During hospitalization, records indicated a significant amount of fluid was removed, which we originally related to the weight loss, however, (R3) continues to lose weight. Staff stated that (R3) eats. Dietary has also been involved. (R3) is food motivated and is consistently observed eating. (R3) is a 1:1 feed and that is provided by the wound care tech. Wounds and nutrition go together. That way the wound care tech has firsthand knowledge if (R3) is eating or not. V2 stated V2 was unaware R3 did not have a 1:1 during lunch on Monday (1/12/26) and will find out what happened.Record review of facility policy titled, Baseline Care Plan, dated 1/2023, documents, To provide the staff with guidance on completion of comprehensive person-centered care baseline care planning. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. The baseline care plan will include at a minimum the following necessary information to properly care for a resident: Supervision needs, activities of daily living needs, dietary orders. Record review of facility policy titled, Activities of Daily Living, dated 5/01/25, documents, A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. 2. A program of assistance and instructions in ADL skills is care planned and implemented. Feeding: Adaptive equipment, assistance and instruction are given as required. Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, . Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure that posted nursing staffing information was complete and accurate. This failure has the potential to affect all 131 residents residing at the facility.Findings include:On 1/12/2026, upon entrance to the facility at 9:00AM, surveyor observed a daily staffing posting on a board behind the reception desk. Upon review of the posting, surveyor observed only the column for the number of staff was completed. The second column, actual hours worked and the 3rd column, total hours were left vacant. The same postings were observed behind the reception desk on 1/13/2026 and 1/14/2026.On 1/14/2026 around 2:30PM, surveyor asked the receptionist who is responsible for the staff posting, and she said the staffing coordinator is responsible. She brings it down every day, and she just puts it in a drawer when a new one is brought down the following day.On 1/14/2026 at 4:18PM, V12 (Staffing Coordinator) said she is in charge of the nursing staff posing and has been doing it since she started working at the facility in February 2025. Surveyor presented the two columns on the posting that were not completed and V12 said that she overlooked those, moving forward, she will correct that.

Based on interview and record review, the facility failed to have a system in place to monitor and investigate how a resident with a history of drug usage was able to obtain illicit drugs in the facility. This failure affected one (R3) of three residents reviewed for supervision. As a result of this failure, R3, who did not have an independent outside pass privilege, tested positive for illicit drugs on 9/19/25, 9/25/25, and 10/3/25, requiring transfer to local hospital.The Immediate Jeopardy began on 9/19/25 when R3 was sent to the hospital and tested positive for illicit drugs while in the facility. V1 (Administrator) was notified on 12/23/25 at 1:38 PM of the Immediate Jeopardy.The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on 12/30/25, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R3 is [AGE] years of age. Current diagnoses include but are not limited to Chronic Obstructive Pulmonary Disease, Asthma, and Chronic Kidney Disease. R3 has a known history of substance abuse. R3's comprehensive assessment section C cognitive status, dated 9/9/2025, documents a Brief Interview for Mental Status score of 15, indicating R3 is cognitively intact.R3 was admitted to the facility on [DATE]. R3 was discharged to the hospital due to chest pain on 10/03/25 and no longer resides in the facility. R3's nursing progress notes from 9/19/25 and 9/25/25 document staff finding a white powered substance and a crack pipe in R3's room. R3's hospital records from 9/19/25 and 9/25/25 both document R3 admitted to using cocaine in the facility. The hospital urine drug screen indicates he was positive for cocaine.R3 was hospitalized on [DATE] for chest pain. While hospitalized on [DATE], his urine drug test concluded positive for cocaine, fentanyl, and opiates. Per hospital records, when R3 arrived at the hospital, the floor the nurse found cocaine and pipes in his pocket.On 9/18/25 at 7:57 PM, V10, RN/Registered Nurse, documented R3 observed in room with increased confusion and aggressive behavior. Nurse practitioner and DON/Director of Nursing made aware. New order for UA (urinalysis).On 9/18/25 at 8:13 PM, V38, NP, note states: Patient seen for initial visit. Patient was seen after nursing report he was extremely agitated and was hitting the walls and bed. He then wheeled out in halls agitated and yelling. Discussed with patient and he reports this happened in the past, had hallucinations with UTI (urinary tract infection). Will have nursing obtain U/A (urinalysis) for further evaluation. Social history: history of substance abuse, crack cocaine, and heroin use. Physical examination: Psych: Agitated mood. Angry affect. Assessment/Plan: Visual hallucinations, Psych to see patient for evaluation. Monitor mental and neurological status. Discussed plan of care with patient, nursing staff and other providers.There was no physician's order written for the psychiatry evaluation.On 9/19/25 at 9:49 AM, V19, LPN, documented a change of condition: altered mental status for R3.On 9/19/25 at 10:03 AM, V9, SSD/Social Service Director's, progress note states: patient with appeared to be a controlled substance in the room. It was a small baggy of crack cocaine with a small crack pie (pipe). Items removed from the patient's room and given to social worker. Resident educated on policy regarding contraband and risk of controlled substances. Patient receptive of education and took full accountability. Patient visits will be restricted for 30 days and visits will be supervised in a common area for 30 days.V9, SSD/Social Service Director, provided R3's Identified Offender Behavior Contract signed on 9/5/25 and 9/19/25. The contract states: Remain clean and sober, that is to refrain from any alcohol consumption and/or illicit drug use for the duration of my stay here.On 9/19/25 at 11:46 AM, V13, LPN/Licensed Practical Nurse's, progress note states: Writer informed by staff that controlled substance was found in resident room. Per MD (medical doctor) send resident to hospital for drug evaluation. Resident cleaned and sat at nurse's station for close monitoring. Ambulance arrived around 11:15 AM to pick up resident.Per nursing note, R3 returned to the facility on 9/19/25 at 8:34 PM. Frequent monitoring ongoing by staff. R3's 9/19/25 hospital records states: [AGE] year old male arrives by ambulance from nursing home- staff states he was using cocaine at the facility- patient admits to a one time use approximately 2 weeks ago. ED (emergency room) Course: Urine drug screen was positive for cocaine. Nursing home staff notified of the results and will accept him back to the facility. No documentation of frequent monitoring and supervision was provided for review by administration upon request.On 9/25/25 at 10:35 AM, V9, SSD's, progress note states: Resident was observed with illegal contraband in his possession. Resident educated on policy regarding contraband. Resident verbalized understanding. Resident verbalized consent for a room search.On 9/25/25 at 12:20 PM, V9, SSD's, progress note states: Nursing did in house drug test which concluded to be positive for controlled substance. Resident passes and visits still restricted until 10/19.2025. Nursing staff continue to monitor. IDT (interdisciplinary team) made aware.On 9/25/25 at 12:55 PM, R3 was sent to the hospital by V10, RN, for altered mental status with expected controlled substance use. V10 documented POA (Power of Attorney), NP, DON, and Administrator made aware.On 9/25/25, R3's hospital records state: Chief complaint: Patient presents with Altered Mental Status, Hallucinations. Nursing facility staff called EMS (emergency medical services) due to patient having hallucinations and more agitated than usual. Nursing facility staff found a crack pipe in patient's briefs. Per ER (emergency room) physician note, patient admitted to using crack cocaine. Laboratory urine drug screen was positive for cocaine. Nursing progress note on 9/30/25 states: R3 admitted from hospital. Patient presented to ED from facility due to AMS (altered mental status) and hallucinations related to substance abuse.On 10/1/25 at 11:50 AM, V37, NP/Nurse Practitioner's, initial evaluation states: Assessment/Plan: Visual hallucinations, Psych to see patient for evaluation. Monitor mental and neurological status. Discussed plan of care with patient, nursing staff and other providers.There was no physician's order written for the psychiatry evaluation.On 10/3/25 at 2:47 PM, V25, RN/Registered Nurse, progress note states: change in condition, chest pain. On 10/3/25 at 11:19 PM, V31, NP/Nurse Practitioner, was called to R3's room by V3, ADON, to evaluate him for chest pain. R3 was sent to the hospital for further evaluation.The 10/3/2025 hospital records document the urine toxicology screen was positive for cocaine, fentanyl, and opiates. The hospitalist history and physical by V39, MD/Medical Doctor, states: When patient got to the floor, the nurse found cocaine and pipes in his pockets. R3's care plan states: Substance Abuse: R3 has a history of substance abuse/chemical dependency. R3 had crack cocaine in his possession on 9/19/2025.2nd incident with resident having an illegal controlled substance of crack cocaine in his possession on 9/25/2025. Date initiated 9/19/2025 by V9, Social Service Director.Interventions: Meet with IDT (interdisciplinary team) to discuss extent of illness. Physician may consider a referral to psychiatrist and/or write an order restricting pass privileges. Date initiated 9/19/2025. V9 SSD.Work with the resident to establish a verbal and/or written behavioral contract specifying what is and what is not allowed. Make sure the resident is aware of rules prohibiting use of alcohol, illicit substances, and intoxication. Date initiated 9/19/2025. V9 SSD.There are no additional interventions documented after R3 was hospitalized on [DATE] or 9/25/25 regarding being evaluated by psychiatry, having a substance abuse assessment, a referral for substance abuse treatment or group therapy. R3's physician orders document the following:drug screen 9/13/2025. All outside passes are revoked for 30 days from September 19, 2025 to October 19, 2025. Resident cannot go out on pass with anyone 9/19/2025. All visits are to be in the 2nd floor dining room only for 30 days from September 19, 2025 to October 19, 2025. 9/19/2025. Naloxone HCL Spray 4mg (milligrams) 1 spray in nostril every 5 minutes as needed for opioid overdose.R3's behavior monitoring and intervention task by staff CNAs was reviewed from September - October 2025. R3 returned to the facility from the hospital on 9/19/25 at 8:34 PM. There is no documentation of frequent monitoring from 3pm-11pm shift and 11pm-7am shift.There is no documentation of frequent monitoring on 9/20/25 for 7am-3pm shift, 3pm-11pm shift and 11pm-7am shift.There is no documentation of frequent monitoring on 9/21/25 for 7am-3pm shift and 11pm-7am shift.From 9/22/25 - 9/25/25 there is no documentation for all shifts. From 9/26/25 - 9/29/25 R3 remained hospitalized .R3 returned to the facility on 9/30/25 at 5:02 PM. There is no documentation of frequent monitoring from 3pm-11pm shift.There is no documentation of monitoring on 10/01/23-10/2/25 for all shifts.On 12/08/25 at 12:25 PM, V9, Social Service Director (SSD), was asked about R3 and the 9/19/25 and 9/25/25 incidents. V9 said, (R3) was here last summer when I started, so I was familiar with him, and knew he had a drug history. I don't think it (drug history) was on his initial assessment when he came back this time. I believe V29 (Former Wound Care Nurse) found the drugs during care. It was a white powered substance. I saw it. (R3) went to the Activity Director and told her he used drugs. She brought him to me, and I had a conversation with him. He denied it at first. He was jittery, his mouth was moving a lot, he had disorganized conversation and was a little agitated because we were questioning him. He wouldn't tell me where he got it. He was going back and forth admitting and denying it. He'd been here a couple of weeks. He had a supervised pass because he wasn't here long enough for the independent pass. After the incident, the pass was revoked for thirty days. He had a behavior contract because he was an identified offender. His behavior was a red flag because he's alert and oriented and his conversation was off, and I knew something wasn't right. I notified (V2, DON/Director of Nursing) and they sent him out. He had supervised visits when he came back. He wasn't allowed to leave the facility with anyone. (V11, Former Administrator) handled it; we didn't call the police. I don't know why the police weren't called, I gave it (alleged drugs) to (V11). She said she'd handle it and it was out of my hands at that point.V9 said the second incident of illicit drugs being found was on 9/25/25. V9 said, The second time (V10, RN/Registered Nurse) found it (drugs) in his room, I was called. (R3) had disorganized conversations, he was going back and forth admitting and denying he used. He was tested for drugs. I didn't do the drug test, nursing did. (V11), (V10, RN) and I went into the room, and I had a conversation with him. When I got there the drugs weren't there. (R3) was saying he didn't wanna (sic) do drugs, but he wouldn't tell me where he got it from. I checked the visitor logs myself; I saw a visitor. (R3's) pass was restricted for another 30 days. He was sent to the hospital the next day for something else, not drugs. (V11) said she'd dispose of it in the dumpster. I asked to notify the police, but (V11) didn't think it was necessary.On 12/09/25 at 11:54 AM, V12, Activity Director, said, Twice he came to me with his personal stuff. It was a small, sealed pack with a grey colored substance. I turned it over to Social Service. He didn't tell me what it was. (R3) said, 'That's my stuff, it's mine. I don't want this.' He was slurring his speech. I let nurse know to check him.On 12/09/25 at 12:26 PM, V10, RN, said, (R3) was delightful, alert and oriented x 2-3. I was rounding and he was doing a lot of mouth moving, very agitated, hallucinating, complaining of chest pain. This wasn't usual for him, so I performed a urine drug test, and he was fine with it. The results said it was positive for cocaine and something else, but I'm not sure what it was. I told (V9, SSD) and (V11, Previous Administrator). His speech was disorganized. We couldn't understand what he was saying. I called the doctor and sent him out. (V9, SSD) and (V11) checked his room. He didn't admit to me he took anything. I didn't find anything and nothing was told to me. I can't remember reporting to the police.On 12/09/25 at 12:55 PM, V2, DON/Director of Nursing, provided the visitor log. There is one visit documented for R3 on 09/15/2025 from 11:53 AM to 12:18 PM. V2 said, (R3) never went out but he had a visit.On 12/10/25 at 12:30 PM, V2, DON, was asked about R3 being sent to the hospital on 9/19/25, 9/25/25, & 10/3/25. V2 said, I'm not sure if I was here for the first incident. I was there for the second one. I wasn't aware there were drugs found in his room. I saw the drug pipe on (V11's, previous administrator) desk, not sure the exact date. I didn't see the substance. We had suspicion that he used so we did a urine test, and it was positive for cocaine. We told his doctor and sent him to the emergency room. The hospital did a drug screen, and it was positive for cocaine as well. Social Service did the behavior contract on 9/19, and he went on pass restriction. He couldn't go out the facility for 30 days unless a doctor appointment, then it would be reassessed. His visits would be monitored and in a public area. Any packages delivered we'd look at the items to see if any contraband was delivered. On Friday 9/19, V13, LPN/Licensed Practical Nurse, sent him out to the hospital and he came back to the facility. My investigation was he returned from the hospital positive for cocaine and treatment of a UTI (urinary tract infection). Nurses did daily assessments; we chart by exception if something is going on. We monitor for changes in behavior. I didn't do an investigation. We did an IDT (interdisciplinary team) meeting and put those interventions in place. Social Service searched his room. I didn't ask him any questions.About the 9/25/25 incident, V2 said, Social service charted (R3) had drugs in his possession, and he was given a urine test. It was positive for cocaine. The 9/15 visit was the only one associated with his name. He was readmitted from the hospital on 9/30. I wasn't involved with any investigation.About the 10/3/25 incident, V2 said, He (R3) didn't go out because of drugs, it was for a medical reason. I'd have to check what it was for.On 12/10/25 at 2:10 PM, V1, Administrator, was asked about investigating an incident involving a possible controlled substance in the facility. V1 said, If something is found, it would have to be identified that it is a controlled substance. We contact the physician and 911. I would call the police, speak to them, and turn it over to them. After, we send the resident out to the hospital to get tested. The hospital will identify if the resident had taken a substance. Once cleared by the hospital on return, we monitor the resident. Our Social Service would go through the behavior contract. We check the log to see if the resident went out. For residents with substance abuse, we'd check if they are bringing things in with deliveries; check with family. If the resident is cognitive, we talk to them, family, interview staff that was mainly around the resident to find out what happened.On 12/15/25 at 8:51 AM, V2, DON, was asked about V11, Previous Administrator's, departure. V2 said, She left the company, she resigned October 24th.On 12/15/25 at 11:19 AM, V9, SSD/Social Service Director, was asked about identifying the white substance found in R3's room on 9/19/25. V9 said, I really didn't know what it was, I just assumed. Just based on knowing what it looks like, I just handed it over to (V11, Previous Administrator). I was told she put in in a drug buster.On 12/15/25 at 1:51 PM, V10 was asked about the 9/18/25 progress note written at 7:57 PM. V10 is on the schedule for the 7am-3pm shift. V10 said, I work full time. I can't recall if I stayed over, but I did chart that note. On 9/18 I charted because he (R3) had increased confusion and agitation. I wanted to rule out a UTI (urinary tract infection). I don't remember what NP (nurse practitioner) I spoke to. I got an order for a U/A (urinalysis) to rule out a UTI because of his behavior. I hadn't seen any other behaviors, and it concerned me. On 9/25, I saw him with the same behaviors and confusion as the first time. He was agitated with hallucinations. I told him we needed to collect a urine sample. I didn't tell him what it was for. A NP (Nurse Practitioner) gave me the order; I can't remember which one. We have urine cups for drug testing. It has a strip on it with abbreviations of the drugs it tested for. His read positive for cocaine and benzos. There was a prescription medication he was on for the benzos (benzodiazepines). I told the NP, DON, and (V11, Previous Administrator). I never saw anything in his room.Review of R3's physician orders do not document any benzodiazepine medication prescribed.On 12/15/25 at 2:26 PM, V6, Certified Nurse Assistant (CNA) said, He (R3) didn't require much assistance from us. His room was junky. We'd offer to help, we tried to straighten it up, but he didn't want our help. He'd be in his room talking to himself, arguing with someone who wasn't there and scaring his roommate. He'd be hallucinating. I didn't see aggressive behavior, just erratic. He'd be in and out of his room. He came out for meals and his medicine. I didn't notice any other residents in his room. The next day the 11:00pm to 7:00am aide said he was found with drug paraphernalia. He was in his room telling people not to touch his stuff. On 9/25 we noticed immediately; he had the same behavior, hallucinating.On 12/15/25 at 2:54 PM, V2, DON, was asked about R3's visitor on 9/15/25. V2 reviewed the September visitor log. V2 said, The visitor is from his insurance; that's the name written above his on the log. Other than that, he didn't have any outside visitors.On 12/16/25 at 10:33 AM, V24, CNA/Certified Nursing Assistant, was asked about R3 on 9/19/25. V24 said, I worked the day it happened the first time. I noticed he (R3) was all over the place. He usually has sense. This morning, he had food all over the floor, stuff thrown everywhere. He hung out with (R9), they'd be in and out of his room. (R9) left; he's not there anymore. He (R3) was hallucinating, fighting the air, he said he was hallucinating. When I walked in the room, I stepped on half of the drug pipe. I picked it up with my gloves on; it was on the floor on the side of his bed. It was burned at one end. It was like 7 in the morning. I took it to (V15, Wound Nurse). He said he'd report it. The staff searched his room. They found drugs; it was white and the other piece of the pipe. Nobody talked to me after it happened. It happened twice with the same resident. The second time staff found a bunch of pens burned at the end.On 12/16/25 at 10:49 AM, V13, LPN/Licensed Practical Nurse, said, I remember what happened, but I don't remember the resident too well. (V15, Wound Nurse) told me he found something in his room. I remember he was aggressive, refusing to be searched. I don't remember what was found.On 12/16/25 at 11:43 AM, V15, Previous Wound Care Nurse/LPN, said, I remember him (R3). I went to his room there was an aide there, can't remember who. I saw all his stuff on the floor. I saw a clear small baggy on the floor, looked like crack cocaine and a pipe with a burned end. The room was trashed, stuff all over. I put it in a bag and reported and turned it in. I don't remember who I gave it to. He was a little erratic. I was doing wound care that day. I'm not sure what happened to him after that.On 12/16/25 at 12:40 PM, V31, NP/Nurse Practitioner, said, I was called by the ADON (Assistant Director of Nursing). I saw him (R3); he was having chest pain. Paramedics were at the bedside when I got there. He had some lip smacking. If we know they had an ER (emergency room) visit, we try to see them within 48 hours. We rely on the hospital after visit summary to see what they were seen for. If it wasn't uploaded in his records I wouldn't see it. The nurses don't give it to us. I saw him for a lab review because he had a UTI (urinary tract infection). I didn't know about cocaine use. That explains his lip smacking.On 12/16/25 at 1:09 PM, R3 said, I had used cocaine. I spent my own money. Another resident brought it in for me and I went down and got it. The other resident got it for me because the person who sold it wouldn't give it to me because he didn't know me. I don't remember who he was. He was on the other unit I think. I made a mistake getting it. It stays in your system a long time. They found other stuff in my urine. I don't know what they cut it (cocaine) with. I had my cell phone, and I went to his room and got it. When they found it (cocaine) it was in the room. I only did a little of it. Other residents did it (cocaine). They couldn't get it themselves, so it was brought it.On 12/17/25 at 12:06 PM, V11, Former Administrator, said, From what I remember, somebody found a crack pipe and a plastic bag with an unknown substance in his (R3's) room. (V9, SSD/Social Service Director) and I interviewed him (R3), and he wouldn't admit to it. He was sent out to the hospital. He did test positive for cocaine, I believe. He came back and his visiting was changed to supervised and his pass was restricted. That's all I can recall about what we did for him. We didn't call police; no reason to. I destroyed it with (V3, ADON/Assistant Director of Nursing). I investigated with interviews from staff, residents, and him (R3). They should be at the facility. I can't recall if he had a history of substance abuse history. I just know he went to the hospital on 9/25 for altered mental status. I don't remember anyone finding anything in his room. I don't remember anything about him testing positive for cocaine when he came back from the hospital. I wasn't aware of him going to the hospital on 10/3.On 12/17/25 at 1:00 PM, V31, NP/Nurse Practitioner, was asked about providing psychiatric services to the residents. V31 said, We write the order for a psych evaluation. We don't do any psych services here.On 12/17/25 at 1:38 PM, V1, Administrator, was asked about R3's substance abuse assessment and psychiatric evaluation. V1 said, (V9, SSD/Social Service Director) said he didn't have a psych eval because he doesn't have a psych diagnosis.V1 provided R3's 9/3/25 social service initial comprehensive assessment with question #4 highlighted: History of substance use/abuse (alcoholism, drug abuse including prescription drug abuse/narcotic seeking) and/or compulsive behavior (uncontrolled or poorly controlled gambling, overeating, exercise, obsessions). A. Yes, is marked. This is the only documentation received.On 12/17/25 at 2:15 PM, V37, NP, was asked about her progress note for R3 on 10/1/25. V37 said, It was my initial visit; I was introducing myself and going over his reasons for admission. I was asked to see him because the nurse said he was having behaviors and hallucinating. His nurse told me he said he had a history of this behavior from a previous UTI (urinary tract infection). I can't remember the nurse. I wrote for a psych evaluation and discussed it with the nurse and resident. My expectation is for the nurse to follow my plan and place the order for him to see psych. Nurses should coordinate with management to make sure it's carried out. The DON (Director of Nurses) is responsible for the nurses.On 12/17/25 at 2:40 PM, V3, Assistant Director of Nursing (ADON), regarding R3's incident on 9/19/25, said, I was informed by (V9, SSD) that he (R3) had a white substance in a bag in his room. (V9) said she believed it was some type of drug. I knew that the resident should have been assessed, drug tested and seen by the medical provider and check his room. I never saw it with my two eyes. I don't recall any results from the hospital. I don't remember destroying anything with (V11, Previous Administrator). He (R3) did come back to the facility. He was on restricted/supervised visits.Regarding R3's 9/25/25 incident, V3 said, I don't remember the 9/25/25 issue at all.Regarding R3's 10/3/25 incident, V3 said, I remember (V25, RN) told me (R3) was having chest pain. We both did further assessments, vital signs, asked him to rate his pain and where it was, checked his respiratory. We checked his medications to see if he had any prn (as needed medications) and we let the nurse practitioner know. We notified (V31, NP). I don't recall getting information from the hospital about him.On 12/22/25 at 9:39 AM, R10 was asked about R3 being his roommate and the incidents on 9/19/25 and 9/25/25. R10 is alert and oriented x 3. R10 appears very guarded. R10 said, I'm familiar with his name. Yes, he was in here. I don't feel comfortable having this conversation today.On 12/23/25 at 1:13 PM, V2, DON, was asked about R3's referral to psychiatry. V2 said, Generally the NP (Nurse Practitioner) will put the order in and the nurses will confirm the order. For the psych evaluation, the nurse would add the resident to the list to be seen by psych. If the resident doesn't get seen and they're having behavioral issues it could lead to them harming themselves or someone else.On 12/23/25 at 4:29 PM, V42, Medical Director, said, (V2, DON/Director of Nursing) updated me with his (R3) hospitalization with polysubstance abuse. The last time he went out to the hospital for chest pain, and he was positive for cocaine and fentanyl. I'm not his attending, so I wasn't told immediately when it happened. We discussed that we are not trained in addiction specialty and how do we put interventions in place. We've had policies in place for residents with polysubstance abuse. We didn't think it was safe to have him come back. The only thing we could do, we can refer him to addiction specialist. We talk to the patient; he was alert and decisional. We do searches on bags and rooms, but we do have limitations. I wasn't informed of the investigation. Refer him to a treatment facility for drug addiction and a psychiatrist. If he was referred to see the psychiatrist by the nurse practitioner and they (nursing) didn't put it in, we have to see why it wasn't written as an order. Educate our Nurse Practitioners; it has to transfer out to an order. Resident Possession and Use of Illegal Substances policy states:Policy: It is the policy of this facility to uphold the resident's right to retain and use personal possessions, unless to do so would infringe upon the rights or health and safety of other residents. The possession and use of illegal substances by residents will not be tolerated.Policy Explanation and compliance Guidelines:1. Facility staff will have knowledge of signs, symptoms, and triggers of possible illegal substance use, which includes but is not limited to: a. Changes in behavior, b. Increased, unexplained drowsiness, c. Lack of coordination, d. Slurred speech, e. Mood changes, f. Loss of consciousness.3. If the facility determines through observation that a resident may have access to illegal substances that they brought into the facility or secured from an outside source, the facility will not act as an arm of law enforcement.4. To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility.4. If facility staff identified items or substances that pose risks to residents' health and safety and are in plain view, they will confiscate them.5. Facility staff will not conduct searches of a resident or their personal belongings, unless the resident or resident representative agrees to a voluntary search and understands the reason for the search.The 5/2025 Contraband Policy states:Policy: This organization reserves the right to conduct inspections if there is a reason to suspect/believe that a resident has contraband items/materials in his/her possession. This includes egregious actions such as secretly (and illegally) recording other persons. These items include, but are not limited to, alcohol, illicit (street or over the counter) drugs, weapons (including any sharp objects/ammunition), and smoking materials (if the individual has assessed as dangerous and irresponsible with smoking related items). The organization will try to balance individual rights against the safety needs of peers, visitors, and staff members in making decisions about further investigation of contraband. In situations where illegal activity appears to have taken place appropriate authorities will be notified. Again, safety and security are of the utmost concern. Room and Person Search PolicyThe following items are NOT ALLOWED in resident rooms at any time and are not allowed on the resident's person unless permission has been granted from administration and supervision is being provided: Drugs, Drug Paraphernalia.The August 2023 Substance Abuse Policy states: Substance Abuse PolicyThe facility reserves the right to protect all residents, staff, and visitors from the negative effects of substance abuse. The facility will take all precautions necessary to prevent residents from using alcohol or illegal substances.1. In the event a resident is suspected of drinking alcohol or using drugs the facility will immediately, medically, and behaviorally assess the resident to verify if hospitalization is needed.2. The resident will be given a drug screen to indicate the specific substance ingested.3. The resident's pass will be immediately suspended pending results of the drug screen.4. The resident will be restricted from attending day program (as applicable) pending the drug screen.5. Refusal to take drug screen is identified as an automatic positive.Upon receiving positive results from a drug screen, the following protocol will be followed:1. Any passes will be restricted for 30 Days. Passes will be reinstated at the discretion of the Administration Team.2. The resident will be suspended from the day program (as applicable) at the discretion of the Administration Team. After two weeks, the Administration Team will assess if the resident is ready to return to the day program.3. Home passes with family will be restricted at the discretion of the administration. After two weeks, the administration team will assess the resident's progress to determine if the resident is appropriate to go home with family.4. The resident will be placed on a behavior contract coinciding with their specific substance abuse issues and treatment plan.Resident Signature/date:Staff/Witness Signature/Date The Immediate Jeopardy that began on 09/19/25 was removed on 12/30/2025 when the facility took the following actions to remove the immediacy. On 12/30/25 the survey team verified by observation, interview, and record review, that the facility implemented the following to remove the immediacy.1. Regional Director of Operations in-serviced the Administrator, V1, regarding the facility's Resident Possession & Use Policy on 12/23/2025 and the Illicit Drug Use Program. The Administrator will be responsible for overseeing the Social Service Director, in ensuring all residents identified with a history of substance abuse and drug seeking behaviors are closely monitored with appropriate and effective interventions.The Regional Nurse Consultant in-serviced the Director of Nursing, regarding the facility's Resident Possession & Use Policy on 12/23/2025 and also the Illicit Drug Use Program. The Director of Nursing will be responsible for overseeing nursing staff in ensuring all residents identified with a history of substance abuse and drug seeking behaviors are closely monit[TRUNCATED]

Based on interview and record review, the facility failed to keep two residents (R3 and R5) free from resident-to-resident physical abuse after R3 was punched in the right eye by another resident (R4), and R5 was slapped on the head by another resident (R1) for two out of five residents reviewed for abuse in a total sample of nine. This failure resulted in R3 sustaining blunt head trauma and a swollen, black eye.Findings Include:1.R3 is a [AGE] year-old female resident admitted in the facility on 5/1/2024. R3 is assessed to be alert, able to make needs known, forgetful at times.R4 is a [AGE] year-old male resident admitted in the facility on 7/8/2025.On 9/16/2025 at 12:07 PM, R3 observed in her room lying in bed. R3 was able to answer questions appropriately, but noted forgetful at times. There was slight purplish discoloration around the right eye observed. R3 was able to remember there was a guy who punched her hard on the face.On 9/16/2025 at 12:10 PM, R3 stated she remembers there was a guy who hurt her on the face. R3 stated R4 punched me hard on the face and was kind of hard while I was standing in the kitchen. It hurt me right here pointing to the right side of her face. R3 stated she feels safe here.On 9/17/2025 at 11:39 AM, V2 (Social Service Director) stated, If the residents are assessed to be at risk for abuse, then they need to be protected. The care plan should be put in place with interventions to prevent abuse. When V2 was asked about the incident that led to R3's injury on 8/25/2025, V2 stated she was not in the facility at that time, but the incident was physical abuse. V2 stated R3 should have been immediately removed from the area and should have been frequently monitored. V2 agreed R3 should have been protected.During a telephone interview on 9/18/2025 at 10:44 am, V8 (Activity aide) stated she was present and was doing pumpkin faces activity in the dining room with residents when the incident happened on 8/25/2025. V8 said she was paying attention to the crafts the residents were doing at that time. There were a lot of people in the room, and music was playing. R3 and R4 were both sitting in the same table across each other. V8 said she was the only activity aide present at the time. V8 said she did not witness the whole incident. V8 said she just saw in her periphery when R4 was coming towards R3, and it was quick and fast. V8 said R4 hit R3, and it was fast. V8 said they disengaged them after the incident and took R3 to the nursing station.On 9/18/2025 at 12:07 PM, V1 (Administrator) stated she is the one who investigated and sent the final report of the incident to IDPH (Illinois Department of Public Health). V1 stated R3 and R4 were both in the activity room when the incident happened on 8/25/2025. R4 was sitting on the opposite side of the table from R3. R4 got up and swung at R3 and hit R3 on the side of her face. The activity aide was sitting right next to R3, the activity aide reported, (R4) was coming towards (R3) so she went to get (R3), but she couldn't grab (R3). (R4) was still able to swing at her and hit her on the side of her face. There was only 1 activity aide at that time. V1 stated, (R4) was very upset and ranting at that time, and we did not know what he is ranting about. V1 also stated R4 was so irritated and not redirectable so the facility had to petition him out, and R4 left the following day. V1 also said they reported it to (local) Police department.R3's Social service care plan on Abuse, initiated on 6/11/2024 states that R3 may be At risk for abuse due to confusion, memory loss, wandering and lack of safety awareness. R3's care plan goal on abuse sates that R3 will be free of abuse/neglect daily through next review.R4's Social service care plan on Abuse, initiated on 7/9/2025 states R4 is At risk for abuse. R4's care plan goal states, Staff will monitor well-being of others. Resident will have zero episodes of abuse and neglect throughout next review.On 8/25/2025, Nursing notes states R3 was sent out to the emergency department (ED) for further treatment after R4 struck her on the face. ED report stated, (R3) had blunt head trauma resulting to right eye blunt injury after being assaulted by another resident.On 8/27/2025' Nurse Practitioner's subsequent visit notes states R3 was recently seen at an acute care hospital on 8/25/25 and returned back to facility on 8/26/25 for Blunt Head Trauma. Blunt head trauma was sustained by another demented resident that punched her in the right side of her face. R3 was transferred to the Emergency Department immediately afterwards and underwent a Computed Tomography (CT) scan of facial bones and Head CT, both without contrast and both resulted negative for acute changes.This incident was reported by R3's daughter to (local) Police Department (H25-14043). The police report stated R3's daughter said she was notified by the facility on 8/25/2025 that R3 was involved in a battery and was transferred to the hospital via private ambulance. R3's daughter said she noticed R3 had sustained a swollen, black eye.R3's facility reported abuse incident to IDPH, dated 9/2/2025, states R3 was struck on the face by R4. The final report stated R4 abruptly walked around the table and swung at R3 before staff could intervene. R4 struck her on the right side of her face. R3 was sent out to the hospital for further evaluation due to blunt head trauma.Record review of R4's Social service assessment are as follows:R4's Behavior Assessment, dated on 8/25/2025, states R4 observed being verbally and physically aggressive towards another resident. Responding to internal stimuli R4 remains unable to be redirected.R4's Behavior Assessment, dated 8/25/2025, states in his Behavioral symptoms include physical aggression towards self/others, and verbal aggression. R4's Response to Interventions states that R4's behavior increased/escalated, and that R4 did not respond to interventions successfully.R4's Potential for Abuse and Neglect Assessment, dated 8/26/2025, stated R4's Mental/Emotional Challenges said R4 has persistent anger, fear and/or anxiety, poor judgment skills, and psychotic symptoms such as hallucinations or delusions. R4's Behavioral Challenges include history of aggressive, combative or abusive physical behaviors, and history of verbally threatening or verbally obnoxious behaviors.2. R1 is a [AGE] year old with the following diagnosis: type 2 diabetes, alcohol dependence, cocaine use, and intervertebral disc displacement in the lumbar region.R5 is a [AGE] year old with the following diagnosis: cerebral infarction and type 2 diabetes.R1 no longer resides in the facility.On 9/16/25 at 12:01PM, R5 stated R5's previous roommate (R1) slapped R5 in the head about one week ago. R5 reported R5 got up from bed, walked into the bathroom, and closed the door. R5 stated R1 began yelling and opened the door on R5 then slapped R5 on top of the head. R5 reported R5 then yelled at R1 to stop touching R5 and staff came into separate them. R5 stated R1 began yelling that R1 was going to use the bathroom and that is when R1 opened the door and slapped R5. R5 reported R1 was lying in R1's bed and said nothing to R5 while R5 walked to the bathroom. R5 said, I had no idea he needed to use the bathroom until he was screaming at me after I closed the door. R5 stated R1 has been verbally aggressive with R5 before but never physical until 9/11/25. R5 reported R1 would tell R5 that R5 was messy and make a big deal out of little stuff such as a paper towel left on the floor. R5 stated R1 would call R5 a slob. On 9/17/25 at 11:25AM, V2 (Social Service Director) stated a nurse texted V2 that R1 hit R5. V2 reported R1 was going to be petitioned out to the hospital for a psych evaluation but R1 left the facility against medical advice instead. V2 stated R1 is normally verbally aggressive and manipulative. V2 reported staff will redirect R1's behavior when possible but R1 cannot be redirected every time. V2 stated the police came to the facility and gave R1 a citation. V2 reported R5 told V2 that R5 went to the bathroom which is connected to R1's room and when R5 closed the door to R1's room, R1 opened the bathroom door and slapped R5 on top of the head with an open head. V2 stated this incident would be considered physical abuse because R1 made physical contact with R5 that was unwanted by R5.On 9/17/25 at 1:17PM, V4 (LPN) stated V4 overheard R1 and R5 arguing so V4 went to see what happened. V4 reported R1 told V4 that R1 was going to the bathroom and left out to get a hand towel when R5 came in to use the bathroom when R1 wasn't done. V4 stated the CNA then reported that R5 told the CNA that R1 hit R5 on the head. V4 reported R1 has been verbally aggressive in the past so staff know how to redirect R1's behavior. V4 stated the police showed up to talk with both residents. V4 reported this incident would be considered physical assault.On 9/17/25 at 1:55PM, V5 (Director of Nursing/DON) stated the nurse reported R1 and R5 got into an altercation. V5 reported V5 explained to R1 that R1 would have to go to the hospital for a psych evaluation but R1 refused. V5 stated R1 told staff that R1 was using the bathroom and left to grab something out of R1's room when R5 entered the bathroom and shut R1's door. V5 reported R1 then told R5 that R1 wasn't finished in the bathroom and R5 grabbed something off the sink that belonged to R1 so R1 grabbed R5's arm. V5 stated R1 admitted to tussling with R5. V5 defined tussling as pushing back and forth. V5 reported R1 told V5 that the tussling continued until R5 called out for help. V5 stated that V5 wasn't exactly sure R5's side of the story but R5 did corroborate that R1 got physical with R5. V5 reported the police came to the facility to issue R1 a citation. V5 stated this incident would be considered physical abuse.On 9/18/25 at 12:00PM, V1 (Administrator) stated R5 reported R1 hit R5 on the top of the head and R1 reported R1 physically moved R5 out of the doorway. V1 reported the police were called at the request of R5 and they issued R1 a citation for slapping R5 without any legal justification.A Nursing note, dated 9/11/25, documents R1 presented with physical aggressive behavior towards a peer. R1 was not receptive to staff redirection. Social services attempted to petition R1 to the hospital for a psych evaluation. R1 refused to go to the hospital and wanted to sign out against medical advice (AMA) instead.A Nursing note, dated 9/11/25 documents R5 informed the nurse that R1 struck R5 on the head. The nurse assessed R5 and R5 was stable with no changes. The physician and emergency contact were notified.A Social Service note, dated 9/11/25, documents Social Services met with R5 following the altercation. R5 discussed with events leading up to the altercation with R1. Police were made aware.The Initial Incident Report, dated 9/11/25, documents R5 reported R1 slapped R5 on top of the head without justification. Residents were separated. Body assessment was completed with no injuries noted. R1 was put on 1:1 monitoring until R1 discharged . Police were notified. An investigation was initiated.The Ordinance Violation from the police, dated 9/11/25, documents R1 slapped R5 on top of the head without any legal justification. R1 must appear for an administrative hearing.The Potential for Abuse and Neglect Form, dated 9/11/25, documents R1 has poor judgement skills, a history of physical abuse, history of being verbally threatening, and history of being aggressive. R1 also has a history of substance abuse and alcoholism. R1 was involved in a physical altercation with a peer.R5's Potential for Abuse and Neglect Assessment, dated 9/11/25, documents R5 is at risk for abuse due to using a wheelchair.R1's Care Plan, dated 8/18/25, documents R1 is at risk for abuse. R1 was involved in a physical altercation with a peer on 9/11/25. This care plan also documents R1 presents with behavioral symptoms by becoming verbally aggressive with staff. R1 is not receptive to redirection. The Care Plan dated 9/9/25 documents R1 presents with manipulative behaviors and make false allegations regarding staff. The Care Plan dated 9/11/25 documents R1 present with physically aggressive behavior. R1 was involved in a physical altercation with a peer on this day. R5's Care Plan, dated 9/11/25, documents R5 is at risk for abuse and neglect. R5 was involved in a physical altercation with a peer on this day.R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status Score (BIMS) as a 15 (no cognitive impairment). Section E documents R1 has exhibited verbally aggressive behavior within one to three days from this assessment.The Minimum Data Set for R5 dated 8/22/25 documents a Brief Interview for Mental Status score as 15 (no cognitive impairment). A policy titled, Abuse Policy and Prevention Program, dated 10/2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to monitor and document a dependent resident's fluid intake for all meals that required one to one supervision during meals and failed to assess for signs and symptoms of dehydration. This affected one of four residents (R1) reviewed improper nursing care and dehydration. This failure resulted in R1 being emergently transferred to the hospital and diagnosed with severe hypernatremia (excessively high sodium level in the blood) and AKI (Acute Kidney Injury). R1 was hospitalized for 5 days requiring intravenous fluids and antibiotic treatment. Findings include: R1 is [AGE] years of age. Current diagnoses include but are not limited to Cerebral Infarction, Dementia, Type 2 Diabetes Mellitus, Hypertension, Hypernatremia, Epilepsy, and Hyperlipidemia. R1's comprehensive assessment section C cognitive patterns, dated 3/31/25, documents a Brief Interview for Mental Status score of 9 out of 15. R1 had moderate cognitive impairment. R1 was initially admitted to the facility on [DATE]. R1's lab results from 4/7/25 indicate a sodium level of 158 H (high). R1's diet order, dated 3/31/25, states: Low Concentrated Sweets Diet Mechanical Soft texture, Thin consistency, 1:1 supervision at all meals. R1's progress notes document him being seen by V11, Nurse Practitioner on 4/17/25. There were no concerns documented regarding the elevated sodium level. There is no area in the electronic charting to document the amount of fluid being consumed by each resident. R1 does not have any fluid intake documentation in his electronic documentation upon review. R1's care plan states: R1 has Alzheimer's Dementia and may display moods/behaviors related to diagnosis. Interventions state: do not rush resident. Provide adequate time during resident care and meals. R1 is as risk for alteration in fluid volume related to disease progression. Interventions state: Encourage fluid intake. Monitor resident for early signs and symptoms of dehydration: thirst, loss of appetite, dry skin, dark colored urine, fatigue. R1's progress notes from 4/20/25 at 6:55 AM state: Contact person made aware of the change in health condition and transfer to the hospital. R1's progress note on 4/20/25 at 7:29 AM states: The resident was lethargic around 6:48 am when the staff went to clean him up. On assessment, BP (blood pressure) 124/93, H (heart rate) 133, R (respirations) 24, T (temperature) 98.6, SP02 (pulse oximetry) 94 RA (room air). Plan to send resident to ER (emergency room) for further evaluation. R1's progress note on 4/20/25 at 10:16 AM states: Per ER (emergency room) RN (Registered Nurse) resident is being admitted for sepsis, acute kidney injury, elevated WBC (white blood cell count) 13.9 and abnormal labs (Sodium 177, BUN 60, Lactic acid 2.1, and Creatine 2.65). R1 was admitted to the hospital with severe hypernatremia (excessively high sodium level in the blood), AKI (Acute Kidney Injury) lab values- creatinine 2.65 suspected secondary to dehydration. (Creatinine is a waste product of muscle metabolism that is normally filtered out of the blood by the kidneys. A high level may suggest kidney damage.) Abnormal laboratory values, elevated troponin level in the blood (damage to the heart muscle), pyuria (presence of abnormally high number of white blood cells or pus in the urine) and hematuria (presence of blood in the urine). Patient initiated on IVF (intravenous fluid) rehydration and IV antibiotics and will be admitted for further workup and management with nephrology on consult. R1's 4/20/25 nephrology consult states: assessment/plan- AKI Acute Kidney Injury secondary to relative hypotension and poor po (oral) water intake. R1 was hospitalized for 5 days. He returned to the facility on 4/25/25, with physician orders to continue oral antibiotics for another 14 days. R1 died in the facility on 5/14/25. On 6/2/25 at 10:43 AM, the secured unit was observed. There was a water station set up with a large container with iced water and cups. Multiple residents were seated at the tables during a coloring and music activity, and only a few have cups of water. On 6/2/25 at 10:46 AM, V3, CNA/Certified Nurse Assistant, was asked about providing hydration. V3 said, Activities does hydrate the residents with juice, snacks, and coffee. We give out water throughout the day. The resident's swallow precautions are on the meal plan and on our charting. V3 was asked about providing care for R1. V3 said, (R1) was on a pureed diet with regular liquids. He had a hard time seeing, so we had to feed it to him. He would spill liquids and make a mess with his food, so we started helping him. His family would come in 2-3 times a week and help with feeding him. I didn't notice him decline when he was sent to the hospital. On 6/2/25 at 11:01 AM, V4, Activity Assistant, was asked about providing hydration. V4 said, I provide snacks and water throughout the day. V4 was asked about R1's hydration. V4 said, (R1) needed help because he couldn't see it all the way. How much he drank would depend on the day and who was helping him at the time. Some people leave if he stopped eating or drinking. I try to come back and finish helping him because sometimes he may forget he has something to drink or eat. I'm a CNA too, for 47 years. He declined a little before he went to the hospital. On 6/2/25 at 12:14 PM, lunch was being served. The meal was meatballs, rice, broccoli, cookie, and 4 oz fruit punch. Water was not provided by staff during the lunch meal to any of the residents eating in the dining room. Each resident's lunch tray was provided a 4 ounce cup of fruit punch. On 6/3/25 at 9:07 AM, V7 said, Most cups are 8 ounces. With breakfast, the residents get 8 ounces of juice and a 8 ounce carton of milk. About 10AM, we pass out ice water. Most of the residents drink whatever we give them. Some drink coffee. The residents that need assistance, I try to sit them close together so it's easier to get to them. We have to stay with them and make sure they drink their cup. We pick up their trays and see much they eat. I've been here 10 years. I remember what they eat. If they don't eat their usual, I know something's going on. We have to pay attention to them. We have to chart it in the computer. On 6/3/25 at 9:27 AM, V8, LPN Licensed Practical Nurse, was asked about resident hydration and intake documentation. V8 said, Most residents on this unit have Dementia or Alzheimer's, and some have high behaviors. They need assistance with ADL's (activities of daily living). We have a few residents who need to be fed. We have staff in the dining room monitoring every 30 minutes. They do activities and provide snacks and beverages. We have a water pitcher, and we give them water every 2 hours. The CNA's (Certified Nurse Assistant) have to monitor how much the resident's intake and chart it. The feeder residents need more attention with meals, and staff is responsible for making sure they're drinking between meals. The nurse makes sure the CNAs charting is done. We have unit managers that come check daily. I come in and assist them when the trays come down. The trays have a ticket with the resident's name and diet to make sure each resident gets the right tray. The aide would have to remember what each resident ate and drank. I don't know about their charting; you'd have to ask a CNA. V8 was asked about R1's hydration and documentation. V8 said, Some days (R1) needed encouragement and other times he'd need to be fed. Most of the CNA's got him up in the dining room. He had vision issues, so we'd have to give him his spoon and tell him where things were on his tray. Someone would have to put his cup in his hand and tell him he had a cup with something to drink. We had to get close to him so he could hear us because his hearing wasn't that good. Before he went to the hospital, he needed more assistance with feeding, and he was talking less. On 6/3/25 at 10:25 AM, V4, Activity Assistant, and V9 passed out 4oz cups of water to the residents in the dining room. At 10:45 AM, residents are seated at the table with water in front of them. Staff were not encouraging residents to drink water. On 6/3/25 at 10:54 AM, V10, Restorative CNA, was asked about resident hydration and intake documentation. V10 said, We can do the meal percent of what they eat for each meal. There should be a way to document the fluid intake. I haven't used the system in a while. On 6/3/25 at 11:25 AM, V7 was asked about documenting a resident's fluid intake. V7 said, There's no place to document the fluids, it's only the amount of food eaten. It's a new charting system since January when the new company took over. On 6/3/25 at 11:27 AM in the dining room, V7, CNA, asked V9, CNA, if there was a place to document the resident's fluid intake in the electronic charting. V9 said, No. On 6/3/25 at 12:12 PM, lunch arrived. The meal was smothered pork chop, carrots or corn, baked potato, Jello, and 4 ounces of juice. Water was not provided by staff during the lunch meal to any of the residents eating in the dining room. On 6/3/25 at 1:19 PM, V5, Registered Nurse, was asked about R1's condition and care. V5 said, I've been working there 2 years, but I don't have a set unit. It was my first time working with (R1). The CNA called me to his room. I don't remember who it was. The CNA said his upper arms were very warm and his legs were cold, so I went in to assess him. I found him tachycardic. The CNA said he wasn't the same as he usually was. I called the doctor, but couldn't get a hold of him right away. I raised his head of bed and did all the vital signs. All the other vitals were OK. I called the Director of Nursing and told her what was going on, and she said it was OK to send him out. I notified the family and called the ambulance. I felt something was going on because his heart rate was so high, so I sent him out for further evaluation. On 6/3/25 at 2:15 PM, V12, CNA, was asked about assisting R1 with care, hydration, and meals prior to him being hospitalized on [DATE]. V12 said, I remember (R1). I helped clean him up that morning before he went out. He was really tired. I got him up and he ate a little breakfast, not too much. He ate just a little at lunch too. It was almost change of shift, and (V14, Family Member) helped me put him in bed. (V14) was there when I changed him. He was wet with urine. He was different than his normal, really tired. (V14) said the same thing. He definitely had some changes that day. He usually has a good appetite, he'll eat everything. He was a total assist with everything, so I fed him. I think he was blind. I'd have to hold the spoon and cup for him. He'd follow commands and respond if he didn't like something. On 6/4/25 at 10:59 AM, V15, Dietician, was asked about fluid intake monitoring and R1's diet. V15 said, I started working with (R1) in May related to his wounds. I only followed him for one week before he died. He was diabetic and had dementia that was progressing. He was underweight, so I ordered a sugar free supplement. He was on a mechanical soft diet with thin liquids. His order was supervision at all meals, but I had just started working with him so I'm not quite sure when it was ordered. Staff should record the percentage of food eaten after each meal, the same with fluids too. It's important because residents with impaired cognition have PO (oral) intake that varies with each meal. Documentation is important because there is a risk for dehydration. Residents forget to drink; they have a decreased instinct to drink water. Staff should encourage and set out hydration. I wasn't aware the facility wasn't documenting fluid intake. On 6/4/25 at 11:52 AM, V2, Acting Director of Nursing, was asked about fluid intake monitoring, documentation, and R1's diet order. V2 said, I am the nurse consultant for the facility. I'm filling in until the new Director of Nursing starts. I'm not familiar with (R1). The CNAs are to monitor how much the residents are eating and report to the nurse if they aren't drinking. They can use the meal ticket to document how much they ate and transcribe it to (electronic documentation). I'll have to check the CNA charting, I'm not sure what they can chart. The facility policy on meal and fluid intake and documentation was requested. V2 did not provide a facility policy for review. The facility assessment is uesd to determine what resources are necessary to care for residents competently during daily operations and emergencies. The updated December 2024 facility assessment states:( the facility is licensed to care for residents with the following) diseases/conditions, physical and cognitive disabilities - Alzheimer's Dementia, Hypertension, Seizures (Epilepsy), Diabetes. General Care- Nutrition: Specific Care or Practices: individualized dietary requirements, fluid monitoring. Assistance with activities of daily living: eating (independent, assist of 1-2 staff, and dependent residents). Staff type: Nursing services (DON, ADON, RN Supervisors, RN, LPN, CNA, etc.). Food and Nutrition Services (Director, support staff, Consultant Registered Dietician). Training topics: Licensed nursing staff: identification of resident changes in condition- identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. Non-licensed nursing staff- care of resident with Dementia. Competencies: Non licensed nursing staff: measurements- recording intake. The undated Registered Nurse/ Licensed Practical Nurse job description states: Basic function: under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, resident nursing care, staff performance and adherence by staff members to facility policies and procedures. Essential duties: 2. Implement total nursing care plan through assessment, planning, and evaluation. 9. Recognize significant changes in the condition of residents and take necessary action. The undated Certified Nurse Aide job description states: Basic function: To provide assigned residents with routine daily nursing care in accordance with established nursing care procedures, state, and federal guidelines, and as directed by your supervisor. Essential Duties: 19. Observe and report any physical or emotional changes observed in the residents including any complaints or grievances made by the resident. 20. Prepare resident for meals, assist serving food trays or feed as necessary and record/or report residents' intake or acceptance of food.

Based on interview and record review, the facility failed to ensure physician orders for daily wound care treatments were completed as ordered; failed to ensure daily monitoring of a wound for presence of possible complications such as signs of increasing area of ulceration or signs of soft tissue infection; and failed to ensure care plan interventions for alteration in skin integrity were implemented for one (R1) of four residents reviewed for wound care. These failures resulted in R1 developing a worsening coccyx pressure ulcer and require transfer to a local hospital with a diagnosis of septic shock due to pressure wound infection requiring admittance to the intensive care unit for five days. Findings include: R1 is [AGE] years of age. Current diagnoses include but are not limited to Cerebral Infarction, Pressure Ulcer of Sacral Region, Obesity, Type 2 Diabetes Mellitus, and Hypertension. R1 was originally admitted to the facility from the hospital on 1/8/25. R1's admission assessment documents a community acquired sacral wound. R1's comprehensive assessment section C cognitive status dated 1/15/2025 documents a brief interview for mental status score of 15 out of 15. A score of 13-15 indicates the person is cognitively intact. Review of R1's records document the following: R1 was admitted to the facility on [DATE] from the hospital. R1's admission assessment documents a sacral wound. The MDS section M documents R1's unstageable sacral wound. R1's 1/9/25 lab results for the WBC (White Blood Cell) count was 13.62 (H) High. The white blood cell count is a measure of the number of white blood cells circulating in the blood stream. [NAME] blood cells are essential for the immune system, playing a crucial role in fighting infections and other threats in the body. The reference (normal) range for adults per the lab result is 4.80 - 10.80. A high white blood cell count also known as leukocytosis, can occur due to a number of possible reasons, including infections, inflammation, or bone marrow disease. R1's care plan states: R1 has alteration in skin integrity to coccyx- unstageable. Date initiated: 01/09/2025. Goal: R1 will be free from complications through next review date. Interventions: Assess wound with each dressing change. Date initiated: 01/09/2025. Monitor for infection: Peri-wound erythema (redness)- Increased drainage and odor- Increase pain- Peri-wound swelling- Exposed bone- Pressure wound deterioration. Date initiated: 01/09/2025. Treat as ordered by MD. Date initiated: 01/09/2025. V9 Wound Physician's 1/21/25 wound evaluation and summary states in part: stage: unstageable DTI (deep tissue injury) within and around wound, wound size (Length x Width x Depth): 15.5 x 20 x 0.1) cm centimeters, exudate: light sero-sanguinous (wound drainage secreted by an open wound in response to tissue damage), wound progress: exacerbated due to generalized decline of patient. Additional wound details: patient with significant wound decline, patient with poor po (by mouth) intake, concern for possible skin failure, if no plans for aggressive interventions i.e. g-tube (gastrostomy/ stomach tube) etc., would consider hospice referral. On 1/10/25, V3, Wound Care Nurse, documents an unstageable coccyx wound measuring 5.0 cm x 1.0 cm x undetermined with light serous drainage. Wound has 75% slough. The wound care order documents clean sacrum with normal saline cover with dry dressing q shift, every day shift for open area and as needed for when wet. V10, NP/Nurse Practitioner's, 1/11/25 progress note states: Patient is compliant with care, dietary, and medication regime. Labs 13.62. Assessment/Plan- monitor labs as ordered. V9, Wound Physician's, note from 1/14/25 states: unstageable coccyx full thickness wound. Etiology (cause): pressure. Noted to be present on admission per staff. R1 underwent a surgical excisional debridement procedure (surgical procedure that involves removing dead or infected tissue from a wound). Dressing treatment plan: Leptospermum honey apply once daily for 30 days. Gauze island with border apply daily for 30 days. V11 Physician's 1/15/25 progress note states: Labs reviewed. Skin: see wound care note for assessment. V8, RN's, 1/21/25 at 11:36 AM, progress note documents, writer received resident in bed resting. Resident was drowsy, responsive to tactile stimuli only, tachycardia noted, hypoxic, and sacral wound has purulent drainage. Primary physician was contacted for recommendation. Resident was sent to hospital via transportation escorted by two EMT (Emergency Medical Technicians). Last vitals, BP blood pressure 140/68, HR heart rate 105, BS blood sugar 133, O2 (oxygen) on 2L (liters) nasal canal 94%. On 1/21/25 R1 was sent to the hospital emergency department and was admitted for septic shock due to a sacral pressure wound infection. R1 was admitted to the ICU (Intensive Care Unit) until 1/26/25 (5 days). V2, Director of Nursing/DON provided R1's 1/1/25 - 1/31/25 electronic treatment administration record. There is no documentation of R1 receiving the prescribed wound care treatments from 1/8/25 through 1/12/25. There is no documentation of the wound care treatment being completed on Saturday 1/18/25. V3, Wound Care Nurse, documented completing R1's treatment on Wednesday 1/22/25, while R1 was admitted to the hospital intensive care unit. R1 was sent to the hospital on 2/8/25 by family request, and did not return to the facility during the investigation. On 2/18/25 at 1:46 PM, V3, Wound Care Nurse, said, I think she came from the hospital with her wound. She admitted here with an unstageable wound to her coccyx area. I did her wound care Monday through Friday. The floor nurses did it on the weekend. On 2/18/25 at 3:10 PM, V6, LPN/Licensed Practical Nurse, said, I work every other weekend. If (V3, Wound Care Nurse) isn't here we're responsible for our resident's wound care. (V3) stocks all the wound care supplies in the carts on Friday. I try to do the dressings changes during the CNA(Certified Nurse Assistant) rounds. On 2/19/25 at 12:03 PM, V8, RN/Registered Nurse, said, I had (R1) for day shift. I float through the building, so I wasn't familiar with her. I didn't get anything concerning in report about her that morning. She was tachycardic (fast heart rate) and her blood pressure was up. Her vitals were accurate as I documented. The aide said she wasn't eating well. She was drowsy. Her wound looked to have some infection; the drainage was thick, yellowish color. I can't recall if it had any odor. (R1) didn't complain of any pain. On 2/19/25 at 12:38 PM, V3, Wound Care Nurse, said, I think she was admitted on [DATE]th sometime that evening. When I came in January 9th, I pulled the admission report to see if we had any new admissions. I went to see her, and she refused. I thought I charted it, but it's not there. January 10th, she allowed me to do a skin assessment. She had a unstageable wound with slough. I don't recall it having any purulent drainage or odor. V3 was asked what were R1's admission orders for wound treatment? V3 said, Clean with normal saline and cover with a dry dressing. V3 was asked where were R1's wound treatments documented? Why is the treatment administration record blank from 1/8/25 - 1/12/25? V3 said, It's supposed to be documented in the TAR (treatment administration record). When a treatment is done it's supposed to be documented. Not sure what happened. V3 said, I'm with the doctor when she comes on Tuesdays. The next day the doctor would have seen her was on January 14th. The treatment ordered was Medi honey with a bordered gauze daily. She had a debridement; the doctor removed the layer of slough from the wound. (R1) tolerated the procedure. V3 was asked about the assessment of R1's wound on 1/21/25. V3 said, The wound care doctor was here and saw R1 that day. The wound declined. There was light serous exudate (wound drainage). When did you become aware of R1 being hospitalized and what was her admission diagnosis? V3 said, I don't know when (R1) went to the hospital. What did you assess during R1's wound treatments from 1/15/25 - 1/21/25? V3 said, I think she had a change in size and appearance. If a wound is infected, you'd see peri wound changes, purulent drainage, heat around peri wound, redness. I didn't see any of this in her wound. V3 confirmed the TAR for 1/1/25 to 1/31/25 was missing documentation of R1's wound care treatments. R1's wound care treatments were not performed as ordered by the physician. V3 and nursing staff did not monitor R1's wound for the presence of possible complications or presence of infection. On 2/19/25 at 1:21 PM, V2, Director of Nursing/DON, was asked about the policy regarding following physician orders for wound care treatments. V2 said, You get the order from the doctor and carry it out per they physician order. I sign out the order that it's completed on the TAR (treatment administration record). Documenting confirms that the treatment was done. There's no signature on the yellow spaces on the TAR. No one signed the treatment out. It's not completed. V2, DON, continued, (R1) had labs done when she was admitted , and her WBC (White Blood Cells) were elevated already. The in house NP, (Nurse Practitioner, V10) and (V11, Physician) saw (R1) that week and said to monitor (R1) since she was asymptomatic. (V10's, NP), 1/11/25 note she documented (R1's) leukocytes as 13.62, she only put continue to monitor in her assessment. (V3) told me (R1) had some slough and (V9, Wound Physician) did a debridement. She had poor intake, and she was refusing wound care multiple times. V2 was asked about documentation of refusing wound care. V2 said, It should be in the progress notes. V2 was asked who is responsible for completing the wound care treatments when V3 is not in the facility? V2 said, The nurses are assigned the treatments per the treatment schedule and it's posted on the dash board in PCC (point click care electronic medical record). The nurses are to complete the treatments and document. V2 confirmed R1's TARs were documented, and the wound treatments were not performed as ordered by the physician. V2, DON, provided 36 pages of R1's progress notes from 1/8/25 - 1/23/25. There was no documentation of R1 refusing wound care treatment multiple times. V2 provided a care plan, initiated for R1 on 2/3/25, documenting refusal of care after her hospitalization for septic shock due to sacral pressure wound infection. On 2/19/25 at 3:00 PM, V9, Wound Physician, said, She had a wound on her bottom with clinical decline. She needed a debridement. I wasn't aware of her elevated WBC (White Blood Cells- lab value). I wasn't informed because I didn't order them. Her wound was significantly larger, much bigger than my debridement and the tissue looked different. It was a deep purple color. I don't remember it having drainage. She wasn't very responsive about having pain. When I saw her on January 14th, I wanted them to contact her primary doctor because she looked different. It wasn't necrotic, it was a deep dark purple color. When I see a wound declining that means something else is going on inside, something clinically was going on with her because her wound had a dramatic change. Everything was documented in the notes. On 2/20/25 at 1:37 PM, V1 was asked about the expectation of the wound care and nursing staff when a resident has physician orders for wound care treatment. V1 said, For the wound care nurse and nursing staff to carry them out and chart the documentation. It's important because it's a part of the resident's medical record and shows that we completed the physician's orders. The 1/2024 reviewed Skin Management: Monitoring of Wounds and Documentation policy states: General: It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. Responsible party: All nursing staff General Guidelines: An evaluation of the PU (pressure ulcer)/ PI (pressure injury) if no dressing present; An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); The status of the area surrounding, the PU/PI (that can be observed without removing the dressing); The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound); and whether pain, if present, is being adequately controlled. General Monitoring Guidelines: With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI should be documented. At a minimum, documentation should include the date observed and: location and staging; size (perpendicular measurements of the greatest extent of length and width of the PU/PI, depth; and the presence, location and extent of any undermining or tunneling/sinus tract; exudate, if present: type (such as purulent/serous), color, odor, and approximate amount; Pain, if present: nature and frequency (e.g. whether episodic or continuous); Wound bed: color and type of tissue/character including evidence of healing (e.g. granulation tissue), or necrosis (slough or eschar); and description of wound edges and surrounding tissue (e.g. rolled edges, redness, hardness/induration, maceration) as appropriate.

Based on interview and record review, the facility failed to immediately notify the physician and obtain an order to transport a resident with an acute change in mental status and respiratory status to the hospital. This affected one of three residents (R1) reviewed for acute change in condition. This failure resulted in R1 experiencing an acute change in condition at on 10.13.24 at approximately 7:00am, and the facility staff not notifying the physician or calling EMS until 10:44am. R1 was admitted to the hospital with a diagnosis of aspiration pneumonia and sepsis secondary to pneumonia. Findings include: R1's EMS (Emergency Medical Services) run sheet, dated [DATE], notes EMS 911 was notified at 10:44AM for an unresponsive resident. Emergency crew was dispatched and arrived at R1's bedside at 10:54AM. R1 remained unresponsive to verbal and painful stimuli throughout transport to the hospital. R1's heart rhythm showed atrial fibrillation with rapid ventricular response. R1's lung sounds with rhonchi (gurgling) throughout right and left lungs. R1's hospital medical record, dated [DATE], notes per facility staff, R1 was eating at 8:30AM and was alert and oriented x 2, R1's baseline. R1 wears oxygen at 2 liters per nasal cannula, oxygen saturation was 85% on oxygen. R1 only responded to painful stimuli. R1 presented to the emergency room with a chief complaint of unresponsiveness and respiratory distress. EMS crew reports that they found R1 with vomit on clothes and mouth, unresponsive, and in respiratory distress. Initial work up in the emergency room revealed opacification throughout the entire right lung with some opacification in the left lung most concerning for aspiration. On initial assessment by the intensive care team, R1 is minimally responsive with audible gurgling with breathing. Per heart monitor, R1 in atrial fibrillation with rapid ventricular response, heart rate 120s-130s. R1 with elevated troponin level (protein found in the heart muscle which leaks into the bloodstream when the heart muscle is damaged resulting in increased level) due to demand ischemia (when the heart's need for oxygen is greater the body's ability to supply it. Initially R1's troponin level was 202 (normal range is less than 52); worsened to 240. CT (computed tomography) scan noted anasarca (severe buildup of fluid in the tissues of several parts of the body). On re-evaluation, R1's gurgling significantly worse, R1 even less responsive than previous with minimal movement to painful stimuli and evident respiratory distress. The intensive care physician expressed concern to R1's family that R1 is unlikely to survive this event and that antibiotics are likely futile given the severity of R1's illness and current medical condition. R1's code status was changed to DNR (Do Not Resuscitate) and R1 was placed in hospice on comfort measures only. R1 expired on [DATE]. R1's medical record, dated [DATE] at 10:55am, V4, RN, noted V14 alerted by staff that R1 was experiencing a change in condition. Further assessment revealed R1 was lethargic unresponsive to verbal and tactile stimuli. Adventitious (abnormal) lung sounds noted. Head of bed elevated to promote effective breathing. Physician made aware. R1 sent to hospital for further evaluation. R1's SBAR (situation, background, appearance, and review and notify) form, dated [DATE], notes the change in condition, symptoms, or signs observed and evaluated is/are: altered mental status, tired, weak, confused, or drowsy, and shortness of breath. The vital signs documented, temperature 97.1 degrees Fahrenheit, pulse 80 beats/minute, respirations 18/minute, blood pressure ,d+[DATE], and oxygen saturation level 98%. It notes R1's physician was not notified. R1's family was not notified until 11:00AM. R1's e-Interact form, dated [DATE], notes R1's most recent vital signs were obtained at 6:57AM: temperature 97.1, pulse 80, respirations 18, blood pressure ,d+[DATE], and oxygen saturation level 98% on room air. There is no documentation found in R1's medical record noting R1's vital signs were obtained at the time of this event. On [DATE] at 2:00PM, V4, CNA (Certified Nurse Aide) stated R1 did not feel well on [DATE]. V4 stated R1 did not eat breakfast due to not feeling well. V4 stated R1 was short of breath. V4 stated R1 had oxygen on, but was still trying to catch her breath. V4 stated R1 looked different, not usual self, at the start of V4's shift that day; V4 works 7:00AM-3:00PM. V4 stated she let nurse/unit manager know right away of R1's condition. On [DATE] at 9:25AM, V6, CNA, stated she was working on [DATE] on day shift. V6 stated she was not assigned to R1 that day, but is familiar with R1. V6 stated breakfast is served on the 500 and 600 nursing units between 8:00AM and 8:30AM. V6 stated V6 was charting at the nurses' station shortly after breakfast time, when V4 asked V6 to come look at R1, because R1 did not look good. V6 stated V6 observed R1's eyes closed, not responding to verbal stimuli, and heard rattling noises in R1's chest. V6 stated V6 left R1's room and sat at the nurses' station while V4 went to find a nurse. V6 stated there were no nurses present on the 500 and 600 nursing units at the time of this event. V6 stated V4 went to get V14 (nurse), who was working on the 800 nursing unit. V6 stated V10 (non-clinical manager on duty) was called. V6 stated when V10 saw what was going on with R1, V10 immediately called for V14. On [DATE] at 9:40AM, V7, CNA, stated she was at the nurses' station after breakfast when V4 CNA told her to look at R1. V7 stated V7 observed R1's eyes were closed, R1 was not talking, non-responsive to verbal stimuli, and with rapid breathing. V7 stated V7 left R1's room after seeing R1. On [DATE] at 9:50AM, V8, RN (Registered Nurse) stated this facility's change in condition protocol is to perform a head-to-toe assessment, obtain vital signs, and call the physician or nurse practitioner and get orders to treat the resident in this facility or send resident out to the hospital. On [DATE] at 10:50AM, V9, ADON (Assistant Director of Nursing) stated she was the clinical MOD (manager on duty) on ,d+[DATE]. V9 stated V9 was notified after breakfast by V14, RN (Registered Nurse). V9 stated V14 informed her R1 did not look well, had vomited, and was not responding like R1 normally does, only responding to sternal rub. V9 stated V14 performed a head-to-toe assessment and obtained vital signs prior to calling V9. V9 stated she was en route to the facility, but not close enough to assess R1 herself, and instructed V14 to send R1 out to the hospital. V9 stated breakfast is served on the 500 and 600 nursing units at 8:45AM or 9:00AM. V9 stated V9 believes it was 9:30AM or 9:45AM when V14 called her. V9 stated V9 arrived at this facility at 10:15AM or 10:30AM. V9 stated R1 was transported to the hospital prior to V9's arrival to facility. On [DATE] at 11:00AM, V10 (non-clinical manager on duty) stated the CNAs, V4 and V7, told her R1 did not look well. V10 stated V10 went to the 800 nursing unit and got V14, RN, to come assess R1. V10 stated V10 went in with V14 to see R1. V10 stated V10 observed R1 still breathing, V14 checked her and then immediately called EMS 911 to transport R1 to the hospital. On [DATE] at 9:50AM, V14, RN (Registered Nurse), stated staff got her about 10:30AM on [DATE]. V14 stated she was informed by V10 (non-clinical MOD) that R1 was experiencing a change in condition, and was asked if she would go assess R1. V14 stated V14 observed R1 to be non-responsive to verbal and tactile stimuli and with adventitious lungs sounds. V14 stated V14 obtained R1's vital signs and checked R1's blood sugar just in case non-responsiveness was due to hypoglycemia (low blood sugar). V14 stated V14 does not recall what R1's vital signs or blood sugar results; would have to defer to her charting from [DATE]. V14 stated V14 elevated R1's head of bed to promote effective breathing and then called EMS 911. V14 stated V14 did not call the physician because it is a medical emergency when a resident is non-responsive. V14 stated V14 did not ask where R1's nurse was, just did what she was asked to do. On [DATE] at 11:46pm, V15, LPN (Licensed Practical Nurse), stated V15 stayed over from the night shift to work on the 500 nursing unit due to a nurse calling off. V15 stated she worked until a replacement nurse took over her assignment. When questioned where V15 was when V4, CNA, was looking for her after breakfast regarding R1, V15 stated she was passing medications to residents in the dining room. When questioned reason V4 did not find V15 in the dining room, V15 stated she was in residents' rooms. V15 stated she last saw R1 at 9:30AM, and R1 was fine and was talking. V15 stated she left the facility at 10:00AM after giving verbal report to V9, ADON, who was taking over her assignment. On [DATE] at 9:15AM, V9, ADON, stated V15 left this facility prior to her arrival. V9 stated V15 did not provide a verbal report on residents, nor R1's change in condition. V9 stated V9 called V15 for a couple of days, without success. V9 stated V9 was trying to interview her regarding the event that took place on ,d+[DATE] with R1. V9 stated when she finally spoke with V15, V15 informed her R1 did not look good, and she reported R1's condition to V19 prior to leaving facility. V9 stated the off-going nurse is expected to stay on the nursing unit until the on-coming nurse arrives and takes over the assignment. V9 stated the nurse is expected to assess the resident, obtain vital signs, and notify the physician immediately when there is a change in resident's condition. V9 acknowledged R1 was not fine at 9:30AM, based on staff interviews. This facility's notification of change policy, dated [DATE], notes the requirement for notification of resident, resident representative, and the physician is when there is a significant change in the resident's physical, mental, or psychological status. A significant change includes deterioration in health in either life-threatening conditions or clinical complications.

Based on interview and record review, the facility failed to prevent an incident of resident-to-resident physical assault. This affected two of three residents (R9, R10) reviewed for physical abuse. This failure resulted in R10 pushing R9 to the ground unprovoked, and R9 sustaining an extensive intraparenchymal and subarachnoid hemorrhages from hemorrhagic contusions and extensive skull fractures extending from the vertex anteriorly and posteriorly. Findings include: R9 was admitted to the facility on [DATE], with diagnosis of dementia without behavioral disturbances, hypertension, dysphagia, and cognitive communication deficit. R9 brief interview for mental status, dated 7/23/24, documents should not be conducted because resident is never /rarely understood. R10 was admitted to the facility on [DATE], with a diagnosis of dementia without behavioral disturbances, cognitive communication deficit, and major depressive disorder. R10's Brief Interview for Mental Status score, dated 7/8/24, documents a 13/15, which indicates cognitively intact. R9's facility reportable, dated 9/24/24, documents: R10 was ambulating in the dining room area. R9 was standing in the pathway of R10. R10 pushed R9 out of the way. R9 fell back and hit her head on the floor. A moderate amount of blood was noted from posterior scalp, first aid rendered. R9 denied any pain and level of consciousness within normal baseline. R9 sent to hospital for further evaluation. R9 admitted to hospital for fractured skull. Under resolution: R10 was ambulating in the dining room as she approached two residents standing in her pathway. R10 pushed R9 out of her way. R10 continued to ambulate and sit down at a nearby table. R9 fell back and hit her head on the floor. R9 was sent to local hospital and admitted for fractured skull. R10 was assessed and said she was looking for something. R10 was calm cooperative and easily redirected. One to one monitoring initiated by staff. R9 and R10 had no previous interactions prior to incident. There was no previous behavior noted by R10. Plan of care updated. No concerns noted. R9's incident report, dated 9/24/24, documents: Resident was standing up when another resident pushed her. The resident fell backwards. Resident was assessed and noted with laceration to the back of her head and two skin tears to the left elbow. Resident alert with confusion. Under statements: V19(Certified Nursing Assistant/CNA) and V22(CNA) I was monitoring the dining room when one resident walked up and pushed another resident down. I was unable to stop it. I notified the nurse. Under notes: Resident was standing in dining room when another resident pushed her, she fell down to floor and to the back of her head. No previous behaviors noted from either resident, Resident was sent out to emergency room and noted with a fractured skull. R9's hospital record, dated 9/24/24, documents under diagnosis subarachnoid hemorrhage, intraparenchymal hemorrhage of the brain, contusion of cerebrum, closed fracture of the skull. Under history: Patient arrived from nursing home with scalp laceration after witnessed fall when patient was pushed by another resident. Under physical exam: Approximate two-centimeter laceration to posterior scalp, skin tear left elbow. Under CT head impression: Extensive intraparenchymal and subarachnoid hemorrhages from hemorrhagic contusions, intraventricular hemorrhages as described with bilateral frontal lobes from the vertex to the anterior skull base. Extensive skull fractures extending from the vertex anteriorly and posteriorly as described. R9's hospital record, dated 9/25/24, documents: trauma transfer. Glasgow coma scale score of 7 (Severe brain injury). Ambulance run report, dated 9/24/24, documents: crew dispatched to local hospital for subarachnoid hemorrhage. Upon arrival resident was found in supine in bed. Patient is responsive to touch but is non-verbal. Per nurse patient was pushed down at the nursing home resulting in multiple fractures to the head and a subarachnoid bleed. Patient is to be transferred to another hospital for further care and treatment. R10's progress note, dated 9/25/24, documents: the writer asked resident why she pushed peer and resident stated there was no reason. Writer informed the resident of the risk of physical aggression. R9's abuse care plan, dated 10/3/24, documents R9 is at risk for abuse. Interventions, dated 10/3/24, documents: Assess for abuse risk quarterly and as needed; Observe for signs and symptoms of abuse; Report all instances of alleged abuse to the abuse coordinator. On 10/9/24 at 10:48AM, V19(CNA) said she was in the dining room when incident occurred between R9 and R10. V19 said she saw R10 was at one table and R9 was at another table and staff was getting ready to serve dinner. R10 and R9 had no previous interactions prior to incident. They both got up and were walking towards each other between table and chairs. V19 said there was enough space for both residents to pass each other. R10 just pushed R9 to the ground and did not say anything and kept walking. On 10/10/24 at 11:59AM, V2(DON) said she spoke to R10 after the incident, and R10 reported she pushed someone but didn't know why, and was looking for something. On 10/10/24 at 4:25pm, V1 (Administrator) said she reviewed the video footage of R9's incident and said R10 was ambulating towards the window in dining room. There were two other residents standing in path of R10. R9 was standing to the right, and R10 used her hands and pushed R9 out of the way and continued towards the window. R9 fell backwards to the ground. Facility's abuse prevention policy undated documents: The facility affirms the right to our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than accidental means. Abuse is the willful infliction of injury with resulting harm, pain or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Based on interview and record review, the facility failed to ensure safety measures were in place to prevent avoidable resident accidents. This affected two of three (R7, R8) reviewed for safety. This failure resulted in R7 wheelchair not being secured in a medivan, R7 sliding out of the wheelchair sutaining a comminuted transversely impacted fracture of the right tibial (shin bone) and fibula (long slender bone in the lower leg that run alongside the tibia) requiring surgical intervention and the application of a long leg cast and a left proximal tibia fracture with hemarthrosis (bleed into joint space) requiring aspiration and application of long-leg splint; and facility staff not applying foot/leg support to R8's wheelchair resulting in R8 feet hitting the ground abruptly stopping and falling forward while being pushed by staff. R8 sustained a laceration to the left eye which required four sutures. Findings Include: 1. R7's progress note, dated 9/9/24, documents: Resident returned from emergency room . Per the previous nurse, resident was sent to the hospital from the dialysis center due to complaint of leg pain. Upon assessment, the right knee looks swollen, and resident complained of pain more to the right leg. emergency room diagnosis states Acute Pain of both knees. Knee pain of uncertain cause. Patient Incident Report Form, dated 9/9/24, documents: While transporting R7, V26 turned around to check on R7, V26 noticed R7 sliding out of the wheelchair. V26 preceded to pull the van over to park safely. V26 went to help position R7 a little better in the chair and moved his leg on the leg rest. The leg rest on his wheelchair was not fully functioning. V26 could only do so much. V26 couldn't fully move him alone. Before proceeding to R7's appointment, V26 asked R7 several times was he ok. R7 responded the first time and said yes but my leg. V26 asked R7 if he was positioned ok now R7 said yes. The second time V26 asked him, he said yes do you have some candy?. V26 chuckled and said no. Once V26 arrived at dialysis to drop R7 off, V26 asked for someone's help to make sure R7 was sitting up properly before removing R7 from the van. They came to help and brought him inside. When V26 returned for pick up, the front desk told V26 they were getting R7 ready. While in the waiting room thirty minutes went by and the ambulance grabbed R7. V26 was then told R7 was not feeling well and complaining about his leg and V26 can V26 return his wheelchair to the rehabilitation center. V16's witness statement not dated documents: asked R7 what happened? R7 said the driver didn't strap him in and they almost had an accident and he flew out of his wheelchair. Fall report, dated 9/9/24, documents: Resident (R7) injury was a result of a fall that occurred during transport to dialysis center. Pain assessment. dated 9/9/24. documents: pain intensity ten (10) out of ten (10), verbal descriptor scale: severe. Staff assessment for pain documents: non-verbal sounds (e.g., crying, whining, gasping, moaning or groaning), Facial expression (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) and Protective body movements or postures e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement). Frequency with which resident complains or show evidence of pain or possible pain documents indicators of pain (1 to 2 days). Dialysis noted, dated 9/9/24, documents: Patient (R7) arrived to the center with transportation/ Transporter requested help to get him out of the vehicle, she stated he had moved while in route. Patient complained of leg pain while he was being removed from the van via his wheelchair. Patient complained of leg pain throughout treatment. Will call 911 to route him to emergency department (ED) for evaluation. Transportation crew stated, 'he kinda slipped down in his wheelchair during route so he might have hurt his leg. Hospital paperwork, dated 9/9/24, documents: R7 presents for bilateral knee pain. Apparently his chair was unlocked and he was rolling around. He denies any trauma. When he presented here he was complained of pain and even more so on the right. Per emergency medical service (EMS) R7 here for bilateral lower extremely (BLE) pain/soreness. EMS reports on the way to dialysis the patient was not locked in and he was rolling around. Pt states he did not hit his legs but has soreness to bilateral lower extremities (BLE.) Hospital paperwork, dated 9/10/2024, documents: chief complaint: Fall- Other closed fracture of proximal end of right tibia, initial encounter (primary). Per EMS and nursing report, patient fell while being assisted by NH (nursing home) staff who were attempting to get patient into wheelchair. Patient fell to right leg. Musculoskeletal: Positive for joint swelling. XR TIBIA FIBULA 2 VIEWS RIGHT (Final result) Result time 09/10/24 Multiple views of the right tibia and fibula demonstrates a comminuted, predominantly transversely oriented fracture involving the proximal tibial metadiaphysis. ED Triage Notes Pt from nursing home due to right knee pain and swelling. Per staff, patient was getting into wheelchair with staff assistance and fell on to right knee. R7's Nurse Practitioner Narrative/Physician Assistant progress note, dated 9/10/24, documents: Seen today because of subsequent complaint of right knee pain and swelling. He reports that while on his way to dialysis, he was not securely placed in the transportation cart, and when the driver hit the brakes, he fell forward, injuring his right knee. The patient rates his pain as 5 out of 10 and states that she was prescribed 1000 mg of Tylenol every 6 hours for pain management. Orthopedic Surgery service date 9/17/24 documents: Right proximal tibia fracture closed reduction and application of cast. Preoperative diagnosis: Left proximal tibia metaphyseal fracture. Procedure Performed: right knee proximal tibia fracture closed reduction and application of a long-leg cast. Left knee aspiration of hemartrosis and application of long leg splint for treatment of proximal tibial fracture. Facility reportable, dated 9/18/24, documents: R7 complained of right leg pain during outpatient dialysis. Dialysis nurse called facility to notify of transfer to emergency department. R7 transferred back to facility from ED where he was treated for pain but still complained of pain upon return. Nurse assessed R7, observed right knee swollen warm and pain upon touch. R7 sent to hospital for further evaluation. R7 was admitted for tibia fracture of the right knee. Occurrence resolution documents: Investigation revealed that R7 began to slide out of wheelchair during transportation to outpatient dialysis center. Transportation professional pulled over, repositioned resident and removed leg rest from wheelchair. R7 complained of pain to right leg at that time. Hospital records indicated R7 was admitted . X-ray of right knee demonstrates a comminuted, predominantly transversely oriented impact fracture of the proximal tibial matadiaphysis. R7 returned with a cast on right leg. On 10/09/24 at 10:31am, R7 was assessed to be alert and oriented to name only. R7 was observed with a cast to right lower leg and a leg immobilizer in place to left lower leg. R7 was unable to report what happened to his legs. On 10/09/24 at 2:56pm, V23 (dialysis nurse) said, (R7) complained of leg pain. (R7) could not rate his pain level. (R7) always complained of leg pain, but this day was different. (R7) did not want to his leg to be touched. (R7's) legs are usually moved around when he is positioned into the dialysis chair. (R7 )is moved from the wheelchair to the dialysis chair via a mechanical lift. (V26, transportation personnel) asked for help with (R7). (V26) reported she was afraid (R7) slipped out of his wheelchair. On 10/09/24 at 3:07pm, V24 (dialysis clinical manager) said, (V26) came into the dialysis facility and asked for help with (V7). Dialysis does not usually help transfer residents out of the transportation vehicle. (V26) reported that (R7) was almost out of his wheelchair. I went outside to the transportation vehicle. (R7) was almost out of his wheelchair. (R7's) mechanical sling was all over the place. (R7's) back was in the middle of the seat portion of his wheelchair. (R7's) buttock was off the wheelchair. (R7) did not have a seat belt or foot rest on his wheelchair. (R7's) legs were pressed against the back of the driver and passenger seats. The seats were holding (R7) up from completely being on the vehicle floor. I believe (R7) slipped from his wheelchair due to having the sling underneath him. On 10/09/24 at 3:43pm, V2 (Director of Nursing/DON) said, (R7) was sent to dialysis with the mechanical left sling underneath him so he could be transferred to the dialysis chair via their mechanical lift. (R7) used a wheelchair for mobility. (R7's) wheelchair did not have a seat belt. (R7) was secured to the transportation vehicle by the driver. Facility staff does not secure any resident to transportation vehicles. (R7's) dialysis nurse called to report (R7) was complaining of leg pain more than usual. (R7) would be transported to the hospital from dialysis. (R7) came back from the hospital with pain patches. (R7's) receiving nurse completed a body assessment noting (R7) with a swollen/warm knee. (R7) was sent to back to the hospital. The second hospitalization reported (R7) had fractures in both legs, with one leg requiring surgery. V2 said she was informed by the transportation company that R7 fell in the transportation vehicle in route to dialysis. On 10/11/24 at 212pm, V26 (transportation driver) said she went to pick up R7 for dialysis, and he was complained of leg pain, which is normal. (R7's) leg are weak. (R7) could not hold his legs in position. It was hard for (R7) to keep his leg up right on the foot rest which was usual. (R7) was secured to the van. V26 said she drove off, constantly looking back to check on R7, because he normally had an escort with him, but he didn't for dialysis. V26 said she came to a stop, and R7 was sliding out of the wheelchair. V26 said,she was not sure how R7 was sliding out of the wheelchair because she was driving. V26 said she pulled over to reposition R7 back into his chair. (R7's) legs pop out. (R7) has no control of legs. (R7) was a heavy big man. (R7'a) legs slips off the foot rest all the time. V26 said she asked R7 if he was ok; R7 said he was ok, then R7 said 'but my leg' and asked for some candy. V26 said she was driving and did not see why/how R7 slipped. R7's knee was bent. V26 said she didn't want to say R7's buttock was completely out of the wheelchair, she just remembered getting R7 back into the seat. V26 said, There is a high step inside the van. (R7's) knees were on the high step. Normally his feet are on the high step. 2. R8 has diagnoses of Alzheimer's disease, anxiety disorder, disorder of muscle, abnormal posture, lack of coordination and unspecified psychosis. R8's brief interview for mental status dated 8/28/24 documents a score of 3/15 which indicate severe cognitive impairment. Height summary dated 7/9/24 documents: seventy (70) inches lying down. R8's plan of care, initiated 9/5/24, documents: R8 presents with wandering behaviors, wandering with or without a purpose. On 9/23/24 resident presented with wandering behaviors in evidence by wandering into other residents' rooms. Nurse attempted to redirect resident out of patient's room and the resident was not receptive. Resident pushed his feet into the floor to stop the wheelchair from moving which caused the resident to fall. Interventions: Staff will assess for elopement. Date Initiated: 09/05/2024; Staff will provide opportunities for safe wandering throughout the unit. Date Initiated: 09/05/2024; Staff will provide redirection when resident is observed wandering into unsafe areas or situations. Date Initiated: 09/05/2024. V18's witness statement, dated 9/22/24, documents: Resident(R8) fell out of the chair by placing feet forward and hit head on the floor above his left eyebrow. R8's progress note, dated 9/22/24, documents: resident observed being mobile down the hallway staff attempted to re-direct resident back to nursing station for close monitoring when the resident fell from chair by placing feet down to stop chair movement and hit his head above left eyebrow. Care rendered to skin injury; laceration about 1 inch noted to the left eyebrow. Ice applied for comfort with gauze to secure bleeding, and tape to secure. Paramedics arrived to transfer resident to hospital further evaluation. R8's incident report, dated 9/22/24, documents under description: resident observed being mobile down the hallway staff attempted to re-direct resident back to nursing station for close monitoring when the resident fell from chair by placing feet down to stop chair movement and hit his head above left eyebrow. Resident unable to give description. Immediate action: R8 hit head laceration noted to the left eyelid, clean with normal saline, gauze and ice applied with pressure, staff stayed with resident until paramedics arrived. Resident transferred to local hospital for further evaluation. Under injury laceration. Mental status: oriented to person. Predisposing physiological factors: confused, noncompliant with safety guidance. Under predisposing situation factors: using a wheelchair, wanderer. Under notes: upon investigation, the root cause was related to resident putting his feet down while being pushed in the wheelchair. Referral made to therapy to evaluate for appropriate wheelchair/footrest. R8's hospital records, dated 9/22/24: R8 presents for evaluation after falling out of his chair at nursing home. He hit his head and caused laceration to left eyebrow. He is alert and oriented x1 at baseline. Under laceration repair left eyebrow, two centimeters length; four sutures. Facility reportable, dated 9/23/24, documents: R8 was observed wandering down unit hallway attempting to go in other resident's room. When verbally redirected by nurse. R8 was noncompliant. Nurse went to assist R8 back to the nurse's station, while mobilizing R8 in wheelchair he placed both feet firmly on the floor abruptly stopping the wheelchair and falling forward. R8's physical therapy note, dated 9/25/24: Patient will benefit with a custom wheelchair to provide proper fitting and increase safety during mobility. Patient was using a regular wheelchair which is short/small for his physique. Staff education needed in using wheelchair leg rests if transporting patient secondary to patients decreased ability to maintain knee in extension. On 10/9/2024 at 10:20am, V17 (Certified Nursing Assistant/CNA) said R8 was able to self-propel in the wheelchair, but required assistance when instructed to go to specific locations. V17 said, (R8) tends to stick out his leg when being wheeled by staff. If you ask (R8) to lift his legs, sometimes (R8) will lift his legs up, and other times (R8) will keep his feet planted on the ground. On 10/9/24 at 10:56am, R8 was observed in bed. A high back specialized wheelchair with no foot rest was observed in R8's room. Foot rest was observed on the floor near R8's wardrobe cabinet. V2 (Director of Nursing/DON) said, That is (R8's) high back wheelchair. V2 said she was not sure if the foot rest on the floor belonged to R8's new wheelchair. V2 said physical therapy assessed R8 after his fall. R8 was given a high back wheelchair with foot rest. R8 had a standard wheelchair prior to the fall. R8 was given a high back wheelchair due to the way R8 positioned himself in the standard wheelchair with his feet dragging the ground. (R8) was holding his feet up while being pushed by (V18, Nurse). (R8) put his feet down resulting in a fall. Staff had access to foot rest. (R8) typically self-propels and did not have foot rest on his previous wheelchair when he was being pushed. On 10/9/24 at 11:06am, V18 (nurse) said, (R8) was in the doorway of another resident's room on the opposite hall. I went to get (R8) after I heard the other resident scream. I pulled (R8's) wheelchair back out of the doorway, turned, pivoted and pushed (R8's) wheelchair forward. (R8) put his feet down to stop his wheelchair. (R8) fell forward hitting the floor. (R8) had a laceration to the left eye. (R8) should have had foot rest on his wheelchair when he was being pushed. On 10/9/24 at 2:28pm, V20 (physical therapy) said, (R8) had a standard wheelchair that was too small and too short for his height. During my assessment, (R8) was asked to raise his legs to assess muscle strength. (R8) was weak. Ideally, leg rest should be used when a resident can't propel themselves. (R8) was given leg rest related to his decreased level of cognition, so if staff need to transport or push (R8) in the wheelchair on weak days, it could be done safely.

Based on observation, interview, and record review, the facility failed to ensure the supervision of one cognitively impaired resident while in the dining room, failed to follow their policy and determine the cause of what triggered a door alarm on the memory care unit, and lacked an effective plan to ensure the outside gate was locked after landscapers/vendors exits. These failures affected one of three residents (R1) reviewed for supervision and elopement. These failures resulted in R1 exiting the locked memory unit and being found nearly one-half mile, after dark, from the facility by local police. The Immediate Jeopardy began on 08/01/2024 when R1 exited the facility unauthorized thru the locked memory care door. V8 (Administrator) was notified of the Immediate Jeopardy on 09/04/2024 at 1035am. The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on 09/04/2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1 is [AGE] year old with diagnosis including, but not limited to Neurocognitive Disorder with Lewy Bodies, Chronic Kidney Disease, Major Depressive Disorder, Schizophrenia, Cognitive Communication Deficit, Hypertension, and Gout. R1's Cognitive assessment, dated 7/22/24, notes R1 has a score of 3, severely impaired cognition. R9's Wandering Risk Scale score is 9, at risk to wander on 7/29/24. On 7/1/24, R1 was identified a High Risk for elopement and identified to have a security bracelet placed. On 8/1/23, the facility reported R1 exited the facility at approximately 7:00PM. R1 was located and transported to local hospital for evaluation. Upon investigation, R1 exited the facility through dining room door. Door alarm triggered, staff arrived to area, no resident visualized in the area. Staff reset the alarm. Code Pink initiated when R1 was not present. An undated written statement presented for V6, Certified Nursing Assitant/CNA, indicates, I was informed by (V7) that we had a resident missing. No alarms were going off prior to my arrival and no alarms were going off at the time I was notified. A written statement presented for V7, Certified Nursing Assistant, dated 8/1/24, indicates, today between 6:45PM and 7:00PM I was asked for the code to the alarm in the 300/400 dining room. I was halfway to the dining room when alarm stopped on its own. I shared the code with (V10). The last time I saw (R1) was before I started my last evening shower. A written statement presented for V11, CNA, dated 8/1/24, indicates, I sat and watched residents until 7:00PM and then I went on my lunch break. I clocked out and came to eat in the unit breakroom. V6 asked me if I have seen (R1), I said no. A written statement presented for V10, CNA, dated 8/1/24, indicates, the last I saw (R1) was in the dining room around closing time. We were assisting everyone out. I asked (V7) to come get (R1) and I walked off. R1's care plan identifies he may not access community independently related to cognitive impairment and evidence of diagnosis of Traumatic Brain Injury. R1's physician orders 6/1/24 to 8/31/24 identify R1 has an independent community pass privileges. A time line provided by V8, Administrator, indicates V4, Director of Nursing, was notified of a code pink at 8:27PM. V4 notified V8 of a code pink at 8:29PM. V4 arrived to the facility at 8:45PM and notified R1's family and local police. R1 was located at a neighboring facility at 9:53PM. [V8 was notified of the code pink approximately 90 minutes after V6 and V7 were aware R1 was missing. The police were called at 45 minutes after V4 was notified of the code pink.] V7's time card dated 8/1/24 has her out at 7:00PM and in at 7:30PM. V11's time card, dated 8/1/24, has her out at 7:00PM and in at 7:30PM. [Both CNAs were on lunch at the same time.] V10's time card has her in at 3:25PM and out at 10:58PM, no other punches are listed for 8/1/24. On 9/1/24 V4 said the out and in punches on the time cards are lunch times when the staff punches out and back in. R1's facility provided hospital record, dated 8/1/24, notes he arrived at 10:26PM and was discharged at 11:52PM on 8/1/24. No labs or imagining were indicated at this time. Review of the facility Door, Locks, and Alarms test, dated 6/6/24 - 8/30/24, notes weekly checks conducted of all doors, including the 300 Dining Room door. No documentation was presented to confirm the gates were locked that lead to the community. On 8/31/24 at 10:30AM, V3, Assistant Maintenance, walked out the dining room door in the Dementia Unit with the surveyor. The alarm sounded. V3 and surveyor walked outside, observed the large yard is fenced in, and one padlock and red wire locked gait observed. V3 said, On 8/1/24, we came in, maintenance walked around and checked all the doors. All locks and alarms were working when checked. V3 and surveyor walked outside towards the south side of the building. Sidewalk led to a short stairwell, approximately 5 feet in height ,and a fence gate with a padlock was observed, locked. V3 said it is not new to lock this gate. A person would need to bend down to get to the gate and walk past it. Past the gate, the facility large lawn that dips down before a hill leading to the road. V3 said, On 8/1/24, the lawn people had left the gate open. Off the 400 unit exit door, there was a gate to side of building. There was no lock on the gate, only a latch. At 11:07AM, V3 said we do door checks weekly. At 11:47AM, V3 said, I just put locks on both gates outside of the 300 and 400 units. On 8/31/24 at 9:45AM, V2, Certified Nursing Assistant/CNA, said, (R1) requires a set up or extensive assist for cares. (R1) can walk. (R1) got out of the facility, it was a while ago. The sidewalk around the back of the building leads to the parking lot. On 8/31/24 at 1:05PM, V7, CNA, said, On 8/1/24, there was a lot going on. I was the only regular CNA on the unit. I heard the dining room alarm, but I am not sure of the time. The other aides pointed out the alarm to me. That alarm, the dining room door, goes off all the time. It goes off if it's too windy. We used to do head counts, but we stopped. This has gone on for a couple of years. The other CNAs asked me for the code. When they asked for the code, I went with the other aides and we turned it off. I did not go outside that time. It was late, after dinner, between 5:30PM -6:00PM. At that time, we take all the residents out of the dining room. I had seen (R1) was sitting in the corner, looking tired, and he was alone. When we turned off the alarm, I did not go outside that time. Then the sliding doors to the unit alarm was going off, and I went there. I stayed with that resident who was trying to open the door. We did not do a head count at that time. Then about 40 minutes later, after I had finished showers, I went looking for (R1). I didn't see him. Then I remembered the door; I was panicking and told the nurse. I couldn't even talk when I was telling her. Then I went to the dining room door, I went outside and looked, and we couldn't find (R1). I told the nurse we had to do a head count and what was going on. The nurse didn't know about it. (R1) walks really slow and he has a limp. On 9/1/24 at 10:26AM, V11, CNA, said after V7 said the alarm was off, she notified the nurse, V6. V11 said, I didn't hear the alarm, I went for break around sevenish. During my break, I remained on the unit in the breakroom, behind nurses' station. During my break I heard the door alarm; I came out and saw a female resident at the unit door. I stayed with her and then I did rounds and was in a resident room. I did clock out for lunch and I forgot to clock back in. Then I saw (V7) and she said the dining room door alarm was going off, she asked me if I heard it, I said no. (V7) asked me if I had seen (R1). (V7) went outside by the door looking for (R1), and I remained with the other residents. (V7) came back inside and (V6) called the code pink. After dinner, the residents were out of the dining room sitting at the nurses' station. When we left the dining room, (R1) was dozing off in his normal chair out of the dining room. The last time I saw (R1) was before I went to break. That dining room door had been setting off (sic). In the past, the wind has triggered the alarm on that dining room door. At night, the entrance doors to the dining room are closed, but they are not locked. We closed the doors when we got everyone out that evening. On 9/4/24 at 9:46AM, V10, CNA, said, When I came back from break, I noticed the dining room door alarm was going off. I went to the door, but I was using the wrong code. I did not look outside to see if anyone was out there, I didn't know that people can do that (get out). I went to get (V7) because I didn't know the code. We started a head count because we didn't see (R1) anywhere. It was maybe around 7:00PM, it was dark outside. It was after dinner, the dining room was cleared out. (V7) was in the shower room when I found her, it took 2-3 minutes to get her. I think (R1) walked back into the dining room. Rhere was another aide sitting at the nurse station. The nurses were doing shift change and the nurses were in the room. I checked (R1's) room, then I checked all rooms, then we checked the entire building, and then a code pink was called. It took about a half hour to do all that. On 8/31/24 at 11:04AM, V4, Director of Nursing, said, (V6, Licensed Practical Nurse/LPN), called me and said code pink was initiated, for elopement. I came to the facility, I called the police, the hospitals, and the family. (V6) reported (R1) had not been visualized for maybe 20 minutes. I got here within 15 minutes of her calling me. (V6) said (R1) had not returned when I got here. Between 10:30 and 10:50PM, (R1) was observed by local police at a center located to the south of us. (R1's) shirt was wet, he was tired, he was sitting, and did not complain of any distress. When I arrived to the location, (R1) was sitting on a cement structure on their property in the parking lot. (R1) was located at a distance of about 2 blocks from the facility. (R1) was wearing a red, long sleeve, thermal top, black fleece pajamas, and house shoes. (R1) is hard of hearing. (R1) pushed through the back doors, on the memory unit. The door leads to patio back yard, there is a fence with a lock; I believe on both sides. The fence was not locked due to landscapers leaving it open. The door alarms went off. Staff reported the door often triggers from weather and movement. Staff said they looked around the back and didn't see anything. Staff reported to the nurse that the alarm was triggered, and the door was slightly cracked. This initiated the missing resident search and staff did a head count. About 2 hours had passed before (R1) was located. It was pretty dark outside when we initiated the search, it was between dusk and darkness. It was a warm night. Once (R1) was found, he was taken to the hospital. On 8/31/24 at 2:18PM, V4 said she had watched the camera recording footage for 8/1/24. V4 said, I did see (V7) walk into the dining room to reset the door alarm, and I saw she did a visual. Then I saw (V7) went back to the dining room. I saw (V7) walk out the dining room door and I saw her looking outside. I could not see how far out she went looking. I remember watching dinner trays being passed between 5:00PM and 6:00PM. We continued to watch past dinner trays. There were glitches in between. (V7) was in the dining room more than just that one time. I can't recall how much time went by when (V7) was seen on the camera. The police did not ask for footage. When staff hears an alarm, they are expected to make sure no one has triggered it. Sometimes the residents will walk to the door. If no one is present when the alarm triggers, then staff should figure out how the door was triggered and see what may have possibly set it off. If it's windy the dining room alarm will go off. If staff cannot determine the cause of the trigger, then they should do a head count to rule out it wasn't a resident. I'm not sure if it was windy on 8/1/24. On 8/31/24 at 1:33PM, V6, Licensed Practical Nurse, said, The CNA said she turned off the alarms to the dining room door. The CNA checked the immediate area and did not see anyone. I said we need to do a head count. That is when we noticed we could not find (R1). I called the code pink, I called the DON, and let her know we could not find (R1). Someone was outside checking the area, since the alarm went off, (R1) may be outside. The search increased to the outside of the facility and we walked the parking lot. The DON called the family and police and hospitals. The police found (R1) a couple blocks down from the facility. The police told us they had him and sent (R1) to the hospital. (R1) may have been at the hospital about 2 hours before I got report that he was coming back to the facility. (R1) had never left the facility before, but he walks to the doors and pushes them. (R1) needs constant redirections. (V7) and (V10), both CNAs, told me about the alarm. They only told me that one time. I don't know how long (R1) had been gone before we called a code pink. The door alarm goes off if a door is pushed. I am not sure of the time when they said the alarm was reset. I was passing medications to the residents sitting across from the nurses' station when they notified me. I started my shift at 7:00PM. The code pink was called around between 7:00PM and 8:00PM. On 9/1/224 at 1:05PM V1, LPN, said, On 8/1/24 at about 6:30PM, I last saw (R1), he was in the dining room, I gave him his medications. (R1) was sitting under the TV area at a table. The CNAs were moving everyone out of the dining room at that time. I was not here anymore when they noticed (R1) was missing. I left shortly after 7:00PM. I gave (V6) report in the nurse's office. When I went to leave, I don't recall seeing (R1) in the hall, I left out the main doors. I was not aware the dining room door alarm went off that day from 3:00PM - 7:00PM; I had not heard it. On 8/31/24 at 2:41PM, V9, Maintenance Director, said, When the landscapers get here, they called maintenance, and we unlocked the gate for them that day. Usually they get here around 3:00PM - 4:00PM, mid-afternoon. I don't know the time they got here on 8/1/24. I always leave the facility at about 4:30PM. I couldn't tell you when they leave the facility. When they are done, they lock the gate. The gates have a padlock and there are always locks on both sides. There are two gates locked because they have access to the community. The camera footage cuts in and out. I saw (R1) walk to the door and the camera stopped recording. It started again when (R1) got up; it was hard to see when he opened the door. There are time stamps on the footage. It was around 6:30PM -7:00PM when the CNAs, a lot of them and the nurses, came on the video looking around. We went back to like 4:00PM that night (8/1/24) watching. About 25 minutes had passed from the first time someone shut the alarm off until I seen everyone there looking. The camera footage is kept for about 30 days. On 8/31/24 at 1:54PM V8, Administrator, said, There were no issues with the doors prior to that time (8/1/24), to my knowledge. On 8/1/24, (R1) went out the dining room door. I had landscapers here that day and they had accessed the gate on the south side of the facility. When I looked outside, I saw foot prints in the mud from the rain earlier in the day. I saw the foot prints around the corner of the building, not in the back of the facility. (R1) would have had to go under the stair to get past the gait. The DON reviewed the camera footage. The camera goes to the back door only. At 3:09PM, V8 said, The footage is gone, we are past the 30 days. On 9/4/24 at 9:33AM, V4 said, It took 45 minutes to call police for the code pink, because the staff was waiting for my arrival. I had to be the one to call police, to make sure everything was done properly. To reside on the memory care unit, the resident has a diagnosis of dementia, is identified to wander, and is an elopement risk. (R1) wanders and is an elopement risk. Because of (R1's) elopement risk he had a monitor device on him. The device was not effective in preventing his elopement. The monitoring alarm is not triggered when exiting those (dining room memory care) doors. The purpose of the unit, a locked unit, is that all doors have a locked door or code, alarms will go off if the handle is pressed or the door open for too long. It is not possible that (R1) knew the code; it is not shared and I don't think he could remember the code. On 9/4/24 at 2:19PM V14, Doctor, said, I remeber a conversation about the police regarding (R1) being missing from the facility. V14 said (R1) has a diagnosis of Neurocognitvie Disorder with Lewy Bodies is a form of Dementia. I remeber (R1) had eloped. (R1) is not safe in the communuty. Risk to (R1) in the community include 1. he wanders 2. he probably would get in the fight with people, he punches people, and this may cause danger for him. (R1's) ambulation is ok, he is not fast, but slow and steady. The facility Elopement and Search (Code Pink) Policy, dated February 2014, states residents are not permitted to leave the building alone, unless a physician order is present. Facility exit door alarm are checked daily for function. All personal are responsible for promptly going to the location and determining the cause of the activated audible door alarm. The Immediate Jeopardy that began on 08/01/2024 was removed on 09/04/2024 when the facility took the following actions to remove the immediacy: Corrective Actions for Affected Residents: Staff were immediately educated on elopement policy and how to respond to a door alarm. R1 has been provided with a musical instrument from family to keep resident engaged. Care Plan updated with the interventions including access to musical instrument and one to one activity. The Director of Nursing has moved her office to the memory unit for additional support/supervision. A schedule of supervision was implemented for the memory unit dining room at intervals of 30 minutes, assigned to CNA staff. Identifying Residents at Potential Risk: Director of Nursing, Social Service Director and Nurse Managers have conducted a comprehensive review to identify other residents who may be at risk for elopement. This review includes interviews of residents, staff observation and review of medical records. Review of assessments and orders, care plan updates, confirmation of device and functional status. These reviews will occur regularly upon admission, readmission and change of condition, quarterly and annually. Review completed 9/4/24. Systemic Changes to Prevent Recurrence: Staff have been reeducated by the Director of Nursing on the Elopement and Search Guidelines Policy including, immediate response to both electronic monitoring alarms and door alarm, immediate search of resident, immediate notification of nurse, Administrator & Director of Nursing, initiating an immediate head count and determining the cause of what triggered the alarm. Outside company tested and confirmed all exit doors are engaged and triggering properly. Licensed staff were educated on the process for monitoring residents on the memory unit. A schedule was implemented assigning a staff member to monitor the dining room on the memory unit. CNA staff will monitor the dining room in 30 minutes intervals per the assigned schedule. Initiated 9/4/24. Staff Training and Re-Education: Reeducation/training has been initiated on 9/4/2024 and will be completed 9/5/24 for all staff, including agency regarding Elopement and Search Guidelines Policy including reeducation on the importance of immediately determining the cause of what triggered alarm, initiation of immediate head count, notification of nurse, Administrator and Director of Nursing and police notification. New hires will be educated during the core orientation process, prior to starting. If unable to reach the employee, the employee will not be allowed to return to work until reeducation is completed. PRN staff on vacation or medical leave will receive training before they start their shift. Agency education will be ongoing prior to start of shift. Staff understanding of education will be confirmed/validated through elopement drills and their response to the drill. Further education as needed. Maintenance/Front Desk Staff and Evening EVS staff educated on process of securing gates and protocol for vender access. Securing gates will be added to their preventative maintenance schedule. Education completed 9/4/2024. Quality assurance 1.DON/Designee will conduct Elopement drills and review of the process will be conducted weekly x 2 months on alternating shifts. 2. DON/Designee will audit will be completed 3x week x 2 months of the memory unit to ensure staff are supervising residents 3. Administrator/Designee will audits will be completed 2x daily for 8 weeks of both North and South Gates to ensure gates are locked.

Based on interview and record review, the facility failed to adequately supervise a resident in the locked unit who was assessed as high fall risk (R1) and failed to ensure two staff were used when providing care for a resident (R7) per the resident's plan of care. These failures affected two (R1, R7) of four residents reviewed for falls and resulted in R1 sustaining a laceration to her head that required treatment for scalp laceration and R7 sustaining a head laceration. Findings include: 1. R1 is a [AGE] year-old female admitted to the facility on [DATE]. Past medical history includes, but not limited to: unspecified dementia, major depressive disorder, anxiety disorder, vitamin D deficiency, unspecified psychosis not due to a substance or known psychological condition, vitamin B deficiency, and cognitive communication deficit. Fall care plan, dated 9/1/1023, stated R1 is at risk for falls d/t (due to) use of antipsychotic medications and weakness. Interventions include, provide proper, well-maintained footwear, provide resident an environment free of clutter, Observe frequently and place in supervised area when out of bed. Minimum Data Set (MDS) assessment, dated 5/16/2024 section GG (functional abilities and goals), coded R1 as requiring partial/moderate assist to supervision /touching assist for all ADL cares, including waling 10 to 50 feet. Facility reported incident, dated 6/01/2024 at 6:41PM, documented R1 expressed discomfort during shower when her hair was being washed. CNA noticed bleeding on resident's hair and called the nurse. R1 was noted with an open area and moderate amount of bleeding from the crown on the right side. R1 was sent to the local hospital emergency room for further evaluation. Hospital emergency room record, dated 6/1/2024, states the chief complaint as head injury with unknown LOC (level of consciousness). The same record states, [AGE] year-old female. Patient unable to provide history, called facility and they said that the aid noticed a head laceration, unsure where the laceration came from, unsure if patient fell . R1 underwent a repair for a laceration measuring 2cm x1cm with five staples. On 7/30/2024 at 12:10PM, R1 was observed in the dining room walking around with a staff trying to redirect R1. She was noted wearing a pair of socks only, no shoes. On 7/31/2024 at 1:10PM, R1 was observed again walking around in the dining room. About 20 residents were in the dining room, not engaged in any activities. One CNA (Certified Nursing Assistant) was in the room at this time. R1 was observed with a sock on one foot and one shoe that looked too big for her on the other foot. Four residents were observed walking up and down the hallway with no staff in sight; one of the residents was entering different rooms and coming out. There were no activities going on in the unit. On 7/31/2024 at 1:15PM, V10 (CNA) said there are three CNA's assigned to the locked unit; she is the only one in the dining room now because one CNA is picking trays in the hallway and the other CNA is assisting a resident. V10 said the nurses were supposed to be monitoring the hallways. All the residents in the unit are fall risk and all require constant supervision. On 7/31/2024 at 1:25PM, V11 (LPN) said she is the only nurse assigned to the locked unit, and all the residents require constant monitoring and supervision. We do the best we can with the number of staff we have, I think the unit needs more staff but was told that one nurse and three CNA's is enough. V11 added sometimes she does not take a break, but when she does, she makes sure all the three CNA's are around, or sometimes someone from activities will be in the unit. I am working with what I am provided. V11 added R1's injury was not witnessed. It was discovered during ADL (activities of daily living) care and R1 requires constant monitoring and supervision. V11 was not sure how R1 sustained the injury. On 7/31/2024 at 4:06PM, V13 (CNA), said, (R1) walks around all the time and requires constant supervision. She is a fall risk and wears nonskid socks. She doesn't usually wear a shoe because she removes them. On 8/4/2024 at 12:16PM, V2 (Director of Nursing/DON) said, (R1) is a fall risk and requires constant supervision. Someone should have known the source of her injury. 50519 2. R7 is an [AGE] year old female admitted to the facility 1/11/24, with diagnoses including but not limited to Hypertension, ipolar, respiratory failure, Rhabdomyolysis, hypothyroidism, celiac artery compression syndrome, and diverticulitis. R7 was admitted to hospice on 05/10/24. On 07/26/24, R7 had a fall requiring transfer to local hospital emergency room to repair laceration requiring 16 sutures. Report reads R7 slid off side of bed during Activity of Daily living. on 07/27/24 report sent to the Illinois Department of Health. On the (MDS) Minimum Data Set assessment of 06/19/24 section C the BIMS (Brief Interviewed Mental Status) score was 14/15. On MDS of 07/29/24 GG section R7 is dependent except for eating. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. On 07/30/24 at 11:32 AM, R7 was in a recliner in the dining room, with right side of the face yellowish/bluish bruises, and a dressing on forehead. R7 was watching television. R7 said, I fell a couple days ago. The Certified Nursing Assistant was assisting me to change, and I was a too far at the edge of the mattress and I rolled out bed. Usually, I get two Certified Nursing Assistants, but I only had one the day of my fall. I was on the floor, and I bleed a lot. I went to the hospital and needed around 16-20 stitches. I was told that it is a V shape. On 07/31/2024 at 12:45 PM, V9 (Unit Manager) said, (R7) requires two staff assist for ADL's (Activity of daily living) and getting up from bed using a lift. Residents have a care card inside their closet door with information for Certified Nursing Assistants to use to obtain information about ADL's and how to get out of bed. Certified Nursing Assistants can also look up under EMR (electronic medical record) under the resident information index. On 08/1/24 at 2:05 PM, V27 (Certified Nursing assistant) said, I was helping (R7) to change on 07/26/24. During the fall, (R7) had a bowel movement. (R7) was at the edge of the bed and (R7) rolled out bed with the head down first. (R7) is extensive assist and requires two nursing assistants during brief changing and repositioning. Because (R7) has an air mattress, I was supposed to have assistance to help (R7), but I didn't have it. I looked for assistance but everyone was busy and my nurse was passing her medications. On 08/05/2024 at 9:55AM, V28 (Licensed Practical Nurse) said, I came in at 7:00 PM to work and the Nursing Assistants start at 3:00PM. I completed my rounds at 7:25PM. (V27) came back from her break and went down to provide care to (R7). (V27) called me and notified me (R7) rolled out of bed during care. I expected (V27) to call for assistance when providing care to (R7). (R7) is on the air mattress and the air can fluctuate and the resident can go all to one side and fall out of the bed. On 08/05/24 at 12:11 V2 (Director of Nursing) said, I expect the Nursing Assistants to use the care cards or resident information system in the EMR to look up how much assistance each resident requires. (R7) requires two person staff assists when receiving care and she is on an air mattress. Facility presented policy titled, Fall Protocol (undated), includes: Assessment and Recognition. As part of the initial assessment the physician will help identify individuals with a history of falls and risk factors for Subsequent falls Treatment and management. Based on previous assessment, the staff and physician will identify pertinent intervention to try to prevent subsequent falls and to address risk of serious falls. Facility presented policy titled, Activities of Daily Living (ADL) (dated 02/2023), includes: Our collaborative professional team, together with the resident and or resident representative: 1. Will recognize and evaluate an inability to perform ADL's or risk for decline any ability to perform ADLs. 2. Develop and implement in the accordance of with resident's evaluated needs, goals and care, and preferences and will address the identified limitations in ability to perform ADLs.

Based on observation, interview, and record review, the facility failed to prevent an avoidable fall for high fall risk resident with poor sitting balance by not providing 2 persons assist during a shower. This affected one of three residents (R1) reviewed for safety and falls. This failure resulted in R1 falling out of the shower chair on 1/24/24, being transported to the local hospital for treatment, and recieving 7 sutures to the left eyebrow area. Findings include: R1's face sheet shows diagnosis of other lack of coordination, need for assistance with personal care, abnormal posture, muscle wasting and atrophy multiple sites, weakness, cognitive communication deficit, other abnormalities of gait and mobility, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, and muscle weakness (generalized). R1's care card, dated 10/23, denotes at risk for falls, extensive assist with grooming, mobility wheelchair/ broda, transfer x 2, additional information denotes fall precautions, dysem to broad chair, two persons assist during bathing, bed at lowest position, call light in reach. R1's ADL (activity of daily living) functional analysis, dated 11/10/2023 completed by V5 (Restorative Manager) denotes bathing, totally dependent, staff support provided 2 plus person. R1's Minimum Data Set/MDS, dated [DATE], section C for cognitive patterns denotes score 99; the resident was not able to complete the interview. R1's MDS (Minimum Data Set), dated 2/7/24, 11/12/23 denotes 01 (dependent) for showers. Facility final accident/incident report to the department, dated 1/30/24, denotes event occurred on 1/24/24 at 8:16am, resident involved-R1 name, date of birth, HTN (hypertension) chronic kidney disease, UTI (urinary tract infection), muscle wasting and atrophy, weakness, cognitive deficit, dysphagia, dementia, and generalized weakness. Family and physician notified. Description of occurrence denotes R1 had fall, upon nurse assessment noted with a laceration to left eyebrow. Ice and pressure applied until bleeding stopped. MD (Medical Doctor) notified with order to send out to hospital. Family was made aware. Hospital reported sutures to left eyebrow. Investigation initiated. Final report to follow. Occurrence resolution denotes investigation completed. R1 was sitting in the chair after her shower. CNA (Certified Nursing Assistant) was bending down drying her legs and feet, when suddenly R1 jerked forward falling to her left side before CNA could stop the fall. The nurse immediately went to assess. Upon assessment noted resident lying on left side in front of the shower chair with bleeding from the left eyebrow. Pressure and ice applied until bleeding stopped, resident remained alert with no other injuries noted. Sent to ER (emergency room ) for further evaluation. R1 returned from ER accompanied by family with 7 sutures to left side of eyebrow, CT (computed tomography) scan negative. MD (Medical doctor) and family made aware and were satisfied with outcome of investigation. Care plan updated, medicate for pain as needed. R1's fall risk observation, dated 1/24/24, denotes score 15, high risk. R1 progress notes, dated 1/24/24, denotes at 8:00am, the writer was called to the resident's shower room to assist a resident that had an injury and needed to be assessed. Staff was giving resident a shower and was drying the resident off. Staff stated as she was performing ADLs (activities of daily living) resident suddenly fell and the staff member couldn't prevent the fall. The writer and co-worker noticed blood and immediately apply pressure with ice to resident's L (left) side of head, assessed ROM (range of motion) and no bruising at this time noted. The writer called 911 while co-worker stayed and applied pressure and bandage on injury. R1 progress notes, dated 1/24/24, denotes, Resident left facility at 8:25 via stretcher w/ (with) 911 alert and verbal. VS (vital signs) stable and within normal limits. Family, DON (Director of nursing) and NP (nurse practitioner) have been notified. R1 progress notes, dated 1/25/24 at 11:51am, denotes, resident received in bed watching TV (television) The resident has stitches on the left eye by eyebrow and a bruise on the right pinky finger due to a fall earlier. Vital WNR (within normal range) no complaints of pain/discomfort. Resident bed is at the lowest position for safety measure call-light in place. On 2/24/24 at 9:07am, R1 was observed resting in bed, alert, speaks simple words. R1 denied pain. On 2/24/24 at 12:24pm, V1 (CNA) said she was the aide working with R1 when R1 had a fall from the shower chair on 1/24/24. V1 said she had given R1 a shower. R1 was sitting in the shower chair, she was bent down drying R1's legs and R1 suddenly fell out the chair landing on her side. V1 said she saw blood on R1's face. V1 said an aide was passing by and assisted her with getting R1 up from the floor. V1 said no one assisted her with giving R1 a shower. V1 said the nurse came right away when she was yelling for help. V1 said she did not look at R1's care card prior to giving R1 a shower. V1 said she doesn't know if R1 was a one or two person assist with showers. V1 said R1 always fidgets. V1 said she doesn't know if R1 has poor /abnormal posture. V1 explained she has been caring for R1 a long time, and she knows what R1 needs. On 2/24/24 at 2:05pm, V4 (Director of Nursing) said residents should not fall from the shower chairs during showers. V4 said, (R1's) root cause of the fall was because she has jerky movements and (R1) fell from shower chair when the aide was kneeling to dry (R1's) legs. V4 said R1 had jerky movements well before she fell from the shower chair. V4 said R1 should have had an assessment to determine how much assistance she needs during showers. V4 said R1 needs one -person assist with showers due to R1 having jerky movements, and the staff don't know when R1 may lean forward in the shower chair. V4 said the restorative person needs to address when the assessments are done because she doesn't know. V4 was asked if R1 is known for having jerky movements, who is responsible for visibly monitoring R1 for this movements while the CNA bends down to dry R1 legs during/ after a shower, to prevent R1 from falling from the shower chair? V4 said I understand what you are saying. R1's current care plan reviewed with V4. V4 said she does not see a care plan developed for activity of daily living for showers, nor she does she see a care plan developed for how much assistance R1 needs during a shower. V4 said her expectation is that the aides look at the care card prior to providing care. V4 said she updated R1's care plan for falls today (2/24/24), denoting R1 needs two persons assist with showers, and it should have been updated on 1/24/24 after the fall. V4 said R1 is a fall risk. R1 needs two persons assist during bathing. V4 confirmed the care card last update was 10/2023. On 2/29/24 at 1:41pm, V5(Restorative Manager) said she does the activity of daily living assessments. V5 said R1 is dependent for showers, and R2 requires two persons assist with bathing/showers. V5 said she completed R1's functional assessment for ADL, and R1 needs 2 person assist. V5 aid R1 needs two person assist for safety reasons. V5 said two persons assist with help prevent R5 from falling from the shower chair.V5 said the staff should provide the level of assistance the resident is assessed to need. V5 said the aide should look at the care card because they do not have access to the care plan. On 2/25/24 at 12:10pm, V7 (Therapy Director) said R1 has poor sitting balance and cognitive deficits. V7 said she recommends R1 have 2 persons assist during showers for safety reasons. V7 said during the recent therapy evaluation, R1 was not able to maintain a sitting position, and she could not follow directives during the treatment. Facility policy titled managing falls and fall risk, revised 2008, denotes, based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.

Based on interview and record review, the facility failed to provide two staff assistance while providing incontinence care. This failure applied to one (R1) of three residents reviewed for falls, and resulted in R1 having a fall while being provided care from one staff member, and subsequently had to be transferred to the local hospital for evaluation and treatment of laceration; R1 required sutures with a skin closure device. Findings include: R1's face sheet documents R1 is a [AGE] year old female with diagnoses that include stroke, diabetes, and weakness. R1's facility assessment, dated 8/23/23, documents R1 is severely cognitively impaired and in need of two person extensive assist for bed mobility, transfers, and toileting. R1's fall risk assessment, dated 10/24/23, show R1 was high risk for falls. R1's progress notes, dated 10/24/23, document, observed resident to the floor with face forward and on the floor. Per CNA, she was changing resident when she fell out of bed and hit her face to the floor. Resident was noticed to have open wound to her forehead and was bleeding profusely, 911 was called immediately, pressure applied to site to control bleeding. R1's Facility Incident Report, dated 10/24/23, documents R1 was alert but non verbal. The assigned Nurse on the unit was called by the assigned CNA. Upon entering the resident's room, R1 was observed lying on the floor. R1 noted with injury to her forehead, bleeding was controlled, R1 was sent to the emergency department. R1's After Visit Summary Emergency Department (ED) document, dated 10/24/23, documents R1 had a head injury, laceration, and would require skin closure device removal (handwritten-note remove in 7-10 days). R1 Facility Reported Incident (FRI) final, dated 10/31/23 (date of incident 10/24/23), reads: during ADL (Activities of Daily Living) care, (R1) experienced a fall .(R1) was subsequently sent to ED (Emergency Department) for evaluation and treatment. (R1) returned to the facility with sutures in place. On 12/8/23 at 11:00 AM, V11 (R1's son) said he got a call from the facility early morning on 10/24/23 that R1 fell out of bed. V11 said he was upset and was wondering how it happened, since he knew his mom (R1) was total care and cannot move by herself. V11 said he brought R1 home as he does not trust the facility taking care of R1. On 12/8/23 at 11:45 AM, V13 (Certified Nursing Assistant-CNA) said on 10/24/23 at approximately 3:30 AM, R1 had a large bowel movement. V13 (CNA) said she knew R1 needed two staff during care, but she thought she could do it herself. V13 said she went ahead and provided incontinence care to R1. V13 said as she turned R1 to her side, R1 rolled out of bed and landed on the floor. V13 said she then called the nurse; R1's forehead was bleeding and R1 was sent to the hospital. V13 said she learned her lesson, that R1 was a two staff assist. On 12/8/23 at 11:20 AM, V5 (Wound Nurse) said R1 returned from the hospital after her fall with a laceration (to R1's forehead) 5.5cm in length with 5 skin closure devices (part of laceration skin closure system). On 12/8/23 at 12:00 PM, V2 (Director of Nursing) said, (R1) was a 2 staff assist for all care. (V13) should have provided care with 2 staff- one on each side of the bed to ensure (R1's) safety and prevented her from falling out of bed.

Based on interview and record review, the facility failed to prevent or determine how an injury of unknown origin occurred for one (R1) of three residents reviewed for resident injuries in a total sample of three. This failure resulted in R1 suffering a right hip fracture after being sent to the hospital for right thigh swelling and not being able to stand. Findings Include: R1 is a [AGE] year old with the following diagnosis: fractured neck of the right femur, urinary tract infection, myocardial infarction, dementia, and history of falling. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score is a six (severe cognitive impairment). A Nursing note, dated 9/19/23, documents it was brought to the nurse's attention by other staff, R1 could not stand or sit on the edge of the bed. Upon assessment, R1's right thigh was swollen. No bruises or redness were noted. R1 verbalized pain on the affected side. The physician was notified and ordered to send R1 to the hospital for an evaluation. The Hospital Records, dated 9/19/23, documents R1 presented to the hospital for the chief complaint of right hip fracture. R1 was also diagnosed with a myocardial infarction, acute kidney injury, and urinary tract infection. An x-ray of the right hip shows a comminuted (bone broken in two places) intertrochanteric involving the right proximal (closer to the body) femur. The lesser trochanter is displaced medially. A CT (computerized tomography) of the chest showed a moderate T10 compression fracture that is possibly acute, but the exact age of the fracture could not be determined. R1 received hip surgery, with a nail being placed in the fractured bone to provide support. R1 was sent back to the facility on [DATE] after medically cleared. The Facility Incident Report Form, dated 9/25/23, documents R1 returned from the hospital with a diagnosis of urinary tract infection in right hip fracture. The CT scan revealed a moderate T10 compression fracture that is possibly acute but exact age is unable to be determined. R1 was sent out to the hospital on 9/19/23 due to not being able to sit or stand from the bed around the morning hours. Swelling was observed to R1's right side. R1 also complained of pain to the affected area during the assessment. Staff were interviewed and no one witnessed R1 fall or be injured. Care was provided at baseline with no injuries or falls noted. R1 normally ambulates on the unit without staff assistance. R1 is capable of getting up independently. R1 is unable to say what happened due to a diagnosis of dementia. A Nursing note, dated 9/25/23, documents R1 readmitted to the facility from the hospital, with a diagnosis of right hip fracture and urinary tract infection. R1 is alert to name. The right thigh was swollen. There's a total of three surgical incisions. On 10/12/23 at 12:45PM, R1 was sitting in the dining room. R1 is alert to self only. R1 can only answer questions with one or two words. R1 did not remember fracturing R1's right hip or vertebrae. R1 was not able to state how the fractures occurred. On 10/12/23 at 1:17PM, V3 (Nurse) stated V3 was the nurse the day before R1 went to the hospital on 9/19. V3 denied R1 complaining of any pain, and denied R1 having any falls/accidents that were brought to V3's attention. V3 denied completing a full body assessment during this shift on R1, because there was no need. V3 stated R1 is confused at baseline and can only answer simple questions. V3 reported R1 went to the hospital and returned with a right hip fracture. V3 endorsed since R1 was not able to say what happened and staff did not witness any accidents/falls, then this type of injury is considered an injury of unknown origin. On 10/12/23 at , V4 (Certified Nursing Assistant/CNA) stated R1 laid in bed all day on 9/18, and did not want to get out of bed. V4 endorsed telling the nurse, but denied R1 having any other change in condition that needed to be reported to the nurse. V4 reported getting R1 ready for breakfast on 9/19, and R1 kept saying ouch when being changed. V4 stated R1 said R1's leg was hurting, but could not say what happened. V4 reported R1 is normally able to stand and ambulate in the halls without assistance, but that day, R1 was not able to stand from the bed. V4 denied knowing R1 had any falls or other incidents before 9/19 that would have caused pain to the right leg. On 10/12/23, V6 (Nurse) stated V4 told V6 R1 was not able to stand after getting R1 ready for day. V6 went and did a full body assessment and noticed R1's right thigh was swollen. V6 was only able to verbalize being in pain on the right leg but could not state what happened . V6 denied R1 being able to stand that morning. V6 sent R1 out to the hospital per physician orders. V6 stated R1 was readmitted to the facility later with a right hip fracture. V6 denied being aware of any accidents or falls that would cause a hip fracture. V6 stated if an injury is unwitnessed and a resident is unable to say what happened, then the injury is an injury of unknown origin. On 10/13/23, V7 (CNA) stated V7 took care of R1 the day before R1 went to the hospital. V7 reported R1 spent the both shifts (3PM-11PM and 11PM-7AM) in the bed. V7 denied R1 having any complaints. V7 denied R1 showing any signs of pain when care was provided. V7 denied R1 having any falls or accidents that would cause a fracture. On 10/13/23, V8 (Nurse) stated R1 stayed in the bed the entire night shift before going out to the hospital the next day. V8 denied R1 complaining of any pain when assessed. V8 denied being aware of any accidents or falls that would cause a hip fracture. V8 stated getting in report R1 spent the entire day in bed. V8 stated R1's fracture would be considered an injury of unknown origin. On 10/17/23, V2 (Director of Nursing/DON) stated R1 returned to the facility on ,d+[DATE] with a fractured right femur and T10 compression fracture. V2 reported interviewing staff that cared for R1, and all staff denied R1 having any falls or accidents that would cause a fracture. V2 reported when a resident has an injury, then an investigation needs to be completed to see how the injury occurred. V2 denied R1 being able to tell V2 how the fractures occurred because of R1's mental status. V2 denied being able to find the source of the injury during the investigation. V2 endorsed this would be considered an injury of unknown origin. On 10/17/23 at 5:17PM, V9 (Medical Director) stated, Staff notified me (R1) had a right hip fracture and T10 compression fracture. The T10 fracture's age could not be determined but was possible acute. A compression fracture in this area of the spine would be from osteoporosis, but other causes would be a hard fall directly near that area, or a motor vehicle accident. She had an intertrochanter fracture that was comminuted. These type of fracture is usually occur due to a fall. V9 endorsed fractures caused by osteoporosis are more in the bone shaft and this fracture was closer to the hip joint. V9 denied R1 having a diagnosis or being on medication that could weaken bones or cause a spontaneous fracture. V9 endorsed these type of fractures are more likely from a fall. The Abuse Prevention Policy, undated, documents, .3. For resident injuries, not involving an allegation of abuse or neglect, the administrator will appoint a person together, further facts to make a determination as to whether the injury should be classified as an injury of unknown source. Any injuries should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious, because of the extent of the injury or the location of the injury (e.g., the injury is located in an area, not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidents of injuries overtime.

Deficienices at this level require 2 Deficient Practice Statements. A. Based on observation, interview, and record review, the facility failed to adequately supervise a resident (R43) with elopement behaviors for residents reviewed for elopement. This failure resulted in R43 eloping and being found unresponsive in the community, sustaining a traumatic muscle injury, and being hospitalized . B. Based on observation, interview, and record review, the facility failed to follow their policy and procedures for accident prevention by not providing adequate staff assistance for a resident who requires two-person assist for bed mobility and transfers, and not providing a cognitively impaired and agitated resident who was refusing care with adequate time to perform activities of daily living, for 2 residents (R20 and R71) reviewed for supervision and accidents Findings include: A.1. R43 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including but not limited to Chronic Kidney Disease, Stage 3 unspecified; Schizoaffective Disorder, unspecified; Unspecified Intellectual Disability; Major Depressive Disorder, recurrent, unspecified; and Anxiety Disorder, unspecified. According to MDS (Minimum Data Set), dated 07/14/2023, under section C, R43 has a BIMS (Brief Interview of Mental Status) score of 15, indicating a high level of cognitive functioning. Section G reads R43 requires supervision and set up across all Activities of Daily Living. R43's Elopement Risk Review, dated 05/07/2022, reads in part, Score: 3. A score of 4 or more indicates risk and requires interventions/plan. R43's Elopement Risk Review, dated 10/14/2022, reads in part, Score: 5. A score of 4 or more indicates risk and requires interventions/plan. R43's Elopement care plan, dated 10/14/2022, reads, (R43) presents with wandering/attempted elopement risky behavior symptoms, wandering with a purpose. On 8/1 (2023) (R43) eloped from the facility. Approach: (R43) is an elopement risk and for safety precautions he wears Wander Guard; social service will assess (R43) for elopement quarterly and as needed; social service will post (R43's) picture in the lobby; staff will provide (R43) opportunities for safe wandering throughout the unit; staff will provide redirection when (R43 )is observed wandering into unsafe areas or situations. Per record review, R43 eloped on 10/14/2022, by running out of the facility's front entrance, and on 08/01/2023, by jumping out of the second floor window. Progress note, dated 10/14/2022 at 7:05 AM written by V19 (Licensed Practical Nurse) reads in part, (R43) noted running out of the facility, police notified, staff was able to safely return (R43) to the facility. Progress note, dated 08/01/2023 at 9:45 AM written by V11 (Licensed Practical Nurse), reads in part, At around 7:20 AM, (R43) was noticed to be missing from his room. The window was seen to have been forced opened. Hospital returned call and stated that (R43) was at their facility. (R43) kept at the hospital for further evaluation. Police report, dated 08/01/2023 at 7:56 AM, reads in part, On 08/01/2023 at 7:56 AM, I was dispatched to (the facility) in reference to a missing person. (R43) left from a window roughly 30 minutes ago. At 10:01 AM (dispatch) confirmed that (area) hospital confirmed that (R43) was admitted . The charge nurse (stated) that (R43) was found in the community unconscious, laying in the grass, with his clothing completely soaked. Paramedics administered (narcotic overdose treatment). Hospital record, dated 08/01/2023, reads in part, Arrival date/time 08/01/2023 at 8:12 AM. (R43) presents to emergency department for agitation. (R43) was found outside of a woman's house, yelling. She called 911. Upon paramedics arrival, he was not making sense. (R43) had pinpoint pupils, so they gave (narcotic overdose treatment). (R43) on arrival states I'm not ok. (R43) doesn't know why he's here. Reason for hospitalization : Rhabdomyolysis. Discharge diagnosis: Rhabdomyolysis likely due to hypovolemia with history of extreme physical activity. Progress note, dated 08/08/2023 at 4:17 PM written by V11 (Licensed Practical Nurse), reads in part, (R43's) Readmission from the hospital. Hospital diagnosis: rhabdomyolysis. On 09/19/23 at 3:17 PM, V1 (Administrator) was interviewed regarding R43's elopement on 08/01/2023, V1 stated, Was this reportable? We found him right away; is this elopement? I did not report it to the Illinois Department of Public Health; V1 further stated: Staff was aware that (R43) was missing but we didn't find him, police called and told us that (R43) was found. To clarify, V1 was asked, Would you consider this an elopement? V1 stated, Yes. V1 continued: (R43) jumped out from the second floor window. (R43) might have been harmed but, because he walked away from the property, that means he wasn't harmed. We called the police as soon as we were aware that (R43) was missing. On 08/01/2023 at 08.30 AM, the floor nurse called me to notify me that (R43) was gone. Code Pink was called, staff initiated search in and outside of the building. That's also when the police, family, and the doctor was called. While all this was being done, around 10:00 AM, the hospital called the facility to notify us that (R43) was found and brought to them. (R43) was admitted to the hospital for a week or so. When he returned, he was placed on elopement precautions. (R43's) window was secured with one screw before the elopement. Now, all facility windows have 2 screws and (R43's) window has an alarm. On 09/19/23 at 3:54 PM, V11 (Licensed Practical Nurse) stated: I worked on day shift the day of (R43's) elopement (08/01/2023). (R43) was in a different room back then. (R43) was placed on precautions since the incident (08/01/2023), so now he is across from the nursing station, his window has an alarm, and we round more frequent on him. (R43) never displayed elopement behaviors before, so we didn't have any precautions for him. On 08/01/2023, I found out about (R43) being gone around 7:15 AM. Night shift nurse said that he was missing at around 7:06 AM. She was notified by (V15, Certified Nursing Assistant) who assisted him about 10 minutes earlier. At around 7:25 AM, we called Code Pink - that's when everyone stops everything they're doing to look for a missing person. We checked the entire building. We then noticed that (R43's) window was slightly opened and that's when we realized he might have eloped through the window, which is located on the second floor. Next, we notified (V1), and he told us to call 911. We also notified family and the doctor. (R43's) family got here right away. They were hysterical. When police arrived, they took (R43's) description, and we provided them with (R43's) picture. At that time, the police received notification through the radio that (R43) was found and is at the hospital. The resident has privilege pass to leave the facility accompanied by the family. (R43) wasn't leaving the facility often; the family was picking him up less and less. When I talked to (R43) after elopement incident, (R43) said that he wanted to see his family. (R43) was admitted to the hospital after elopement for rhabdomyolysis and came back with ordered antibiotics. On 09/20/2023 at 1:23 PM, V12 (Social Service Case Manager), stated: I have known (R43) since he was admitted (on 05/02/2022). (R43) is quiet, he used to keep to himself, but lately he interacts more with other residents and staff. (R43) is close to his family. He has privilege pass to go out with them. Initially, (R43) wasn't going out often at first, but more recently, he was going out every two weeks or so. For safety reasons, (R43) has to be assisted by somebody because of some mental issues and confusion. (R43) has had two elopement incidents during his stay at the facility, one on 10/14/2022 and on 08/01/2023. After incident on 10/14/2022, (R43) was evaluated by psychology and started wearing elopement prevention device. I talked to (R43) after the incident on 08/01/2023. (R43) said he just wanted to leave. (R43) should be always wearing his elopement prevention device. It was placed on his ankle. When (R43) returned from the hospital 8/8/23, his elopement prevention device was gone, so we gave him a new one that he wears on his wrist now. (R43) was able to elope because of the way he exited which was through the window; the elopement prevention device would alarm if (R43) would attempt to exit through the breezeway by the main entrance. On 09/20/2023 at 2:02 PM, V13 (Medical Doctor/MD), stated: I'm (R43's) primary physician. Rhabdomyolysis is a breakdown of the muscle. It could be caused by multiple reasons, such as trauma to the muscle. On 09/20/2023 at 2:45 PM, V14 (Maintenance Director), stated: I've been a Maintenance Director since May of 2023. The elopement incident happened on 08/01/2023. As staff was searching for the resident, we reinforced every window in the facility. Previously, windows had screws that were screwed into window frame, whereas now, there are brackets that wrap around window frame that are secured with two screws. Brackets are installed to allow to open a window by 2-3 inches, same as before. (R43) was so strong that he broke the screw out and was able to open a window completely. On 09/21/2023 at 2:38 PM, V14 (Maintenance Director) measured the distance of R43's window from the ground; the measurement is 12 feet. R43's picture was not observed to be posted in the lobby throughout the course of the survey. On 09/20/2023 at 1:43 PM, R43 was wearing elopement prevention device on left wrist. Elopement and Search (Code Pink) policy, dated February 2014, reads in part, All personnel are responsible for Knowing the whereabouts of residents for which they are assigned; Employees are instructed in elopement prevention and search protocol during initial orientation and throughout the year. Code Pink drills are conducted by qualified facility staff throughout the year. B. 1. R20 is a [AGE] year-old male with a diagnoses history of Quadriplegia as of admission 04/01/2019. R20's quarterly Minimum Data Set, dated dated [DATE], documents he requires total dependence on two people for transfers and extensive two person assistance for bed mobility. R20's Fall Risk Evaluation, dated 08/01/2023, documents he does not walk, he is paralyzed at all body parts, he is unable to turn in bed on his own and requires assistance. Current care plan started 02/05/2023 documents, (R20) had actual fall related laying to close to edge of bed by way of wiggling himself with interventions including Wing tip overlay applied to air mattress, Bilateral floor mats bed in lowest position. bed locked, Keep call light in reach at all times. Resident's ability to perform ADLs and mobility is impaired related to quadriplegia with interventions including Follow Physical/Occupational Therapy recommendations to complete activities of daily living and assist with mobility. R20's progress note, dated 08/15/2023 07:05 PM, documents while receiving care he had a change of plane. Abrasion noted to left cheek. First aid completed by writer. Transferred to (local) hospital. On 09/18/23 at 10:05 AM, R20 stated he went to hospital recently because he fell out of bed when staff was changing him, and hit the bedside dresser. R20 stated his dresser is still broken from the fall, and asked surveyor to look at the dresser. Observed R20's bedside dresser drawers broken. R20 stated there was only one staff changing him when he fell . On 09/21/23 at 10:18 AM V2 (Assistant Director of Nursing) stated only V24 (Certified Nursing Assistant) was present and providing care for R20 when he fell [DATE]. V2 stated V24 was in- serviced because R20 can't hold on and can slide during care; there should be two people providing care. B.2. R71 is a [AGE] year-old male with a diagnoses history of Parkinson's Disease, Dementia, Paranoid Schizophrenia, Abnormalities of Gait and Mobility, Abnormal Posture, Lack of Coordination, Difficulty in Walking, Muscle Wasting, Need for Assistance with Personal Care, Unsteadiness on Feet, and Repeated Falls who was admitted to the facility 12/18/2019. R71's Current care plan, initiated 12/10/2019, documents, (R71) is at risk for deterioration in activities of daily living (bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene) related to comorbidities with interventions including do not rush (R71). Allow extra time to complete activities of daily living. Care plan, initiated 03/19/2020, documents, (R71) displays behavioral symptoms directed toward others as evidenced by (verbal aggression towards staff, bizarre behavior, physical/verbal aggression towards peers) with interventions including staff will provide (R71) diversional activities to reduce behavioral symptoms, staff will attempt to anticipate (R71's) needs in order to decrease behavioral symptoms. Care plan, initiated 06/26/2021, documents, (R71) displays a rejection of care with interventions including, Staff will provide education if possible on the risks and consequences of their refusal of care, Social Services to provide support, Staff will provide reassurance to the resident when they are displaying anxiety regarding receiving care. Care plan, initiated 12/06/2022, documents, (R71) at risk for falling related to repeated falls and weakness. Care plan, initiated 02/16/2023, documents, (R71) is at risk for falling related to psychotropic medication use and antihistamine drug use. R71's Fall Risk Observation, dated 08/07/2023, documents he is disoriented times three, has a visual impairment, takes antidepressants and antipsychotics/Neuroleptics Confined To Chair, Totally Unable To Ambulate Without Assist; Wheelchair For Locomotion, has Decreased Muscular Coordination, has had one or two falls in the past three months, has a risk score of 18, and is at high risk for falls. Fall log, dated 04/18/2023 - 09/18/2023, documents R71 had a fall at 9:30 AM on 05/27/2023, a fall at patient sitting area on 05/27/2023 at 1:50 PM, and an unwitnessed fall in the dining room on 09/17/2023 at 3:13 PM. Resident was sitting upright in wheelchair upon last assessment 20 minutes prior to fall. Resident denies pain at the time of assessment. No redness, swelling, or bruising at this time. On 09/18/23 at 12:11 PM, R71 was in his room with V20 (Certified Nursing Assistant) agitated, cursing, and refusing care. V20 repeatedly said over the course of the interaction (R71) get up. Loud scuffling and thumping sounds were heard coming from R71's room. V20 came out of R71's room [ROOM NUMBER]-20 seconds later. V20 stated she was getting R71 ready for lunch, and he just kind of slid out of his chair. R71 was laying on floor in front of his wheelchair with his head on the front wheel of the chair. V20 returned to R71's room with V21 (Registered Nurse). V21 stated to V20 she could have come to get her, and she would have assisted her. V21 assisted V20 with raising R71 off the floor and assisted him to the dining area and sat him at a table. V21 stated to V20 she'll let someone know R71 is weak in the legs. V21 began feeding R71. No head to toe assessment or vitals were taken. On 09/18/23 at 12:31 PM, V10 (Nurse Practitioner) stated he came to check R71 because it was reported to him that he was on the floor. V20 (Certified Nursing Assistant) told V10 as R71 was getting dressed he slid to the floor. V21 (Registered Nurse) stated R71 can become rigid and stiff when receiving care and sometimes needs two people to assist him. V20 reported to V10 (R71) didn't hit his head or anything. On 09/18/23 at 12:36 PM, V20 (Certified Nursing Assistant) stated she was getting R71 dressed when he started to slide down. V20 stated she was getting R71 to stand up so she could button his clothes. V20 stated R71 had a bowel movement and she was changing him. R71's pants did not have a button. R71's progress note, dated 09/18/2023 at 10:55 AM, documents Bilateral hip X-rays done today and results pending. R71's progress note, dated 09/18/2023 at 1:34 PM, documents, (R71) slid from edge of bed during care and assisted to floor per certified nursing assistant at 1:00PM. (R71) was assisted to feet per staff. Head to toe done and no injuries noted. Vital signs within normal limits. In-house nurse practitioner made aware. R71's Nurse Practitioner Progress note, dated 09/18/2023 at 9:58 PM, documents [Recorded as Late Entry on 09/19/2023 09:58 PM] Chief Complaint: Seen post Assisted Fall; Nature of Presenting Illness: (R71) is a [AGE] year-old male who was seen on 9/18/23 post assisted fall. Resident was seen sitting at the table eating lunch with one assistant. Per the nursing staff, (R71) slid from the edge of the bed with certified nursing aide assistance to the floor. No injuries were reported. The resident has continuous nonsensical speech with intermittent yelling and vowel language. No injury, swelling, bruises, or bleeding were noted from all visible sites. On 09/20/23 at 1:22 PM, V2 (Assistant Director of Nursing) stated, If a resident is agitated or resistant during care sometimes you just need to leave them alone for a few minutes and reapproach them, or sometimes ask for assistance. If none of these options are effective, staff can have Social Services check on the resident to find out why they're resistant to care. Sometimes another staff may be able to encourage the resident to be compliant. (V20 (Certified Nursing Assistant)) may have continued to attempt to provide care to (R71) on 09/18/2023 when being resistant and agitated because he's like that all the time, every day, and always resistant to care with all staff. V2 (R71) responds to internal stimuli. Sometimes (R71) is not resistant to care. (R71) needs to be encouraged a lot to receive care, go to the dining room for meals, to be changed etc. and he will be compliant eventually if you're attentive. If staff continue to provide care when residents are resistant, they could become more agitated. (V20) could have decided to come back and attempt to provide care to (R71) later, and she could have informed someone (R71) wouldn't allow her to dress him and have someone come in and assist her. V2 stated she wouldn't say get up to a resident when attempting to provide care, but would say it's time to get up. V2 stated she wouldn't use the phrase get up because whenever you're addressing a resident or anyone, you should find better ways of communicating. V2 stated she attempts to train staff to be approachable and kind to residents. On 09/20/23 at 2:07 PM. V10 (Nurse Practitioner) stated, According to the nurses, (R71) can fight and become agitated. V10 stated he asked the facility why they called him if he just slid to the floor and did not fall. V10 stated, (V20 (Certified Nursing Assistant)) reported she was trying to dress (R71), and he was resistant, and slid to the floor because he did not want to be handled or something. V10 stated when he asked V21 (Registered Nurse), V21 reported R71 was on sitting on the floor on his knees leaning forward with his hands in front of him on the floor, when she observed him after the incident. V10 stated according to V20, R71 just slid from edge of bed. V10 stated V20 reported she grabbed R71 and assisted him to the floor after he began sliding to the floor, because he was resistant to being dressed. On 09/20/23 2:54 PM, V20 (Certified Nursing Assistant) stated, (R71 )slid off the side of the bed on 09/18/2023. (R71) was sitting on the side of the bed when I was attempting to dress him. (R71) was sitting on the edge of the bed, and I wanted to stand him up, so I could finish buttoning his pants, which I started doing when he was laying down after I performed incontinence care. V20 stated she wanted to stand him up to ensure his pants were fully up before buttoning up. V20 stated when her and V21 (Registered Nurse) stood him up and continued to try to raise his pants, is when she realized he didn't have a button. V20 stated she didn't find a button on R71's pants when he was lying on his bed towards the edge of the bed after providing incontinence care. V20 stated she then decided to stand R71 up and look for a button. V20 stated R71 was resistant to receiving incontinence care, and during the whole process of attempting to dress him. V20 stated usually if R71 is resistant he would become a two person assist but she was the only staff there at the time. She anticipated R71 would resist care. V20 stated she was going to attempt to change R71 standing up in the bathroom, but needed assistance and could not find any other staff to assist her. V20 stated R71 needed to be changed because it was time for lunch, and it was past time for him to receive incontinence care. V20 stated, When (R71) fusses, he's not talking to us, he's talking to people in his head. (R71 regularly attempts to sit down as if there is a chair behind him, so we encourage him to get up. When in the process of raising (R71) from the edge of the bed, he was partially raised, and sat back down, but missed the bed, and slid the whole way down to the floor because she never let him go. V20 stated a way to encourage R71 to stand up is get up (R71) just get up. V20 stated telling someone to get up is not a way to encourage them, however, she does not feel this is inappropriate. V20 stated a way to encourage a resident to get up may be to ask them to get up. V20 stated neither R71 or her came into contact with any objects when he was sliding to the floor. V20 could not explain the loud scuffling and thumping sounds heard when sliding R71 to the floor. V20 stated she moved R71's fall mat because she was about to stand him up, and he needs the fall mat while in bed. On 09/21/23 at 10:18 AM, V2 (Assistant Director of Nursing) stated she can't say if it would have put R71 at risk for a fall if V20 (Certified Nursing Assistant) was continuing to stand him up when he was resisting care. The facility's Refusal of Treatment Policy, reviewed 09/21/2023, states: Our facility shall honor a resident's request not to receive care routines outlined on the resident's assessment and plan of care. 46066

Based on interview and record review ,the facility failed to protect a resident (R1) from physical abuse by (R2). This failure applied to two (R1 and R2) of five residents reviewed for abuse, and resulted in R1 obtaining a hematoma, facial laceration, laceration of right lower leg, and closed fracture of condyle of right femur. Findings include: R1's Facility Census documents R1 was admitted on [DATE], with the following medical diagnoses: Parkinson's Disease, Schizoaffective Disorder, Muscle Weakness, Major Depressive Disorder, Anxiety Disorder, Cognitive Communication Deficit, Personal History of Traumatic Brain Injury and Conversion Disorder with Seizures or Convulsions. R1's Minimum Data Set (MDS), dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) score 10, moderately impaired. R2's Facility Census documents R2 was admitted on [DATE], with the following medical diagnoses: Mild Intermittent Asthma, Major Depressive Disorder, Anxiety Disorder, Other Sleep Disorders not due to a Substance or Known Physiological Condition, Dysphagia Oral Phase and Weakness. R2's Minimum Data Set (MDS), dated [DATE], documents R2's Brief Interview for Mental Status (BIMS) score 14, cognitively intact. R1's Nursing Notes, dated 5/29/23 at 7:04pm, documents ,(V3, Licensed Practical Nurse/LPN) was alerted to room by loud screams, observed (R1) sitting in wheelchair screaming and crying, blood coming from the mouth and grabbing (R1's) right knee. (R1) states that **** hit me (R2). V3 alerted more staff for assistance. First aid rendered to mouth with blood trickling down the jaw. Vital signs taken. Manger on Duty (MOD) notified, Local Emergency Response Activated. R2's Nursing Progress Notes, dated 5/29/23 at 7:04pm, documents, (V3) heard screaming coming from bedroom, (V3) observed (R2) sitting in wheelchair on (R2's) side of the room. (V3) asked (R2) what happened? (R2) responded, (R2) hit that **** (R1), (R2) was verbally and physically aggressive towards roommate and using profanity with staff. (V3) asked (R2) to show (V3) how (R2) hit (R1). (R2 )stated, '(R2) hit (R1) with this (pointing at the arm of the wheelchair)'. (V3) called out for more staff assistance. Staff removed (R2) from the bedroom. R1's Nursing Notes, dated 5/29/23 at 7:34pm, documents R1 leaving the building alert and verbal with Local Emergency Response Team. R2's Nursing Notes, dated 5/29/23 at 7:47pm, documents R2 leaving the facility with local emergency response going to hospital with petition. R1's Hospital Report, dated 5/29/23, documents, Two absorbable sutures placed in the left corner of mouth, and three ethilon sutures in the right knee. R1's Nursing Notes, dated 5/30/23 at 8:11am, documents, (R1) returned to the facility, alert and quiet, hematoma, facial laceration, laceration of right lower leg, closed fracture of condyle of right femur, received diphtheria pertussis-tetanus on 5/30/23, dissolvable sutures in mouth with bruising observed on left upper lip, sutures on knee to removed in 7-10 days, right leg immobilized, to eat soft foods and to rinse mouth after meals for cut inside of mouth to reduce pain, follow up appointment . Order Tramadol (pain medication) 50 milligrams, by mouth every 8 hours as needed for pain, return to room without roommate. On 7/15/23 at 1:30pm, V3, Licensed Practical Nurse (LPN), said V3 was working on 5/29/23, and at around 7:00pm, heard loud screams coming from R1 and R2's room. V3 said V3 entered the room, and observed R1 sitting in wheelchair screaming and crying, blood coming from the mouth, and grabbing R1's right knee. V3 said R2 was sitting in R2's wheelchair on the other side of the room. V3 asked what happened, and R1 informed V3 that that **** hit me (R2). V3 alerted more staff for assistance. V3 asked R2 what happened and R2 said R2 hit R1 because R1 would not stop talking. V3 asked R2 how R2 hit R1, and R2 removed the wheelchair arm which consisted of the arm rest and metal frame from R2's wheelchair, and said (R2) hit (R1) with this. V3 said R1 and R2 were transferred to the emergency room for evaluation and treatment. On 5/30/23 at 8:11am, R1 returned to the facility, alert and quiet, with a hematoma, facial laceration, laceration of right lower leg, and closed fracture of condyle of right femur. On 7/17/23 at 9:40am, V1, Administrator, said, On 5/29/23, (V3, Licensed Practical Nurse) informed (V1) of an altercation between (R2) and (R1). (V1) immediately started an investigation, and all notification was done, along with notifying Illinois Department of Public Health. (V1) interviewed (V3), who informed (V1) that (V3) heard a noise coming from (residents room). (V3) immediately entered the room, and (V3) saw (R1) holding (R1's) mouth. (V3) asked (R1) what happened, and (R1) informed (V3) that (R2) hit (R1). (R1) and (R2) were sent to emergency room for evaluation. On 5/30/23, (R1) returned from the hospital with diagnosis of hematoma, facial laceration, and laceration of the right lower leg. The Facility's Illinois Abuse Prevention Policy, dated 10/24/22, documents: this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 Interpretive Guidelines). The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CFR 483.5). Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (66 ILL Adm Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. (42 CFR 483.12 Interpretive Guidelines).

Based on interviews and record reviews, the facility failed to keep a resident free from sexual abuse by not having effective interventions in place including monitoring and supervision, for a resident with known wandering behaviors and who was exhibiting an increase in behaviors related to dementia diagnoses. This failure applied to one (R2) of one resident reviewed for abuse, and resulted in R2 wandering into another residents room and being sexually assaulted. Findings include: R2 is a [AGE] year-old female, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was admitted to the facility 09/27/2022. R2's admission abuse risk review 09/28/2022 documents she is at risk of abuse due to her exhibited history of elopement and her exhibited lack of safety awareness; risk factors include serious mental illness, wandering, and impulse control issues. R2's current care plan documents: R2 is at risk of abuse due to her severe mental illness, impulse control issues, minimalizing circumstance, exhibited history of elopement and exhibited lack of safety awareness. R2's progress note, dated 10/10/2022 at 07:29 PM, documents R2 was observed in other resident's rooms three times and was returned to her room by the nurse during night shift. CNA (Certified Nursing Assistant) also reported that resident wanders the halls during 1st shift and often found on a different unit. Will continue to monitor; at 07:32 PM, R2 was found in other resident's room during the writer's first round and day shift CNA reported that resident again was near elevator, and also on a different unit frequently. R2's progress note, dated 10/30/2022 at 11:49 AM, documents R2 noted with odd behavior. Walking on unit and standing in one spot falling asleep. R2 redirected to room and will rest but gets up again and walks through out unit. Physician called and made aware of behavior. Antipsychotic 5mg twice daily decreased to at bedtime only and monitor behavior. Will continue to observe resident for any changes. R2's progress note, dated 11/05/2022 at 10:00 AM, [Recorded as Late Entry on 11/06/2022 04:15 PM] documents R2 incoherent and unable to follow simple commands. Generalized weakness noted. Physician made aware at 07:15AM and new orders to send R2 to nearest hospital emergency room for evaluation; at 10:35 PM [Recorded as Late Entry on 11/06/2022 10:49 PM] Received R2 from local hospital via stretcher accompanied by 2 emergency transportation personnel, discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress note, dated 11/06/2022 at 10:30 PM, documents R2 was observed in bed with a blood clot to her left forehead, painful to touch when asked what happened resident stated she did not fall she bumped her head on the wall a couple of days ago, placed call to physician to give update; at 10:45 PM Placed call to ambulance service was informed there were no transportation available at this time. Place call to 911 for transportation. On 11/11/22, R2's interventions included: Staff will provide redirection to R2 to ensure her safety and well-being needs are being met daily and as needed; social service will assess R2 for abuse risk quarterly and as needed; staff will observe R2 for signs and symptoms of abuse daily and as needed to ensure her safety; abuse care plan initiated 11/12/2022. R2 presents with exhibited history of elopement risky behavioral symptoms with interventions including: Staff will provide opportunities for R2 safe wandering throughout the unit daily; Staff will provide redirection when R2 is observed exhibiting wandering into unsafe areas or situations and/or elopement risky behavioral symptoms as needed. R2's progress note, dated 11/11/2022 at 4:58 PM, documents R2 was eating supper in room and appetite good; at 09:14 PM, R2 noted in male resident's room while CNA (Certified Nursing Assistant) was completing scheduled rounds. R2 noted in the bed with male resident on top of her. Staff members interceded and notified appropriate parties. Message left for Physician on answering service line. R2 transported via 911 to local hospital for examination. R2's Incident Investigation Report, dated 11/11/2022, documents: CNA Witnessed R2 in R3's room, observed both residents in the bed undressed, police were called. Physician and families notified. R2 was sent to the hospital for evaluation. R3 was petitioned out to the hospital for Psych evaluation. Police Report, dated 11/11/2022, documents R3 was observed by staff engaging in sexual intercourse with R2 against her will. On 11/11/22 at 8:43PM, police responded to the facility in reference to a criminal sexual assault. Upon arrival, the responding officer spoke with floor nurse who informed that staff were conducting room checks when they noticed R2 was not in her room and began to look for her. V7 (Certified Nursing Assistant) and V6 (Certified Nursing Assistant) then told the nurse they found R2 in the bed of R3 engaged in sexual intercourse with vaginal penetration. R2 could be heard telling R3 to stop, and both V7 and V6 told R3 to stop also. R3 refused to stop, forcing the staff to pull R2 from underneath R3. R3 then admitted he pulled R2's leggings off of her. The nurse advised all patients housed in the unit suffer from dementia, and both R3 and R2 suffer from various forms of dementia and other mental and physical health conditions. Both V7 and V6 agreed with the nurses statements. The responding officer spoke with R2 who advised she was watching a movie with R3 when she willingly walked to the rear of the room where R3's bed was. R2 could not give any more information of what else occurred except she told R3 to stop multiple times. The responding officer spoke with R5 who reported R2 was in the room watching a movie when she went towards the rear of the room with R3. R5 then heard R2 telling R3 to stop multiple times but he did not see what was happening. R2's Hospital Record, dated 11/11/2022, documents R2 is a [AGE] year-old female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 reports last night she wandered into a male resident's room voluntarily and went to sleep. R2 reported the next thing she knew the CNA's (Certified Nursing Assistants) at the facility were pulling the male patient off of her after he forced himself onto her without her consent. Alleged sexual assault was witnessed by two Certified Nursing Assistants from facility. Emergency Medical Services reports that the patient wandered into another patients room voluntarily, but he forced himself onto her without consent. R2's progress notes, dated 11/12/2022 7:38 AM, documents: Resident returned from hospital alert and oriented to self. No pain or distress noted at this time. New order for two [CONDITION(S)] antivirals to be started to be taken until November 15. R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She was diagnosed with paranoia and [CONDITION(S)] disorder with paranoid exacerbation. R2 was admitted to the facility on [DATE] to the secure unit. R2 was seen today for follow up to emergency hospital room visit on 11/11 due to alleged sexual assault. Per nursing and notes, R2 was found in male room pinned under him. R2 was sent to emergency hospital room for assessment and sent back this morning with new orders for two [CONDITION(S)] antivirals until 12/13. She appears calm and is confused. She does not want to discuss feelings today. On 11/14/2022 from 1:03PM - 1:27PM, a large bump was on the left side of R2's forehead. R2 stated she bumped her head up against the frame of the wall in front of her bathroom. Observed the frame of R2's bathroom while she showed the surveyor where she bumped her head. R2 stated it happened early one morning when she was on her way to the bathroom and still half asleep. R2 stated the nurse did examine her and she was sent out to the hospital. R2 stated she was watching a movie with R3, and he climbed on top of her. R2 stated she asked R3 multiple times to stop and get up, but he would not get off of her. R2 stated when R3 climbed on top of her she was confused about what he was trying to do. R2 stated she was sent to the hospital after this incident. On 11/14/2022 from 2:04PM - 2:09PM, V3 (Registered Nurse/Nurse Manager) stated she wasn't in the building during R2's alleged sexual assault, but was the manager on duty. V3 stated on 11/11/2022, she received a call the CNA (Certified Nursing Assistant) found R2 in another residents room and was partially unclothed, and didn't know what to do. V3 stated since R2 can't consent to having sex, they sent her out via 911 to be evaluated for potential abuse. V3 stated R3 was monitored by a police officer who sat in the hallway, until it was determined what to do with him. V3 stated the CNA explained to her during rounds around 6:30PM, she observed R2 in her bed in her room appearing to be settled in for the night then continued rounds. V3 stated when the CNA began the next round around 8-8:30PM, she noticed R2 wasn't in her room, and found her in R3's room next door. V3 stated R2 was living in a room directly next door to R3 at the time of the incident. V3 stated she had R2 sent to hospital to be evaluated. On 11/14/2022 at 4:34PM, V6 (Certified Nursing Assistant) stated she has worked for the facility for seven years. V6 stated she has worked with R2 and R3 often. V6 stated on 11/11/2022, she observed R2 in her room at 5:30PM while collecting dinner trays. V6 stated she and V7 (Certified Nursing Assistant) were conducting rounds on 11/11/2022 at approximately 6PM, and observed R2 was not in her room. V6 stated she and V7 checked all rooms and bathrooms on the locked unit, and when she entered R3's room at 6:30PM or close to 7PM, she looked around the curtain and saw R2 and R3 in R3's bed having sex. V6 stated R2 and R3 were having full intercourse. V6 stated she and V7 instructed R3 to get off of R2 and he refused. V6 stated R3 just gave her and V7 a mean look and continued. V6 stated she stayed in the room while V7 went to go get other CNA's and Nurses to assist getting R3 off of R2. V6 stated she, a nurse, and two agency CNA's all redirected R3 to get off of R2, and after numerous requests he finally complied. V6 stated R2 was taken to her room, her pants, and a clean pull up were placed on her, and they had her sit at the nurses station. V6 stated R3 remained in his room, and 5 minutes later came out into the hall and asked where R2 was. V6 stated after that, R3 went back in his room and remained until the police arrived. V6 stated the police stayed with R3 once they arrived. V6 stated the police asked staff and R2 what happened. V6 stated when R2 was asked what happened, she reported she wandered into R3's room, sat on his bed, they began talking, he then pushed her back onto his bed, pulled down her pull up and pants, and began having intercourse with her. V6 stated R2 reported when she told R3 to stop he wouldn't stop. V6 stated R2 reported she told R3 to stop, and he just kept going. V6 stated R2 typically roamed sometimes, but in the last couple of weeks had been roaming around a lot in and out of people's rooms. V6 stated the nurses and V2 (Registered Nurse/Assistant Director of Nursing) were aware of R2's behavior. V6 stated the facility's instructions on interventions for R2's wandering is to redirect her, have her come to the dining room, and provide her with a snack or coloring material or something like that. V6 stated R2 and R3 did not interact much prior to this incident. V6 stated R2 sometimes hallucinates and is sometimes confused. V6 stated R2 has not engaged in any other sexual activity prior to this incident. V6 stated R3's roommate R5 was in the room when the incident took place. V6 stated R2 and R3's rooms were right next to each other during this incident. On 11/15/2022 from 3:17PM - 4:45PM, V2 (RN/Assistant Director of Nursing) stated most of the memory care residents sit in the dining room for supervision, and this is also where they participate in activities and watch television. V2 stated if R2 was noted to be going in and out of residents rooms, and if it was observed to be an ongoing behavior, it should be reported to social services and the supervisors. V2 stated the nurse and the staff should be informed of this behavior so R2 can be supervised and redirected by the nursing staff. V2 stated if this behavior is ongoing, R2 should be in a supervised area or constantly or frequently supervised by the staff. V2 stated the CNA (Certified Nursing Assistant) would be instructed to monitor R2 and make sure they know her whereabouts. V2 stated she would try not to have a resident with the behavior of wandering into other resident's rooms out of sight. V2 stated at all times the nursing staff should be aware of where residents who are wandering are located. On 11/16/2022 from 12:10PM - 12:48PM, V1 (Administrator) stated abuse risk assessments are completed through social services on admission and as needed. V1 stated the abuse care plan interventions would be implemented based on the admissions policy, abuse policy, care policy, and results of standard assessments. V1 stated the residents abuse care plan should be personalized based on their specific needs. V1 stated increased safety concerns for R2 should have been reevaluated each time she returned from the hospital after a change in her condition. V1 stated determination of a dementia residents decision making ability would be completed with the interdisciplinary team including the physician and she is not certain how this assessment would be completed. V1 stated she would refer to social services on how this assessment would be completed. On 11/16/2022 from 4:56PM - 5:26PM, V5 (Social Services Director) stated she is aware R2 wanders the unit, however, she had not received any information R2 had been wandering into resident's rooms. V5 stated if R2 was wandering into residents rooms, there would be increased location monitoring and frequent rounds to make sure she is safe and secure. Review of medical record does not show there was any change to R2's plan of care or increased monitoring based on increasing behaviors demonstrated by R2. The facility's abuse prevention policy (October 2022) reviewed 11/16/2022 states: The facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse; This will be done by: establishing an environment that promotes resident security and prevention of mistreatment. Sexual abuse includes but is not limited to sexual assault including non-consensual or non-competent to consent sexual activity. As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. The facility's Resident Rights Policy reviewed 11/16/2022 states: The resident has the right to be free from sexual abuse. Residents will be cared for in a manner and in an environment that promotes maintenance or enhancement of each residents quality of life, dignity, and aspect in full recognition of his or her individuality. The facility's Dementia Care policy reviewed 11/16/2022 states: Many individuals with a recent hospitalization will still have [CONDITION(S)] for some time after discharge. [CONDITION(S)] may be especially problematic in individuals with underlying dementia. The staff and physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions. Individuals with dementia can also have a personality disorder, mental illness, [CONDITION(S)], [CONDITION(S)], or other conditions causing or contributing to impaired cognition and problematic behavior. The facility's Care Plan Policy reviewed 11/16/2022 states: Each resident's comprehensive care plan has been designed to: Incorporate identified problem areas. Reflect treatment goals and objectives in measurable outcomes. Collaborate with the resident, family and friends of the resident to identify and implement individualized interventions. Care plans are revised as changes in the resident's condition dictates.

Based on interview and record review, the facility to follow their weight loss policy to develop a plan to reduce an insideous unplanned weight loss and failed to notify the physician of a significant weight loss. This affected 1 of 3 residents (R126) in a sample of 133. This failure resulted in R126 having a 11.7% weight loss in 30 days. Findings include: R126's weight variance report, dated 7/1/22-09/12/22, documents: 09/12/2022 Weight: 147.6 lbs 08/07/2022 Weight: 167.2 lbs 07/08/2022 Weight: 170.0 lbs On 10/18/22 at 12:58 PM, V23 (Dietitian) said, I saw (R126) on 9/13/22 for a weight loss of 11.7% decrease since 8/7/22. The full reason of (R126's) weight loss was unclear. (R126) denied any change in eating habits and reported only having four working teeth. (R126) was on a regular diet. I increased (R126's) health shakes to 4ounces twice a day. I ordered weekly weights. The weekly weights were not done. I did not see any weekly weights . If I had seen (R126's) weights, I would have written a progress note. I don't have any progress notes for (R126) related to the weekly weights. (R126's) weight on 9/12/22 was re-weight. On 10/18/22 at 2:30pm, V2 (don) said, weekly weight are done to determine the effectiveness of the intervention, view further weight loss and a new to implement a new interventions. On 10/19/22 at 1:51 PM, V29 (Medical Doctor) said, I expected the Dietitian recommendations to be followed. The weekly weight should have be completed. They would have documented further weight loss. I don't recall be notified of (R126's) weight loss. If I had been notified of (R126's) weight loss, I would have orders some labs, such as a complete blood count (CBC), basic metabolic panel (BMP), and possibly a carcinoembryonic antigen (CEA). On 10/19/22 at 2:51 PM, V3 (Assistant Director of Nursing/ADON) said, (R126's) weight on 9/12/22 was a reweight. I refer to the Dietitian. (R126) did not have an order or labs for CBC, BMP and or CEA in the month of September. I'm not sure if the doctor or nurse practitioner was notified. Let me check. On 10/19/22 at 4:15 PM, V29 (Medical Doctor) said, I talked to (R126) today. (R126) reported a loss of appetite. I just ordered some labs. On 10/19/22 at 4:20 PM, V3 (ADON) did not present any document related to doctor/nurse practitioner notification for R126's weight loss. R126 did not have a an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Weight Assessment and Intervention 8/2008 Policy: Any weight changes of greater than or less than five pounds within 30 days will be retaken for confirmation. If the weight is verified and triggers a significant weight change, the physician will be notified. #4 dietitian will determine if addition interventions are warranted. #5 significant weight changes are defined as more or less than 5% within 30 days.

Based on observation, interview, and record review, the facility failed to assist a resident with gaining access to vision services by failing to make requested appointments and arrange for transportation. This failure affected one (R1) of four residents reviewed for vision services. This failure resulted in R1 becoming depressed and feeling socially isolated and worthless as a result of not being able to participate in activities due to poor vision. Findings include: R1 is a [AGE] year old female who has resided in the facility since 2018 with the following past medical history: Lumbosacral root disorder, not elsewhere classified, Type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, unspecified lack of coordination, Candidiasis unspecified, weakness, major depressive disorder, and low back pain. On 12/07/2021at 11:30AM, R1 was observed in her room, awake, alert and oriented x3. R1 stated that she is upset because the facility took a year and a half to schedule her for a needed eye appointment/surgery as recommended by facility ophthalmologist in 2018. R1 stated she finally got an appointment in March of 2021, got to the clinic and was told that the doctor does not work there anymore. R1 stated she paid $200.00 in transportation for the appointment. R1 continued to state that she finally saw an eye doctor on 6/7/2021, who stated that she is almost blind in her right eye. At that time, R1 made a follow-up appointment and informed the facility staff, but they forgot to arrange for transportation, so she missed that appointment (which was in August 2021) and has not been rescheduled for another one since. R1 said that she feels hopeless and worthless because she cannot participate in activities because she cannot see. R1 stated, Right now, I can't even see your face, just a shadow. Per R1, her social worker wasn't doing much and R1 was just assigned a new social worker in November. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of social service progress notes also show several documentations that R1 feels bad and does not feel good about herself due to her bad sight, dating as far back as 12/05/2020. On 12/08/2021 at 12:08PM, V7 (Social Service Director) said that nurses make the arrangements for resident appointments, and the scheduler arranges for transportation. V7 said that she is not aware that R1 missed her doctor's appointment due to transportation; V7 recalls R1 telling her that V7 was informed of an appointment but V7 forgot to tell the staff. V7 said that she educated R1 on the importance of telling staff about upcoming appointments and that V7 mentioned it to nursing. V7 further stated V7 was not sure who V7 told in particular and not sure if V7 wrote a progress note either. On 12/08/2021 at 12:30PM, V5 (Scheduler) said that R1 does not have any scheduled appointments; he only arranges for transportation and the nurses usually schedule the appointment, then inform him. On 12/09/2021 at 2:42PM, V8 (Social Worker) said that she has worked on and off with R1, but R1 was never on her caseload; V8 only covers when R1's assigned social worker is not available. V8 stated that for the small period she worked with R1, R1 was concerned with going home and having a cataract surgery but V8 does not handle resident appointments; nurses do that. Documentation by a psychiatrist assistant dated 9/20/2021 includes: R1stated her frustration. R1 missed her eye appointment due to lack of transportation, staff said she never told them about the appointment, but it has been rescheduled. On 12/09/2021 at 12:46PM, V7 (Social Service Director) stated that she does not know which staff was told of appointment and could not find any documentation of the appointment being rescheduled. V7 added that she agrees that someone dropped the ball; the appointment should have been rescheduled and the resident should have been informed of what was going on. Surveyor requested a facility policy and/or protocol related to scheduling of appointments for residents, but none was provided during the course of this survey.

Based on observation, interview, and record review, the facility failed to monitor and supervise a resident who is a known fall risk per care plan. This failure affected one (R4) of four residents reviewed for accidents. This failure resulted in R4 having a fall that required emergent transfer to the hospital, where she was diagnosed with an acute nondisplaced fracture of the bilateral nose. Findings include: R4 is a [AGE] year old female who has resided in the facility since 6/26/2021 with past medical history including: Unspecified sequelae of cerebral infarction, Alzheimer's disease, [CONDITION(S)], cognitive communication deficit, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side, disorientation, dysphagia oropharyngeal phase, weakness, unsteadiness on feet, etc. On 12/08/2021at 3:30PM, R4 was observed in the dining room with other residents. R4 was sitting in a wheelchair and tearing off her incontinence brief. Large pieces of the brief were observed on top of the table by R4. No staff were close to R4 or monitoring R4. Surveyor continued to observe R4 for 10 minutes before a staff noticed what R4 was doing and then took R4 to change her incontinence brief. R4's care plan dated 4/26/2021 includes that R4 is at risk for falls. The care plan states: Resident had a fall on 6/19/2021, 6/24/21, 7/10/21, 8/31/21 r/t Impaired Cognition. Interventions included: Bilateral floor mats when in bed, monitor at all times when in wheelchair and not in bed, observe frequently and place in supervised area when out of bed, place on early morning get up list. Another section of the same care plan states that R4 had a fall with injury on 6/20/21. Interventions included wheelchair for locomotion, frequent visual checks, occupy resident with meaningful distractions, etc. Facility Minimum Data Assessment (MDS) dated [DATE] section G (Functional status) has R4 coded as 3/2 for all ADLs (Activities of Daily Living) which indicates that R4 requires extensive assist with one person physical assist. On 12/09/2021 at 1:46PM, V12 (Restorative Certified Nursing Assistant/CNA) stated that the day R4 sustained the injury to her nose (11/28/21) she (V12) had gotten to work around 8:00am and was informed that R4 was found on the floor. V12 was not working directly with R4 but helps with monitoring in the dining room. V12 stated R4 uses a wheelchair and has an unsteady gait due to stroke. V12 added that R4 requires constant supervision and extensive staff assistance with ADLs. On 12/09/2021 at 2:17PM, V13 (Licensed Practical Nurse/LPN) said that (11/28/21) she (V13) got to work at around 7:10AM the day that R4 had her injury, and she did not see anything; R4 was already on her way out (to the hospital) when V13 came in. The night shift nurse reported to V13 that she was doing rounds when she noted R4 with blood on her nose. R4 returned from the hospital on V13's shift with a swollen nose, but it was no longer bleeding, R4 denied pain and vital signs was stable. V13 received a report from the hospital that resident had a fractured nose, she reported to DON (Director of Nursing) and also called the family. V13 said that she has worked with R4 for a few months and (R4) requires extensive care with ADLs, constant supervision and was on a get up list for overnight shift. V13 added that residents on the early get up list are usually up and in the nursing station by the time morning shift gets to work. R4 does not use a walker or bed alarm but has an electronic monitoring device. On 12/09/2021 at 3:10PM, V15 (LPN) said that she was the assigned nurse for R4 on 11/28/21; V15 was passing meds and around 6:30am while coming back from another resident's room, V15 saw R4's roommate with a sheet covered in blood. V15 entered the room and saw R4 in her bed with blood, asked R4 what happened and R4 could not answer. V15 asked the roommate, who said that she does not know, she just trying to help out. V15 assessed R4, vitals were okay, R4 denied pain but V15 could not stop the bleeding. V15 called the doctor and got an order to send resident out to the hospital. V15 also notified the family and the DON. V15 added that that was her first time working with R4; the only thing they told her was that R4 tries to get up by herself. V15 stated she did not receive any report of R4 requiring constant monitoring and/or supervision. V15 added that the last time she saw R4 was around 4:45am when V15 gave R4 her medication. Review of R4's POS (Physician Order Summary) for the month of November 2021 does not include any orders for medication to be given during the night shift; there are orders for two medications to be given as needed. Review of MAR (Medication Administration Record) for November 2021 does not include documentation that R4 received any scheduled or as needed medications on 11/28/21 (per V15's statement) or at any other time during the month of November 2021. There is no documentation in R4's medical record to show that a visual check was performed as care planned from the evening of 11/27/21 - 11/28/21 when R4 had the fall with injury.

Based on interview and record review, the facility failed to provide a resident with restorative therapy to help with the use a prosthetic leg to maintain the resident's ability to walk for 1 of 54 residents (R155) reviewed for restorative therapy. This failure resulted in R155 who was adjusting to his disability, expressing words of disappointment and sadness because he was not provided with the daily restorative therapy using a prosthetic leg. Findings include: R155 is a [AGE] year old male admitted to the facility 2/20/2019. R155 has a Brief Interview for Mental Status (BIMS) score of 15 as indicated on the Minimum Data Set assessment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/02/21 11:54AM R155 was observed in his room sitting in wheelchair watching television. R155's prosthetic leg observed in front of book cabinet. During interview with R155 on 11/02/2021 at 12:00PM, R155 said, I am supposed to get therapy and use my prosthetic leg every day. I used to go to therapy and used it there, but they said I was discharged from therapy and haven't used it since. I feel like the nurses and those taking care of me don't want me to walk ever again. They just want me to waste away in this chair. I have a way to walk and they won't help me. They are supposed to help me and that makes me feel like no one cares about me. On 11/03/21 at 02:13pm V21 (Restorative Nursing Director/Restorative Nurse) said, We have a certified occupational therapy assistant who provides restorative therapy to the residents as well as the CNA (Certified Nurse Aide) and restorative aide. I am responsible for supervising to make sure restorative nursing is completed or effective, and I do the quarterly and annual assessments. R155 has two programs in place, but I am not sure exactly which ones. I have not worked with him personally. I'm not familiar with his plan of care off the top of my head. If the minutes are not documented in the Point of Care charting, the CNA or Restorative Aide probably forgot to chart or it didn't happen. A resident with a prosthetic device should be worked with daily in order to reach their best potential. Physical Therapy discharge summary documentation dated 7/23/2021 indicates R155 was to be transitioned to restorative nursing program in order to facilitate patient maintaining current level of performance and in order to prevent decline, {sic} and instruction in the following Restorative Nursing Programs has been completed with the interdisciplinary team. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan for ADL Functional Rehabilitation Potential updated 10/31/2021 indicated that R155 requires a restorative amputation/prostheses program. Goals of the care plan include, R155 will apply and remove prostheses with extensive staff assistance 6-7 days per week through next review. R155 Electronic Medical Record history was reviewed from 8/1/2021 to 11/2/2021 for amputation/prosthesis care. In August 2021 prosthesis care was charted as not performed for a total of 15 days. In September 2021 POC for prosthesis care was charted as not performed for 17 days. In October 2021POC for prosthesis care was charted as not performed for 14 days. Facility Rehabilitative Nursing Care Policy states in part, General rehabilitative nursing care is that which does not require the use of a Qualified Professional Therapist to render such care. Nursing personnel are trained in rehabilitative nursing care. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence.

Based on observation, interview and record review, the facility failed to provide grooming and hygiene assistance for Activities of Daily Living (ADLs) for dependent residents in order to avoid excessive wetness or having feces on them and not being groomed in appropriate manner. This applies to six dependent residents (R25, R60, R99, R126, R146, and R156) in a sample of 54. This failure resulted in R156 experiencing psychosocial harm as evidenced by R156 crying during interview and expressing how staff will not assist her in a timely manner and R156 displaying symptoms of depression. Findings include: 1. On 11/01/21 at 12:06 PM R156 stated she receives a water pill at 6AM so she begins to urinate soon after. R156 stated she was last changed between 5-5:30 AM. R156 was crying as she stated staff won't change her because of her size. R156 stated she has explained to nursing aids that she is able to assist with being changed if they turn her a certain way to make it easier on them to encourage them to cooperate with changing her. On 11/01/21 at 01:05 PM, V31 (Restorative Aid) stepped in to assist with incontinence care for R156. R156's brief, pad, and linens were observed soaked in urine. V31 stated R156's bed linens and pad were wet. On 11/02/21 at 10:47 AM, R156 was crying while stating R156 was left soiled for long periods of time which makes her feel depressed, and it reminds her that she can't take care of herself. R156 stated she has asked the CNAs (Certified Nursing Assistants) if they would want someone to treat them like this. On 11/03/2021 at 2:25PM V23 (Social Services Director) stated R156 desires to return home and be able to care herself. V23 stated R156 did express depression and was referred to social services for depression. 2. On 11/01/21 at 01:13 PM R126 stated she last received incontinence care at approximately 8AM. R126 stated she was pretty wet. Surveyor observed R126's brief, which was soaking wet. R126 was also observed soiled in feces when being changed by V32 (Certified Nursing Assistant). 3. On 11/01/21 at 11:40 AM R146 stated she had not been changed since 9:30PM last night. V32 (Agency Certified Nursing Assistant) came to provide care for R146. R146's incontinence pad laying underneath her was heavily soiled and brown. V32 stated R146's incontinence status was terrible. R146's brief was soaked through to the pad underneath her. V32 wiped feces from between R146's legs. V32 stated R146 does have feces in her genital area. R146 stated she had pulled call light for incontinence care assistance and was still waiting to be changed. R146 stated she just doesn't want to develop bed sores. R146 stated she pressed her call light at 8AM and staff told her they don't start until 8:30. R146 stated she pressed her call light again later and the nurse responded and told her the CNAs (Certified Nursing Assistant) would be making rounds. R146 stated when the nurse came to give her medication, R146 asked the nurse where the CNAs were and reported they hadn't come yet. R146 stated the nurse checked and stated they were making rounds and would be on their way. R146 stated she reported to the nurse it was getting close to lunch time and still hadn't been changed since last night. R146 stated a CNA made sure to change her last night before her shift ended at 10PM, but she had not been changed since then. 4. On 11/01/21 at 01:03 PM R99 received incontinence care from V35 (Certified Nursing Assistant) and V32 (Certified Nursing Assistant). R99's brief was observed soaked with urine through to the pad underneath him. On 11/01/21 V32 (Agency Certified Nursing Assistant) stated she started working in another unit at 7AM and was just beginning to do rounds on the unit where R99, R126, R146, and R156 are located. V32 stated she was initially working on the dementia unit and was then pulled over to work on the unit R99, R126, R146, and R156 are located. On 11/04/21 at 01:05 PM V2 (Director of Nursing) stated CNAs (Certified Nursing Aides) are expected to conduct resident rounds every two hours and as needed. V2 stated residents who require incontinence care should not have to wait more than two hours to be changed and should not be left soiled for extended periods of time. 5. On 11/01/21 at 11:12 AM R60 was in room his room with door closed. R60's room had a strong urine odor. R60's bottom half was naked. R60 appeared confused. On 11/03/21 at 09:02 AM R60 was observed with long fingernails and hair only half groomed. On 11/02/21 at 03:12 PM V39 (Family Member) stated R60 could use more frequent haircuts, shaves and grooming. 6. On 11/02/21 at 11:45 AM R25 was alert and oriented sitting in wheelchair in room. R25 stated the care received by nursing staff isn't very good and that no staff check on R25 during the night. R25 stated there are no staff after 3pm and R25 has to wait hours for assistance to bed. R25 stated, Lots of agency people here. Sometimes we get good ones then we don't see them anymore. R25 stated that he needs assistance with bathing/dressing. R25's care plan indicates R25 as an extensive staff assist of one. R25 stated shower days are Wednesday and Saturday and that staff come to resident for showers. R25 doesn't remember the last time he received a shower. On 11/03/21 at 02:14 PM R25's bath and skin report sheets were reviewed. These sheets did not specify whether bath or shower was given. The following entries were documented: June 2021 documentation only for 6/2/2021; July 2021 documentation only for 7/14/2021; no documentation available for August and September 2021. October 2021 with documentation only for 10/2, 10/6 and 10/9. On 11/04/2021 at 11:55 AM, V2 (DON) stated bath sheets should be filled out on days completed. V2 also stated her expectation of nursing staff is to complete bathing as scheduled. Per facility bathing sheets, skin assessment is to be completed by floor nurse on shower days. R25's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked who tracks the completed bathing sheets, V2 states she will find out from the nursing staff. On 11/04/21 at 01:14 PM surveyor made multiple requests to facility staff for bathing/ADL policies, however documentation was not provided during the course of this survey.

Based on observation and interview the facility failed to provide washcloths and towels to clean 1 (R1) of 3 residents reviewed for dignity after R1 had been incontinent in his brief. This failure resulted in R1 stating feeling humiliated and angry because staff used a sheet to wash and dry him. Findings include: R1 is a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Cognitive assessment dated [DATE] notes he is cognitively intact. On 10/20/21 at 12:21PM R1 said he was left in stool this morning. R1 said no changed him because there were no towels. R1 said, I pulled my call light at 5:30AM. The Certified Nursing Assistant (CNA) came in and said she had to find towels to clean me so she left. The CNA then returned and said she can't find towels. R1 then said V4 (Restorative Nurse) checked on him and R1 reported to him he was waiting to be changed. R1 said V8 (CNA) came in and used a bath sheet to clean him because she told him there were no towels or washcloths. R1 said this made him feel humiliated and angry. R1 said, The worst part is the way the staff look at me; they make me feel like it's my fault. On 10/20/21 at 12:39PM surveyor observed a linen cart on R1's unit with 1 washcloth and 4 bath towels. A second linen cart adjacent to R1's unit was observed to have no towels or washcloths. On 10/20/21 at 12:42PM V9 (CNA) looked in the large linen cart on the floor and said there are only 2 washcloths on this cart. On 10/20/21 at 12:50PM V8 (CNA) said, I told R1 there were no linens this morning. V8 said she went to laundry in the morning and there were no clean towels or washcloths. V8 said washcloths and towels are used to clean incontinent residents. V8 said she washed R1 using a bath blanket to wash and dry him. V8 said R1 was angry but not at her. V8 said the towels came to the unit on the cart later in the morning. On 10/20/21 at 1:19PM V7 (CNA) said, There are no towels or wash cloths on my linen cart. We have not had any towels delivered. V7 said she has not had any towels since the morning. V7 said she brings her own wipes to clean her residents. On 10/20/21 at 1:25PM surveyor observed 2 stacks of towels and washcloths on folding table in laundry room and being stacked onto 2 large linen carts. V5 (Housekeeping Manager) showed surveyor closet with bags of new towels and linens on 2 shelves. V5 said, We have enough and extra towels. V6 (Housekeeping) said, No one has come to the laundry room to ask for towels today. Surveyor attempted to contact V26 (CNA) who worked on 10/20/21 at 5:30AM with R1. Surveyor was unable to reach V26 on 10/22/21 at 10:06AM and 4:42PM.

Based on interview and record review, the facility failed to monitor a resident (R3) while sitting at the nurses' station in a wheelchair and failed to develop fall interventions for 2 resident's (R3 and R4) that address their risk for falls while in a chair or transferring. These failures resulting in R3 sustaining a nondisplaced left subcapital femoral neck fracture and a traumatic subarachnoid hemorrhage and R4 sustaining a skin tear. Findings include: 1. Review of R3's facesheet documents an [AGE] year old male admitted to the facility on [DATE] and was discharged on [DATE]. Minimum Data Sheet (MDS) dated [DATE] section GG documents R3 requires substantial/maximal assistance with transfers and sit to stand. Review of admission fall assessment dated [DATE] documents R3's fall risk score as a 10 and fall risk level as High. Review of fall report dated 9/9/2021 documents resident had an unwitnessed fall and was found on the floor by staff not on floor mats. On 10/21/2021 at 12:27 PM during interview V24 (Licensed Practical Nurse/LPN) stated she remembered R3. V24 stated she did not remember any fall precautions that R3 was on. Regarding R3's fall on 9/9/2021, V24 stated R3 did not have a floor mat on the floor when we found him on the floor as I charted. Review of R3's care plan did not mention R3's 9/9/2021 fall. The only intervention on R3's care plan for risk for falls was dated 9/9/2021 and stated: keep bed in low position with breaks locked. Facility Reported Incident dated 9/19/2021 documents: the nurse noted R3 stood up out of his wheelchair by the nursing station and nurse could not reach him before he lost his balance and fell on his left side hitting his head on the floor. On 10/21/21 at 12:58 PM V30 (Certified Nursing Assistant/CNA) stated R3 was sleeping in his wheelchair at the nurses' station. V30 stated, I was coming from the bathroom from the 100 side and walking towards the nurse's station. V27 (LPN) came out of a room and was walking with me towards R3. The other CNA was coming down the hall of 200 unit from doing patient care. We all were walking towards the nurses' station. All of a sudden R3 stood up and we all started running towards him and he fell . Surveyor asked was there anyone at the nurses' station with R3. V30 responded, No. There was not anyone at the nurses' station with him. The night shift said R3 kept getting out of the bed overnight. He was already at the nurses' station when I got here. I knew he was a fall risk. On 10/22/2021 at 10:20 AM V18 (CNA) stated in regard to R3's fall on 9/19/2021, It was right after breakfast; he (R3) was sitting at the nurses' station. I was coming from the 200 side giving patient care and doing rounds. As soon as I saw R3, he stood up and fell forward. V27 (LPN) was coming out of room right next to him. V30 (CNA) was coming from the other hallway. We all saw him at the same time. It was a hard fall. He was responding verbally. R3 was saying, 'I fell . I fell .' I didn't see anyone at the nurses' station with him before he fell . On 10/26/2021 10:50 AM V27 (LPN) stated the following regarding R3's fall on 9/19/2021: I was down the hall passing medications. I came to fill a water pitcher and when I turned around, he (R3) was standing in front of his wheelchair. I ran to try to catch him and couldn't get there in time and he fell . Progress note written by V27 (LPN) dated 9/19/2021 documents the following: Writer observed resident stand up from sitting position in wheelchair, lose balance, fall to left and hit his head on the floor. Review of staff interviews post incident document the following: V30 (CNA) was coming from patient care when she saw R3 fall V18 (CNA) was coming from break when she saw R3 fall V28 (CNA) was on break and did not witness the fall. R3's hospital discharge instructions document the following: Discharge diagnoses: 1. Status post fall, at the nursing facility, resulting in nondisplaced left subcapital femoral neck fracture and traumatic subarachnoid hemorrhage. R3's care plan does not document any interventions for falls that address risk for falls while in a chair or transferring. 2. Review of admission fall assessment dated [DATE] documents R4's fall risk score as a 15 and fall risk level as High. Minimum Data Sheet (MDS) dated [DATE] section GG documents R4's chair to bed transfer as dependent. Post Fall report for R4 dated 8/1/2021 documents: CNA informed nurse she observed resident on the floor. V29's (Nurse) progress note dated 8/1/2021 documents the following regarding R4: Resident was observed sitting on the floor next to his bed. Resident stated he was trying to walk from his wheelchair to his table and lost his balance and slid to the floor. (R4) has a skin tear to the right elbow. On 10/22/2021 at 11:06 AM R4 was in his room sitting in a wheelchair. R4 stated, I get dizzy all the time and fall. Regarding R4's recent fall on 8/1/2021, R4 stated, I got out of the wheelchair to get in bed and fell . What was I supposed to do? These people are busy. I don't have time to sit around all day. I slid under the bed. I injured my arm. I was on the floor for 2 hours. They couldn't see me. I couldn't get out for a whole 2 hours. R4's fall care plan dated 7/13/2021 documents the following intervention: keep bed in low position with breaks locked. V24 (LPN) stated she didn't know R4 was on any fall precautions. V24 stated, Mostly we are told in report who is a fall risk. We don't keep fall risk posted anywhere in the room or on the door. Fall precautions should be in care cards, the ones that the CNAs use. I have seen a few behind the beds on the wall. V24 stated she is not sure if care plans are in the computer. On 10/22/21 at 12:29 PM V18 (CNA) stated, R4 transfers himself all the time. We tell him to call us when he needs to go to the restroom or if he needs to get up. You can hook the light straight on him and he will not pull it. V18 stated she will put him in the chair and walk down the hall and he puts himself back in the bed. Review of R4's care card that was hanging in his room is absent of documentation of fall precautions. R4's Care plan does not document any interventions for falls that address risk for falls while in a chair before 8/1/2021 fall. Facility Falls and Fall Risk, Managing policy dated 2001 documents the following: Policy statement: based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 6. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on observation, interview, and record review, the facility failed to follow their COVID-19, Person Under Investigation, (PUI) policy by failing to notify the Director of Nursing (DON) and infection preventionist when R2 developed a new respiratory system consistent with COVID-19, then failed to immediately test place R2 on contact isolation precautions. This deficient practice resulted in a delay of R2 being tested for COVID-19 and not being placed on isolation until he tested positive for COVID-19, 8 days after facility was aware of symptoms. The facility staff also failed to wear appropriate Personal Protective Equipment (PPE) when in isolation rooms and failed to follow instructions for proper use of cleaning and disinfection products for R1 and R4. Findings include: On 12/21/20 at 12:19pm, V7 (Nurse) stated that R2 is on contact and droplet isolation for COVID. For this isolation, we wear a gown, gloves, a N95 mask and eye protection. He had symptoms of nasal congestion and a cough on 12/12/20. He was placed on isolation on 12/20/20 (8 days later). He would come out of his room and go to appointments before he was placed on isolation. On 12/21/20 at 12:41pm, V16 (Certified Nursing Assistant, CNA) stated that R2 tested positive for COVID, yesterday, Sunday on 12/20/20 and was placed on isolation then. Until then, he would come out of his room but would wear a mask. On 12/21/20 at 1:40pm, V11 (Nurse) stated that R1 is on contact and droplet isolation as a person under investigation for COVID-19, since his roommate just tested positive for COVID. On 12/21/20 at 1:47pm, V12 (Activity Aide) stopped outside of R1's room when he saw a sign that stated, Stop, Ask Nurse. He looked through the bin that was outside of R1's room. There was no gown, gloves or facemasks in the bins. V12 wore a surgical mask and stated out loud, they do not have what I need. V12 then when into R1's room with his activity cart and stood in front of R1, (within 1 foot) reading cards and placing items from the cart on nightstand and bedside table that was next to the resident. V12 left the room without washing hands or using alcohol sanitizer. On 12/21/20 at 1:55pm, V12 stated that I believe R1 is a person under investigation for COVID-19 and is on isolation. I did not see a gown or gloves in the bin. Since I did not see those in there, I thought it wasn't that serious. We are supposed to wear a gown, gloves and a N95 mask. I did get an N95 mask once and was told they would let us know if it ever gets that point that we need to wear it. I know we can wash our hands in the resident bathrooms, but I personally don't do that. I go to my office upstairs on the second floor. I know that could spread germs. When asked about hand sanitizer, V12 stated that he does not have any. R1's physician orders [REDACTED]. On 12/21/20 at 2:20pm, V13 (Housekeeping) stated that for the COVID unit, I use a foam cleaner for the bathroom. I just spray it on and can wipe it off right away. If there is a stain, I may leave it on for a little longer, maybe 5 minutes at the most. I also use brand name disinfectant for bathrooms and everywhere else. You don't have to leave it on, you can just wipe it off. In R4's room, V13 sprayed brand name disinfectant on the bathroom sink, the grab bars next to the toilet, the toilet seat and the doorknobs, then wiped it off right away with a rag. V13 then sprayed a Foaming cleaner in the toilet bowl and on the rim and wiped it off right away. V13 stood next to R4 without eye protection on when R4 was coughing. V13 stated that he forgot to put the goggles on, and they were sitting on his housekeeping cart. The sign on R4's door notes to wear eye protection. R4 tested positive for COVID on 12/10/20 and was moved to the dedicated COVID unit. On 12/21/20 at 3:20pm, V14 (Housekeeping Supervisor) stated that housekeeping staff working on the COVID unit should be wearing goggles or face shield before they enter every room. The brand name disinfectant should be sprayed, then left on the surface for 10 minutes before wiping it in order to disinfect it. When asked about the foam cleanser, V14 stated that it is used in the bathrooms as well but with the brand name disinfectant, not alone. Surveyor checked the Centers for Disease Control (CDC) N list for the foaming cleanser and disinfectant but the (Environmental Protection Agency, EPA) number on bottle and Material Data Sheet (MDS) sheet did not reveal any data. On 12/21/20, at 3:20pm, V1 (Administrator) stated that the foaming cleanser was not on the approved CDC list to kill COVID-19. On 12/21/20 at 4:00pm, V4 (Infection Preventionist) stated that per R2's progress notes, on 12/12/20, notes he had a cough, congestion and cold-like symptoms. If new symptoms related to COVID are found, the nurse enters it on the 24-hour report and notifies the unit manager. The unit manager, myself and the Director of Nursing, DON will determine if they meet the (Person Under Investigation, PUI) status. I was not made aware that he developed symptoms of cough and congestion on 12/12/20. I would have put him on isolation and tested him right away for COVID-19. He went out to a doctor's appointment, on 12/14/20. R2 was tested (5 days later) on 12/17/20 as part of the facility wide testing. The lab reported he was positive for COVID on 12/20/20 and he was started on isolation at that time. For residents on Contact/Droplet isolation and PUI, staff need to wear a N95 masks, a gown, gloves and eye protection. On 12/22/20 at 1:05pm, V4 stated that the 24-hour report from 12/12/20 has been thrown away. Our protocol for placing residents on isolation and under Person Under Investigation (PUI) status is as follows: Interventions will be implemented for any resident noted with signs and symptoms of respiratory infection, including a temperature of 100.0 or greater and a pulse ox of 92% or lower. Staff are to notify the Director of Nursing (DON) and Assistant Director of Nursing, ADON. There is currently no ADON, they would notify me. Immediately place residents under PUI on isolation. Post sings and (Personal Protective Equipment, PPE) supplies close to the door to ensure availability on unit. Obtain CXR, labs, COVID 19 test. Cough and congestion are respiratory symptoms and should warrant a PUI investigation. We follow the CDC (Centers for Disease Control) guidelines for COVID symptom's and isolation precautions. On 12/22/20 at 11:18am, V3 (Director of Nursing, DON) stated if a resident has a new symptom of COVID, and the nurse feels it is suspicious of COVID, then they should make myself, V4 as well as administration aware. I do not recall if I was notified on 12/12/20 when R2 developed symptoms of COVID. On 12/20/20 at 12:15pm, V2 (Assistant Administrator) stated that if there is a new respiratory symptom for a resident, then we have a PUI protocol. The staff would notify DON and ADON which in this case is V4, the infection preventionist. R2's progress notes on 12/12/20 at 4:00pm, notes that he complained of nasal congestion and cold like symptoms. V17's (Nurse Practitioner's note) on 12/12/20 at 2:53pm, documents that R2 was seen today at the request of nursing staff for complaints of cough. R2 is alert and oriented to person, place and time. He reports congestion and non-productive dry cough. He requests [MEDICATION NAME] and says that it usually works well for him at home. Assessment notes a cough, congestion and dry, non-productive cough. If he becomes febrile or develops productive cough, [MEDICAL CONDITION], or respiratory distress, consider CXR and additional COVID testing. R2's progress notes on 12/14/20 at 12:14pm, notes that R2 left the facility to go to an orthopedic appointment. R2's progress notes on 12/17/20 notes that R2's weekly COVID test was done R2's COVID test results were reported positive on 12/20/20 and physicians obtained to start R2 on contact and droplet isolation for COVID. Facility's PUI Protocol updated 11/1/20 notes the following interventions will be implemented for any resident noted with signs/symptoms of respiratory infection: Notify the DON/ADON, immediately place resident under Persons Under Investigation (PUI) in standard, contact and droplet precautions. Obtain order for stat Chest x-ray and COVID-19 test. If hospitalization is not required, keep all residents in room and PPE appropriately which includes gloves and gowns. Facility COVID-19 Policy and procedure notes COVID-19 is a [MEDICAL CONDITION] respiratory infection with symptoms that include cough and nasal congestion. Wear PPE including gown, mask face/eye shield, gloves as directed. Perform hand hygiene before and after all resident contact and before putting on and removing PPE. Wash hands with soap and water for at least 20 second or use alcohol-based hand rub. EPA-registered products should be used for cleaning and disinfecting. Facility cleaning and disinfecting policy revised last on 3/27/20 notes to follow manufactures instructions/guidelines for proper use of cleaning and disinfecting products, including contact time. Brand name disinfectant bottle lists directions for use: Thoroughly wet surface with solution using cloth or spay and allow the solution to remain wet for 10 minutes before rinsing or allowing to air dry.

Based on interview and record review the facility failed to ensure a resident at risk for developing pressure ulcers did not develop pressure injuries from an immobilizing splint and had pressure relieving interventions in place. The facility also failed to assess a resident with an immobilizer in place and failed to get treatment orders for a resident with an immobilizing splint. This failure resulted in R1 developing multiple deep tissue injuries to her right heel and foot. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 25. Findings include: R1's face sheet showed she was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] shows R1's cognition is intact. The skin Braden scale assessment dated [DATE] shows R1 is at risk for developing pressure ulcers. The Event Report dated July 17, 2020 at 5:19 PM, V13 (Registered Nurse) documents R1 had an unwitnessed fall in the bathroom and was sent to the local hospital. The nurse's note dated July 18, 2020 documents R1 returned back to the facility with a right tibia fracture and instructed to wear the splint until the follow up appointment with V27 (Orthopedic Physician). The ER discharge instructions dated July 17, 2020 states to follow up with V27 (Orthopedic Physician) on Monday July 20, 2020 to set up the follow up appointment. Instructions to wear the splint until the follow up appointment and no walking while wearing splint until cleared by orthopedics. The nurse's note dated July 20, 2020 V8 (Licensed Practical Nurse) documents the facility was unable to set up R1's orthopedic follow up appointment. V26 (Assistant Director of Nursing) was notified and the facility scheduler to follow up. The nurse's note dated August 3, 2020, documents (R1) has an appointment scheduled for 8/10/2020 with the orthopedic physician. R1's follow up appointment was not scheduled until 14 days later. The nurse's note dated August 10, 2020 documents when R1 returned from her orthopedic appointment, 25 days later after her initial appointment was not scheduled, R1's long leg splint was removed. The wound nurse assessed R1's right lower extremity and found that R1 had four new pressure ulcers to her right lower extremity. The pressure ulcers are as follow: Right heel deep tissue injury measuring 7.0 cm (centimeters) x 7.0 cm Right medial foot deep tissue injury measuring 3.0cm x3.cm Right lateral foot deep tissue injury measuring 3.0cm x2.0cm Right dorsal foot deep tissue injury measuring 15.0cm x10.cm The Treatment Administration Record for July 2020 shows orders for daily skin assessments. There is no documentation/assessment for the following days: July 18, July 19, and July 22, 2020 - July 31, 2020, 12 days with no skin assessments. The Treatment Administration Record for August 2020 shows orders for Turn and Reposition every two hours; this is left blank for 31 days. The Care Plan dated through September 2020 shows R1 is at risk for developing pressure ulcers but does not include pressure relieving interventions. The Physician order [REDACTED]. On November 3, 2020 at 9:15 AM, R1 said she had a splint in place after she fell at the facility. R1 said, I had to stay in bed with the immobilizer on until my follow up appointment. R1 said the staff told her they couldn't do anything with the splint because that's what the Dr. ordered. R1 said, It hurt so much. The staff didn't care. They said, 'there's nothing I can do.' R1 said staff did not elevate her leg and would not remove the splint to look at her leg/foot. On November 3, 2020 at 9:00 AM V4 (Wound Nurse) said, R1 had a fall on July 17, 2020. She went out to the ER for evaluation. She came back to the facility and had a right tibia fracture with an immobilizer on. The ER orders were not to remove the splint until she was seen by the orthopedic physician, so we followed those orders until her orthopedic appointment on August 10, 2020 (25 days later). V4 said R1's follow up appointment was supposed to be for July 20, 2020 but was rescheduled for August 10, 2020 (25 days later). V4 said when R1 came back to the facility after her orthopedic appointment, R1 had multiple deep pressure ulcers to her right foot. V4 said R1's immobilizer caused the pressure on her right foot. V4 said, R1 complained of pain to that area, but we were following the orders not to remove the splint until R1 followed up with orthopedic physician. V4 said residents who are at risk for developing pressure should have pressure relieving interventions in place. V4 said they did not call to get additional orders for R1's splint. On November 4, 2020 at 2:30 PM, V24 (Orthopedic Physician Assistant) said R1 was evaluated on 8/10/20 almost 4 weeks after her fall. R1 had a long leg splint (temporary splint), not a cast. When the splint was removed, she had multiple pressure ulcers to her right lower extremity. R1 had a pressure ulcer to her right heel, right medial and lateral area of the foot, and on the front of her right ankle. V24 said there was delay in R1 having her follow up appointment in a timely manner. On November 5, 2020 at 9:15 AM, V8 (Licensed Practical Nurse) said she called to make R1's appointment for July 20, 2020 but was unable to make R1's appointment. V8 said she notified V26 (Assistant Director of Nursingo follow up to make R1's appointment. On November 2, 2020 at 11:50 AM, V2 (Director of Nursing/DON) said staff should follow up with the physician and get additional orders for residents with splints. On November 5, 2020 at 10:00 AM V26 (ADON) said normally she would call and make the appointment herself but does not remember if she called to set up R1's appointment. V26 said staff should assess a resident's skin and extremity every shift and follow up with additional orders for care of a resident's splint. The facility's Pressure Ulcer and Wound Prevention/Management Program dated December 2006 states, To identify residents who are at risk for developing pressure ulcers and skin breakdown. To prevent pressure ulcers and skin breakdown. To provide a guideline for the appropriate nursing management of skin breakdown when it occurs.

Based on interview and record review the facility to ensure a resident was supervised during toileting. This failure resulted in R1 falling in the bathroom and sustaining a right tibia fracture. This applies to 1 of 7 residents (R1) reviewed for safety in the sample of 25. Findings include: R1's face sheet showed she was admitted on [DATE] with [DIAGNOSES REDACTED]. The Physical Therapy Evaluation dated July 14, 2020 shows R1 presents with muscle weakness, has reduced ability to safely ambulate, and requires maximum two person assist with transfers and standing. R1 is at risk for falls and has weakness to her trunk area and lower legs. The Minimum Data Set assessment dated [DATE] shows R1's cognition is intact and requires extensive assist with toileting. The Nurse's note dated July 14, 2020 at 3:25 PM documents R1 was found on her knees next to her bed. The Event Report dated July 17, 2020 at 5:19 PM, V13 (Registered Nurse/RN documents R1 had an unwitnessed fall in the bathroom. V13 documents she was notified of R1's fall in the bathroom. R1 said she was trying to stand. The report documents R1's ambulation status is independent and has no weakness to her extremities. R1 was transferred to the ER for evaluation. The Nurse's note dated July 18, 2020 at 12:34 AM, documents (R1) returned back to the facility. (R1) has a right tibia fracture. R1's care plan dated through September 2020, showed she was at risk for falls with interventions including to observe frequently and place in supervised area when out of bed. On November 3, 2020 at 9:15 AM, R1 said a Certified Nurse Assistant (CNA) assisted her to the bathroom. R1 said the CNA left her in the bathroom and said when you're done pull the call light string. R1 said she pulled the string and waited and waited and no one came. R1 said then she stood up and fell . On November 3, 2020 at 1:05 PM, V13 (RN) said she was R1's nurse on 7/17/20 when R1 fell . V13 said she was notified that R1 was on the floor in the bathroom. V13 said she does not remember who took R1 to the bathroom and said it was not safe to leave her in the bathroom un-supervised. V13 said during report she was notified R1 had a recent fall. On November 3, 2020 at 10:05 AM, V10 (Physical Therapist) said R1 was a two person assist with transfers, she had weakness and decreased strength in her right leg and could not stand well. R1 was a fall risk and needed assistance with toileting. On November 2, 2020 at 1:50 PM, V3 (Director of Nursing) said fall risk assessments are done on admission and after each fall to determine a resident's fall risk with interventions in place to prevent falls. On November 3, 2020 at 11:35 AM, V2 (Assistant Administrator) said R1 did not have any fall risk assessments. The Fall Clinical Protocol Policy Revised August 2008, states, As part of initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falls .the staff will document risk factors for falling in the resident's record and discuss the resident's fall risk .based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls .

Based on interview and record review the facility failed to protect and prevent a resident (R2) from being abused by another resident (R1). The facility also failed to prevent R1 for possessing a firearm while residing in the facility. As a result, R1 fatally shot R2 with a firearm he possessed while in the facility. R2 later died from multiple gunshot wounds to the chest, arms, and legs. This was identified as an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] around 3:00 AM when R1 shot and killed R2. V1 (Assistant Administrator), V10 (Administrator) and V4 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]. However, the non-compliance remains at a level three until the facility evaluates the effectiveness of the removal plan implemented. Findings include: 1. According to the face sheet R1 a [AGE] year-old male resident admitted to the facility on [DATE] due to open wound of right buttock. R1's [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated his cognitive function was intact. According to a R1's criminal background data, R1 had convictions for possession of controlled substance, domestic battery with bodily harm, aggravated battery of officials and the unlawful possession of a weapon. 2. According to the face sheet R2 was [AGE] year-old male resident with [DIAGNOSES REDACTED]. R2 was admitted to the facility on [DATE]. The last re-admission was on [DATE]. R2's progress note dated [DATE] indicated R2 was being petitioned out to a local hospital due to recent behaviors. On [DATE], at 11:43AM, V20 (Registered Nurse) stated, R2 needed increased supervision due to his verbal and physical aggression. R2's agitation would come out of nowhere; it was very sporadic. 3. The State Agency was notified about a shooting involving two residents, but no reported incident was received from the facility. The surveyor conducted interviews regarding the incident that occurred on [DATE] involving R1 and R2; the following was indicated: On [DATE], at 10:00AM, R3 stated, I was asleep, and the noise woke me up. I heard the gunshot. I could not see who it was; it was a man. The door was open. R2 was lying on the floor when I left the room after the police came. There was a lot of blood. On [DATE], at 10:15AM, R4 stated, On [DATE] at 3:01AM, I heard three-gun shots. It sounded like it was right at the door, but it was behind me in the other room. R1 was in and out of the room all night. I heard the three-gun shots and then R1 returned to the room. R1 told me he shot someone. Then R1 said it was someone else who had shot someone. I have never seen R1 or R2 talk to each other. I know staff heard the shots and no one did anything. I never saw R1 with a gun. I keep to myself. R1 was always on the go, like he was on drugs, everyday all day. On [DATE], at 10:20AM, R5 stated he heard two pops because his door was wide open. On [DATE], at 10:30AM, R6 stated, I heard 3 gun shots early this morning. I heard that the police found a gun on R1. I used to tell R4 that R1 acted like he was on drugs. I thought something was wrong with him because of how he acted. On [DATE], at 10:22AM, V3 (Licensed Practical Nurse/LPN) stated, On [DATE], around 3:00AM, I heard 2 gun shots. V2 (LPN) and I went and looked for help. R1 would be roaming the halls going to visit other residents all the time. I did not notice that he left the floor on [DATE], because I was working on the other unit. V2 and another certified nursing assistant (CNA) worked the entire floor. There are usually two CNAs, but one CNA had to be pulled to another floor. There is no type of security. The receptionist is there until 11:30pm. After that, there is no one. The facility is always short staffed. I believe that R1 got the firearm when he eloped because he was determined to get outside of the facility. On [DATE], at 10:49AM, R7 stated, On [DATE], R1 came to my room flashing a gun around the room. R1 would not tell me where or how he got the gun. I told R1 that he could be locked up for having a gun. R1 said that he didn't care about being locked up or being in jail. R1 stated that my roommate was bothering him (R2), and they had gotten into it. I am not sure what they had gotten into it about. R1 told me that 'he was taking care of business like he always does. R1 has gotten aggressive with me before. I was scared to death when R1 showed me the gun. I was not sure if he was going to pull the trigger on me or what he was going to do. Immediately, I told V12 (CNA). V12 told me not to worry about it; he would take care of it. On [DATE] in the morning, I told V11 (LPN). Staff do not always pay attention to us or care to get involved. I do not feel safe in the facility because something like this happened once and it could happen again. On [DATE], at 11:14AM, V11 (Unit Supervisor/LPN) stated, No one ever came to me and said that a resident had a gun. No one has ever reported anything like that to me. On [DATE], at 11:27AM, V12 (CNA) stated, No resident has ever told me that another resident had a gun. On [DATE], at 2:04PM, V7 (LPN) stated, On [DATE] at 11:15PM. the alarms on the first floor were going off on my unit. I thought the receptionist was there, but she is only there until 11:30PM. R1 was always roaming the building due to his [MEDICAL CONDITION]. R1 was like this every night. I asked R1 why the alarms were going off. R1 stated he wanted to get some fresh air. I took R1 back upstairs to his unit. A few minutes later, the alarm went off again. When I went out by the outside doors of the facility, I saw R1 was outside of the building hiding. I called staff upstairs. R1 saw me and came to the door. I told R1 that he is not allowed out of the building. I took R1 back upstairs and re-educated him that residents cannot be outside. A few minutes later, the alarm goes off for a third time. This time, V2 (LPN) was with R1. R1 was wandering the building and kept on going right through the front doors. I don't recall if V2 tried to stop R1. V2 took R1 back to the unit. About 3:00AM, V3 (LPN) came down from the second floor of the unit. She asked if I heard a noise. She wasn't sure if it was gunshots. We went upstairs; all the lights were off. R1 told me that two women had been shot on the first floor. The police were called. The police arrived and told us that R2 had been shot. Chest compressions were being performed on R2 as his body was being taken out of the facility. On [DATE], at 2:52PM, V2 stated, V3 (LPN) and I heard gunshots. We took off running from the gun shots to a secure unit downstairs and called 911. I told 911 that there were gunshots and an active shooter. I told police that we were not comfortable returning to the unit until they arrived. R1's behavior was never like this before. The police told us that R1 had shot another resident. Police took over everything after that. 4. Ambulance records dated [DATE] documented the following: R2 found unresponsive and not breathing. Ambulance crew found multiple gunshot wounds on the resident. Medical records from the local hospital emergency room dated [DATE] documented R2 expired from multiple gunshot wounds and cardiac trauma. On [DATE], at 11:56AM, V6 (Detective) stated, The firearm was located in the back of R1's personal wheelchair. When paramedics arrived at the scene, R2's body was on the ground. They stated that there were no signs of life. R2 was transported to a local hospital. R2 was pronounced dead at 4:11AM. On [DATE], at 12:54PM, V16 (R2's family member) stated, I talked to the doctor that treated R2. The doctor said that R2 had been shot six times: twice in the arm; twice in the chest; twice in the leg. The physician told me R2 did not survive. Facility policy titled Abuse Prevention Policy documents The facility is committed to protecting our residents from abuse by anyone including, other residents. The facility affirms the right of our residents to be free from abuse. 5. In the absence of V10 (Administrator), V1 (Assistant Administrator) was notified the immediacy was removed on [DATE] after the surveyor verified through interviews and record review of implementation of an acceptable removal plan which included the following: On [DATE], the facility's management team initiated and completed an hours-wide search of resident rooms and personal property in an effort to identify if any resident had contraband items in his/her possession. Any items identified as contraband were immediately removed and secured. No weapons were discovered during the search. The facility developed a Contraband and Search policy on [DATE] in effort of identifying if contraband items are brought into the facility. The policy was reviewed and approved by facility Medical Director on [DATE]. Staff training on the Contraband and Search policy was initiated on [DATE], on the facility's 2nd shift. Training will continue until all staff have been in-serviced, with anticipated completion date of [DATE]. Employees not available to receive training due to extended time off (vacation, sick, leave etc.) will be trained on policy upon return to work. Resident education on the Contraband and Search policy was initiated on [DATE] via individual visits and review of policy. This was conducted room to room by the facility's Activity staff. Education for all residents with the ability to comprehend policy and acknowledge the same will be completed by [DATE]. Facility administration will send all resident's responsible parties and families a copy of the policy via email or postal mail by [DATE]. The facility's Admission Staff initiated an audit of all resident's pre- and post-admission background checks on [DATE] to ensure timely completion and identification of residents with criminal backgrounds (identified offenders). The full audit of resident background checks will be completed by [DATE]. The facility's Social Services Director initiated a care plan review of residents with criminal background (identified offenders/IO) on [DATE]. All IO care plans will be reviewed and updated as needed by [DATE] to ensure that appropriate interventions are in place. The facility's Social Services Director has identified residents with aggressive behaviors and initiated review of the care plans for all identified residents on [DATE]. The review of all identified residents will be completed by [DATE].

Based on interview and record review the facility failed to supervise and monitor residents who had potential to bring and/or use a weapon into the facility. The facility also failed to plan and implement individualized monitoring and supervision interventions to address a resident's negative behavior or the potential to have negative behaviors. As a result, R1 fatally shot R2 with a firearm he possessed while in the facility. R2 later died from multiple gunshot wounds to the chest, arms and legs. This was identified as an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] around 3:00 AM when R1 shot and killed R2. V1 (Assistant Administrator), V10 (Administrator) and V4 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]. However, the non-compliance remains at a level three until the facility evaluates the effectiveness of the removal plan implemented. Findings include: 1. According to the face sheet R1 a [AGE] year-old male resident who was admitted to the facility on [DATE] due to an open wound of the right buttock. R1's [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated his cognitive function was intact. The facility initiated a criminal background check on R1. The result of R1's criminal background check was available [DATE]. According to a R1's criminal background data, R1 had convictions for possession of controlled substance, domestic battery with bodily harm, aggravated battery of officials and the unlawful possession of a firearm. On [DATE], at 10:23 AM, V14 (Social Worker) stated, I received an email from the admissions department that the background check was in my mailbox on the evening of [DATE]th. I left early on [DATE]th. I put the background check on my desk to be completed upon my return. No one completes documentation for identified offenders when I am absent. I have no idea why no one completes them in my absence. R1 indicated he was sad, had a loss of appetite, and just wanted to leave. R1 reported that he had been in a mental institution at one point in his life. The facility that the resident was in usually deals with conduct and behaviors. R1's comprehensive care plan that correlated with the last care conference dated [DATE] did not contain a potential for criminal behavior based on R1's criminal history for monitoring and supervision of R1's activities. 2. According to the face sheet R2 was [AGE] year-old male with [DIAGNOSES REDACTED]. R2 was admitted to the facility on [DATE]. The last re-admission was on [DATE]. R2's progress notes note dated [DATE] indicated R2 was being petitioned out to a local hospital due to recent behaviors. R2's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R2 was moderately cognitively impaired with a BIMS score of 8. R2 was noted to have verbal behavioral symptoms directed toward others (e.g. threatening, screaming, cursing). R2 had a history of [REDACTED]. R2 also had a history of [REDACTED]. On [DATE], at 11:43AM, V20 (Registered Nurse) stated, R2 needed increased supervision due to his verbal and physical aggression. R2's agitation would come out of nowhere. It was very sporadic. R2's progress notes contained the following regarding behaviors: [DATE], R2 continually pushes on all alarmed doors attempting to get out of the facility. R2 refuses to be re-directed, uses continuous belligerent behavior toward staff and uses curse words. V16 (R1's family member) called in attempt to calm R2; stated leaving facility now. The psychologist was notified and R2 petitioned to local hospital. On [DATE], at 1:03PM, facility was notified R2 would be returning to the facility because the doctor did not see any reason to keep or medicate R2. The psychologist stated he would not prescribe any medication at this time because he does not think R2 liked the facility and medication would not solve the issue. Social workers need to follow up with R2 the next day. [DATE], at 6:35PM, R2 noted getting out of bed and continuously trying to exit the facility, being belligerent, and using curse words when staff try to redirect R2. The psychologist was notified and R2 was again petitioned to a local hospital. On [DATE], R2 returned to the facility. [DATE], R2 required frequent redirecting, and up all through the night with short periods of sleep. [DATE], R2 displayed impulsive behavior related to running out of the facility and attempting to leave the facility unauthorized. R2 is also verbally aggressive towards staff, threatening to become physical. R2 does not yield to redirection. [DATE], at 9:30AM, R2 observed pushing bar to gain access outside to exit the facility. R2 stated to not worry about what he is doing and leave him alone. R2 redirected and eventually moved from the door. At 10:35AM, R2 observed trying to exit the facility, using profanity, and holding up balled fists. R2 redirected away from the area. At 11:00AM, door alarm was beeping. R2 observed standing outside the door. Social services noted of an attempt to elope. At 11:10AM, R2 noted with multiple attempts to elope, verbal and physical aggression towards staff. R2 was sent to local hospital for psychological evaluation. [DATE], R2 returned to the facility. On [DATE], at 9:30PM, R2 observed with increased agitation, stating he wants to leave the facility, pushing exit doors in an attempt to leave the facility. Several attempts made to redirect. The psychologist did not prescribe any medication at this time because he believes the behavior stems from R2 not wanting to be in the facility. Gave orders to petition out R2 out to local hospital. On [DATE], R2 returned to the facility. On [DATE], at 9:17AM, R2 observed pushing the exit doors and went outside. V20 (Registered Nurse) attempted to bring R2 back into the facility and R2 began to hit, punch, and choke V20, along with digging his nails into V20's skin. V20 was able to bring R2 back into the building with the help of a nurse's aide. At 9:53AM, R2 presented with aggressive and impulsive behaviors. R2 attempted to leave the facility. When staff tried to redirect R2 back into the facility, R2 became combative, punching, choking and scratching staff being very irate and aggressive. R2 would not yield to redirection. The psychologist was made aware and R2 was sent out to local hospital for psychological evaluation. On [DATE], V20 stated that R2 quickly has aggressive behaviors and then reverts to a calm state. R2's calm state is for a short period of time and then the aggressive behavior would return. On [DATE], R2 was readmitted to the facility. On [DATE], R2 observed going through roommate's belongings. Staff attempted to redirect R2 and R2 became aggressive. [MEDICAL CONDITION] medications given. On [DATE], R2 was observed walking the halls demanding to call his job and tell them that he would be late. Staff tried to redirect R2 numerous times. [DATE], at 1:31PM, V14 (Social Worker) informed V16 that R2 would be involuntary admitted to the hospital, due to R2's recent behaviors. On [DATE], R2 was readmitted back to the facility to a new room on the second floor of the nursing facility. Record review of R2's comprehensive care plan dated [DATE] noted the behavior problem of episodes of verbal/physical behavioral symptoms directed toward other. The interventions included the following: -Anticipate resident's needs in order to decrease verbal/physical behavioral symptoms. Re-direct and intervene during periods of increased agitation -Refer to psychologist/psychiatrist for behavior management as needed. -Social Services to assess for aggression. There were no changes in these interventions after any of R2's hospitalization s for behaviors, nor was there any individualized monitoring or supervision care plan for R2. 3. The State Agency was notified about a shooting involving two residents, but no initial reported incident was received from the facility. The surveyor conducted interviews regarding the incident that occurred on [DATE] involving R1 and R2. The following was indicated: On [DATE], at 10:00AM, R3 stated, I was asleep, and the noise woke me up. I heard the gunshot. I could not see who it was; it was a man. The door was open. R2 was lying on the floor when I left the room after the police came. There was a lot of blood. On [DATE], at 10:15AM, R4 stated, On [DATE] at 3:01AM, I heard 3 gun shots. It sounded like it was right at the door, but it was behind me in the other room. R1 was in and out of the room all night. I heard the 3 gun shots and then R1 returned to the room. R1 told me he shot someone. Then R1 said it was someone else who had shot someone. I have never seen R1 or R2 talk to each other. I know staff heard the shots and no one did anything. I never saw R1 with a gun. I keep to myself. R1 was always on the go like he was on drugs, everyday all day. On [DATE], at 10:20AM, R5 stated he heard two pops because his door was wide open. On [DATE], at 10:30AM, R6 stated, I heard 3 gun shots early this morning. I heard that the police found a gun on R1. I used to tell R4 that R1 acted like he was on drugs. I thought something was wrong with him because of how he acted. On [DATE], at 10:22AM, V3 (Licensed Practical Nurse/LPN) stated, On [DATE], around 3:00AM, I heard 2 gun shots. V2 (LPN) and I went and looked for help. R1 would be roaming the halls going to visit other residents all the time. I did not notice that he left the floor on [DATE], because I was working on the other unit. It was just V2 and another certified nursing assistant (CNA) for the entire floor. There is usually two CNAs, but one CNA had to be pulled to another floor. There is no type of security. The receptionist is there until 11:30pm. After that, there is no one. The facility is always short staffed. I believe that R1 got the firearm when he eloped because he was determined to get outside of the facility. On [DATE], at 10:49AM, R7 stated, On [DATE], R1 came to my room flashing a gun around the room. R1 would not tell me where or how he got the gun. I told R1 that he could be locked up for having a gun. R1 said that he didn't care about being locked up or being in jail. R1 stated that his roommate (R2) was bothering him, and they had gotten into it. I am not sure what they had gotten into it about. R1 told me that he was taking care of business like he always does. R1 has gotten aggressive with me before. I was scared to death when R1 showed me the gun. I was not sure if he was going to pull the trigger on me or what he was going to do. Immediately, I told V12 (Certified Nursing Assistant/CNA). V12 told me not to worry about it; he would take care of it. On [DATE] in the morning, I told V11 (LPN). Staff do not always pay attention to us or care to get involved. I do not feel safe in the facility because something like this happened once and it could happen again. On [DATE], at 11:14AM, V11 (LPN) stated, No one ever came to me and said that a resident had a gun. No has ever reported anything like that to me. On [DATE], at 11:27AM, V12 (CNA) stated, No resident has ever told me another resident had a gun. On [DATE], at 2:04PM, V7 (LPN) stated, On [DATE] at 11:15PM. the alarms on the first floor were going off on my unit. I thought the receptionist was there, but she is only there until 11:30PM. R1 was always roaming the building due to his [MEDICAL CONDITION]. R1 was like this every night. I asked R1 why the alarms were going off. R1 stated he wanted to get some fresh air. I took R1 back upstairs to his unit. A few minutes later, the alarm went off again. When I went out by the outside doors of the facility, I saw R1 outside of the building hiding. I called staff upstairs. R1 saw me and came to the door. I told R1 that he is not allowed out of the building. I took R1 back upstairs and re-educated him that residents cannot be outside. A few minutes later, the alarm goes off for a third time. This time, V2 (LPN) was with R1. R1 was wandering the building and kept on going right through the front doors. I don't recall if V2 tried to stop R1. V2 took R1 back to the unit. About 3:00AM, V3 (LPN) came down from the second floor of the unit. She asked if I heard a noise. She wasn't sure if it was gunshots. We went upstairs; all the lights were off. R1 told me that two women had been shot on the first floor. The police were called. The police arrived and told us that R2 had been shot. Chest compressions were being performed on R2 as his body was being taken out of the facility. [DATE], at 2:52PM, V2 stated, V3 and me heard gunshots. We took off running away from the gun shots to a secure unit downstairs and called 911. I told 911 that there were gunshots and an active shooter. I told police that we were not comfortable returning to the unit until they arrived. R1's behavior was never like this before. The police told us that R1 had shot another resident. Police took over everything after that. 4. Ambulance records dated [DATE] documented the following: R2 found unresponsive and not breathing. Ambulance crew found multiple gunshot wounds on the resident. Medical records from the local hospital emergency room dated [DATE] documented the following: R2 expired from multiple gunshot wounds and cardiac trauma. On [DATE], at 11:56AM, V6 (Detective) stated, The firearm was located in the back of R1's personal wheelchair. When paramedics arrived at the scene, R2's body was on the ground. They stated that there were no signs of life. R2 was transported to a local hospital. R2 was pronounced dead at 4:11AM. On [DATE], at 12:54PM, V16 (R2's family member) stated, I talked to the doctor that treated R2. The doctor said that R2 had been shot six times: twice in the arm; twice in the chest; twice in the leg. The physician told me R2 did not survive. On [DATE], V1 (Assistant Administrator) stated, We do not have a contraband policy. On [DATE], at 11:46, V10 (Administrator) stated, There is no failure; we are doing what we are supposed to be doing, in regard to screening the residents. 5. In the absence of V10 (Administrator), V1 (Assistant Administrator) was notified the immediacy was removed on [DATE] after the surveyor verified through interviews and record review of implementation of an acceptable removal plan that included the following: On [DATE], the facility's management team initiated and completed an hours-wide search of resident rooms and personal property in an effort to identify if any resident had contraband items in his/her possession. Any items identified as contraband were immediately removed and secured. No weapons were discovered during the search. The facility developed a Contraband and Search policy on [DATE] in effort of identifying if contraband items are brought into the facility. The policy was reviewed and approved by facility Medical Director on [DATE]. Staff training on the Contraband and Search policy was initiated on [DATE], on the facility's 2nd shift. Training will continue until all staff have been in-serviced, with anticipated completion date of [DATE]. Employees not available to receive training due to extended time off (vacation, sick, leave etc.) will be trained on policy upon return to work. Resident education on the Contraband and Search policy was initiated on [DATE] via individual visits and review of policy. This way conducted room to room by the facility's Activity staff. Education for all residents with ability to comprehend policy and acknowledge the same will be completed by [DATE]. Facility administration will send all residents' responsible parties and families a copy of the policy via email or postal mail by [DATE] The facility's Admission Staff initiated an audit of all resident's pre- and post-admission background checks on [DATE] to ensure timely completion and identification of residents with criminal backgrounds (identified offenders). The full audit of resident background checks will be completed by [DATE]. The facility's Social Services Director initiated a care plan review of residents with criminal background (identified offenders/IO) on [DATE]. All IO care plans will be reviewed and updated as needed by [DATE] to ensure that appropriate interventions are in place. The facility's Social Services Director has identified residents with aggressive behaviors and initiated review of the care plans for all identified residents on [DATE]. The review of all identified residents will be completed by [DATE].

Based on interview and record review, the facility failed to have two staff members present during incontinence care for one of three residents (R5) requiring extensive staff assistance of two or more staff for incontinence care. This failure resulted in R5 falling from an elevated bed to the floor and sustaining a laceration (cut) to her head and a subcaptial femur fracture (broken hip). Findings include: Review of the facility's incident report of 07/19/2019 documents: Investigation conducted with assigned nurse and CNA revealed fall occurred due to resident rolling out of bed during incontinence care. Review of R5's hospital record of 07/17/2019 documents: Nurse was changing her diaper and was way too aggressive with her causing her to fall off the bed. Laceration above right eye was closed with two sutures. X-ray of right femur noted a subcapital [MEDICAL CONDITION] left femur ([MEDICAL CONDITION]) requiring in situ pinning of the left hip (type of surgery using pins, screws or plates to hold broken bones together). V16 (Certified Nursing Assistant, 08/07/2019 8:58 AM-9:14 AM. 11:21 AM-11:32 AM) stated: I was doing patient care. I got the materials I needed, explained the procedure to her. I raised the bed just above my waist so I could get the proper reach. I undid her brief, I brought her toward me and up in the bed (using the pad underneath resident). I used the pad to pull her on her side. I guess in helping me she continued to roll over. I tried to grab her but I couldn't catch her. She could move in bed, cuz (sic) when she moved over that's when she continued out of bed. There was nothing on her bed that she could grab onto that I can remember. V16 stated. You're supposed to read the care card. If you need assistance, you ask for assistance. I didn't read the care card. My personal opinion is that you would need two (staff for incontinence care for resident). I didn't get help because I didn't think I needed it at the time. I don't know, I think I was on the last round. You have other patients, I guess I was trying to get done before the end of my shift. V16 stated the last in-service regarding proper procedure for residents who require assistance with ADLs (Activities of Daily Living) was after R5 fell . Prior to that in-service V16 stated: I can't remember the last time; I probably had it years ago. V15 (Fall Nurse, 08/07/2019, 3:03 PM-3:19 PM) stated: R5 was able to complete bed mobility herself. V15 stated V16 failed to read R5's care card before rendering care and did not get assistance to help with incontinence care. V15 stated: I had to remind her (V16) to get help. You want her (R5) safe and you should have someone on the other side. God forbid you don't get assistance and someone falls. V12 (Licensed Practical Nurse, 08/07/2019, 1:42 PM-1:57 PM) said, I was notified by V15 that R5 fell out of bed; she was on the floor on the side of her bed. I asked her what happened. She told me she rolled over too far during incontinence care. She had a skin tear to her arm, a laceration to her head (described both as small, did not qualify small, did not measure). Review of V12's progress note in R5's medical record (07/19/2019 at 4:15 AM) confirms the above statement. Review of R5's Care Card (no date) and MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 07/15/2019 documents R5 requires extensive assistance with transfers (requires use of mechanical lift) and toileting. R5's At risk for abuse care plan (initiated 05/21/2019) documents R5 has accused staff of improper nursing care and under Approach, Staff will provide care in pair.

Based on interview and record review, the facility failed to implement, communicate and document in care plan, fall risk assessment and interventions for 1 of 3 residents (R1) reviewed for falls in a total sample of 3. This failure resulted in R1 falling out of bed, sustaining a laceration to forehead, a fractured nose and separated left shoulder. Findings include: R1 was admitted to facility on 4/13/19 at 6:35pm from a local hospital. Hospital Discharge Summary on 4/13/19 documents R1 is a fall risk. On 5/6/19 at 4:45pm, V10 (Licensed Practical Nurse/LPN) stated, I admitted R1 to facility, accompanied by family who made it very clear he was a fall risk. I also received report from local hospital before he came that he was a fall risk as well. With him coming in on the weekend, we would not be able to get floor mats or other proper fall precautions until the next day unless we saw some laying around in another room. I did what I could. Then, V12 (Licensed Practical Nurse/LPN) finished the admission. V12's Admission Fall risk assessment on 4/13/19 notes R1 is high risk for falls. V12's progress note on 4/13/19 at 8:07pm notes R1 had multiple falls at home and writer explained to family that staff will put down a floor mat. On 5/6/19 at 1:30pm, V5 (Certified Nursing Assistant/CNA) stated, I worked with R1 during the day on 4/14/19 for the first time and I saw his legs sliding off the bed and stiff as a board. I told him he would fall like that so we assisted him up and the floor mat was put against the wall. He was in the dining room the rest of the shift. On 5/6/19 at 12:50pm, V4 (CNA) stated, I started my shift that afternoon (4/14/19) and was not briefed that R1 was a fall risk or using a floor mat. There was a mat in the room but I thought it was for his roommate. There was not a care card made for him yet that lists if he is a fall risk or the interventions. I laid R1 in bed, then left the room for a minute. When I returned, R1 was on the floor and bleeding from a gash on his forehead. On 5/6/19 at 4:30 pm V9 (Registered Nurse/RN) stated, I took care of R1 on 4/14/19, the evening he fell . The family had been there when I started my shift. After the family had left, I asked V4 to get R1 into bed. I heard that the family told V4 to put the floor mat on the floor. R1 was a new admission so V4 and I didn't even know about the floor mats or that he was a fall risk. There was no care card for him yet and R1's name was not on the fall risk list so there were no interventions listed. The restorative nurses make the care card, which states if the resident is a fall risk. There was a laceration on the forehead after he fell . There was no floor mat. He was sent to the emergency room . On 5/6/19 at 4:46pm, V8 (Restorative Nurse) stated, When someone is admitted and a fall risk, it is in the admission packet. I am off on the weekends, and when I come in on Monday, myself and the other restorative nurses look at the admissions and go thru to see who is a fall risk. The admitting nurse would add the fall interventions. On weekends, the nurses give verbal report if resident is a fall risk and the interventions in place to the other nurses. The care card is put in place by restorative CNAs, so on the weekends, the staff just give verbal reports about fall risk and interventions. On 5/7/19 at 10:16am, V3 (Director of Nursing/DON) stated, The restorative aides work 7 days a week and are responsible for seeing the new admissions then creating a care card for the CNAs with the fall risk and interventions listed. If that was not done for some reason, the nurses on the unit are able to create this as well, in addition to verbally informing the CNAs and other nurses of fall interventions. R1 should have had a care card by the next evening (the evening of R1's fall) that lists interventions and fall risk or been given verbal report. There is no policy or protocol for nurses to create, report and document fall interventions when resident is admitted . V9's progress note dated 4/14/19 at 9:40pm, notes V4 was making rounds and noted R1 laying on his left side on the floor near the bed. R1 had half inch laceration noted to the forehead with small amount of blood noted. Pressure dressing applied. R1 was sent to the local emergency room for evaluation. emergency room report dated 4/14/19 states R1 is status [REDACTED]. The patient showed signs of intractable pain during the course of the hospital stay and several medication were initiated in an effort to control his pain. Eventually, he was placed on oral [MEDICATION NAME] and discharged to home on hospice on 4/20/19. Care plan dated 4/13/19 notes that R1 is at risk for falling related to impaired mobility and does not include floor mat as an intervention as stated in V12's progress note. Physical Therapy notes dated 4/14/19 (the evening of R1's fall) note R1 is a fall risk and has impaired range of motion to upper and lower extremities as well as right hip and knee. R1 is totally dependent with bed mobility.

Based on interview and record review, the facility failed to prevent one resident (R4) from sustaining a fall out of a sample of three residents reviewed for falls, from a total of 22 sampled residents. This failure resulted in R4 sustaining an injury to the head requiring sutures. Facility data sheet documents R4 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 6/19/18 at 10:29 AM V10 (family member) stated, I received a call from the facility on 4/28/18 at 5:00 AM informing me R4 had a fall and had to be transferred to the emergency room for evaluation. V10 said, I arrived at the facility and asked the nurse on duty what happened and was told the CNA (Certified Nurse Assistant) was providing care to R4 without assistance and R4 sustained a fall. I asked for the CNA's (Certified Nursing Assistant) last name and was told by the nurse that she could not provide that information until she spoke to her supervisor. V10 said, The nurse on duty called the DON (Director of Nursing) who refused to speak to me until Monday. On Monday I received a call from the DON who stated she was not told by the nurse who called that I wanted to speak to her right away. V10 stated the DON did meet with her on Monday. On 6/20/18 at 11:15 AM V3 DON stated, On the date in question I received a call from the nurse informing me R4 had a fall while staff was providing care. R4 was sent to the hospital and returned the same day with a laceration to the right forehead. I called the emergency contact and let her know we would be doing an investigation and could we meet on Monday as the incident occurred on the weekend. The family member agreed to allow us to finish the investigation. I called the family to inform them of the results of the investigation. V3 said, There is no reason why the nurse on duty could not give the last name of the CNA caring for R4, because our staff is required to wear their name badges. I provided the emergency contact with the full name of the CNA caring for R4. On 6/20/18 V9 CNA stated R4 was in bed and he was providing care. V9 said R4 has bed bolsters on both sides of the bed which he removed in order to provide care. V9 said, I had one hand on R4 when she began making jerky movement and rolled over. I was not able to hold her and she rolled out of bed. V9 said he immediately called for the nurse on duty. Review of facility incident report form dated 4/28/18 documents V9 stated as he was repositioning R4 in bed he had one hand on R4 and reached back for an item. V9 stated R4 began to cough and then shifted away from him quickly and he was unable to prevent her from falling from the bed. An initial report was faxed to IDPH (Illinois Department of Public Health) on 4/28/18 at 7:51 AM and the final report was faxed to IDPH on 5/3/2018. Review of facility MDS (Minimum Data Set) dated 8/23/17 Section G Functional Status documents R4 Self-Performance for Personal hygiene indicates extensive assistance, ADL Support provided indicates 2 plus person physical assistance with hygiene. Review of facility care plan dated 8/27/17 documents R4 as high risk for falls.

Based on observations, record review and interviews the facility failed to have trained staff members to intervene to prevent or stop physical abusive behavior to avoid resident injury, have crisis interventions protocols for residents with combative/aggressive behaviors and have individual care plan interventions for residents to address combative/aggressive behavior. These failures apply to 10 of 17 residents (R1, R3, R6, R11, R12, R13, R14, R15, R16 and R17) reviewed for behaviors in a sample of 17. As a result of the facility's failure, on 7/22/2014 R1 was physically abused by a staff member (E7) during a physical intervention to stop a negative behavior. During this encounter E7 caused multiple injuries to R1's facial area. R1 was admitted to the hospital and treated for [REDACTED]. On 8/07/2014 an immediate jeopardy was identified to have begun on 7/22/2014 when R1 was abused. Multiple residents reside in the facility who demonstrated physical abusive behavior and staff members were not trained to implement physical and non-physical interventions to avoid injury to the residents. On 8/07/2014 at 10:00AM E1 (administrator) was informed of the immediate jeopardy. While the Immediate Jeopardy was removed on 8-08-14, the facility remains out of compliance at a severity level two. Additional time is needed to monitor and evaluate the effectiveness of the training of staff members and revised policies & procedures to ensure their implementation. Findings Include: 1. R1 is an eighty-one (81) year old resident admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. -The facility's incident report dated 7/22/2014 at 6:00 PM denotes: "R1 was receiving activities of living (ADL) and R1 became agitated and combative during care. R1 lost his balance and hit his head on the headboard but R1 stated he was hit by staff. R1 was assessed by the nurse and was observed with a laceration to the lip. R1's family and physician were notified R1's physician gave orders to send to the hospital for an evaluation." R1's hospital emergency record dated 7/22/2014 denotes R1 had a laceration to the upper lip and received three sutures. A local police report dated 7/22/2014 stated: E7 (Nurse's Assistant) was arrested and detained for 2 days at the police station. E7 was questioned about the incident involving R1 that lead to his injuries and required hospitalization . E7 explained to the local police R1 became very uncooperative and very combative, unable to get assistance. R1 swung both arms at him and after a few minutes of struggling with one another; R1 fell off the bed and struck the corner of the table located next to the bed. On 7/24/2014 at 3:30PM, Z1 (Psychiatric Physician) explained " the facility never call me about the incident of R1 being sent to the hospital for a facial lacerations. Nothing was told to me about an emergency room visit, police reports or an arrest of an employee. They just informed be about R1 having negative acting out behaviors. The facility spoke to me about consultations and medications." R1 was observed on 7/24/2014 at 5:00 PM, on the skilled nursing unit in a wheel chair. R1 is alert and he was propelling his wheelchair independently while stating, "I am busy and I don't have the time to talk to you." R1 had sutures on the upper lip on the left side. The left side of R1's his face was discolored with mild swelling to the jaw line (middle of face) and lip. On 7/31/2014 at 12:20pm, Z2 (family) stated she went to the hospital on [DATE] after being called by the facility. Z2 stated, R1 told her the boy he was working with, hit him in the mouth. My husband has a big piece missing out of his lip, I don't like this. - Next, the facility's incident report dated 7-25-14 denotes: R1 was calm initially and during care became aggressive. E3 (staff nurse) held R1's arms down and did not apply any pressure. On 7-25-14 at 9:30AM, E6 (Social Worker) explained R1 was transferred out of the facility to the hospital because R1 hit a nursing staff. On 7/25/2014 at 11:00AM, E3 explained R1 hit her in the face while she was assisting E4 (Nurse's Assistant) with putting on R1's pants. E3 explained she held one arm across R1 ' s chest at the wrist and held the other arm against the side his body, holding the lower arm, while he was lying in bed. E4 then put the pant on while R1 remain lying in the bed. R1 was resistant to care at that time. On 7/25/2014 at 12:30PM E4 (Nurse's Assistant), admitted she and E3 went into the room and E3 held R1's hands and arms down. " I pulled his pants up " -R1's nursing progress notes from admission on 6/14/2014 to 7/25/2014 had documentation of R1's multiple physical altercations with staff and other residents as follows: 7-6-14 at 10:55AM: (R1) continues to be combative with staff members and refusing care. Notes several scratches on both lower extremities. 7-7-14 at 10:19AM denotes R1 became aggressive and attempted to hit staff and curse at staff. 7-8-14 at 7:06AM; combative, kicking and punching staff. 7-9-14 notes R1 increasing agitated and agitated and aggressive and combative. Hitting and punching staff. 7-11-14 at 5:30PM denotes combative, swinging and hitting staff. Also incident reports documented R1's aggressive/abusive behavior as follows: 7-16-14 denotes R1 was scratch at the bridge of his nose by another resident, (R5). 7-20-14 denotes R1 was in a verbal and physical altercation with another resident, R5. R1's clinical record had no psychosocial interventions to decrease, re-evaluate, or re-assessment of medications to address the severity, duration of (30 days) R1's combative aggressive behavior toward staff and other residents. 2. The facility has nine (9) other elderly residents (R3, R6, R11, R12, R13, R14, R15, R16 and R17) who have been identified by the social service department as demonstrating combative aggressive behaviors. -E5 (Therapy aide) explained on 7-24-14 that R3 hit her because an explanation was not given before she reach to zip up her pants. R3 is a [AGE] year old resident. -R6 according to progress notes, attempted to get physically aggressive with another peer using an object on 7-8-14. -R11 ' s progress notes dated 6-8-14 denotes, resident physically threatening another resident. Both were separate and resident educated." -R12's progress notes dated 7-28-14 stated, "resident with erratic behavior which is difficult to re-direct with staff. Resident behavior to be potentially harmful to self and others." -R13's progress notes dated 6-12-14 at 10:47AM and 1:07PM denotes, R13 became physically aggressive and attempted to hit staff and hitting staff with close fist. -R14's progress notes dated 7-21-14 denotes, (R14) hitting and screaming at staff and her peers." -R15's progress notes dated 7-29-14 denotes, (R15) resident has a history of physically abusive, kicking, swing his arms toward staff." -R16's progress notes dated 6-25-14 denotes, " (R16) pushed another resident " on 6-30-14 physically aggressive toward peers." -R17's progress notes dated 7-24-14 denotes, aggressive behavior, told unable to smoke, not going to meds (medication), will exit facility through a window. R3, R6, R11, R12, R13, R14, R15, R16 and R17's current care plans, had no staff crisis interventions for catastrophe adverse behaviors nor how the staff would intervene physically to stop physically abusive. When requested, the facility did not present a policy governing resident's safety measures to protect the residents or employee from any resident's with aggressive combative behaviors. The facility's current abuse policy does not address any preventive intervention. On 7-25-14 at 4:00PM, E6 (Social Service Director) explained, there is no protocols to follow when dealing with elderly residents identified with combative aggressive behaviors. E6 explained, we assess, identify and document behaviors, along with consultation in house and provide one to one therapy. If these things are not effective, a psychiatric evaluation, family involvement and possible discharge (is implemented) if adverse behaviors continues. R1 should have been discharge from the facility because of his behaviors not being address safely and other multiple incidents he was involved in. E6 gave no comments about the 9 other residents who required behavior modifications for physical assault toward the staff and or others. E1 (administrator) and E6 explained on 8-6-14 at 2:00PM in the conference room, the facility has no direct policy or procedures in place to treat or care for residents with aggressive combative behaviors. The facility's policy entitled,"Problematic Behavior management - Clinical Protocol" dated August, and 2008 stated the following: Treatment Management 1). the staff will use protocols to identify pertinent interventions, other than medications for the nature and causes of the individual ' s problematic behavior. a). the rational should be based on information contained in pertinent protocols and guidelines regarding the use and adjustment of such medications. Monitoring and Follow-up 1). If the resident is being treated for [REDACTED]. This policy did not outline what a staff member would or should do if it became necessary to physically intervene when any resident has a catastrophic behavior. The facility did not offer any training of staff member regarding this specific topic within the last year. The Immediate Jeopardy was determined to have begun on 7/22/2014 when the facility failed to intervene with appropriate behavior modifications, implement safety and protect the resident from abuse The surveyor confirmed through record review and interviews, the facility took the following actions to remove the immediacy on 8/08/2014. 1). An emergency quality assurance (QA) Committee meeting was called on 8/07/2014 at 12:00PM to discuss and plan the removal of the Immediate Jeopardy. The meeting included: Administrator, Medical Director, Assistance Director of Nursing, Social Service Director. 2). Certificated trainers taught the employees of the facility how to treat and care for aggressive/combative residents residing in the facility. Including but not limited to physical crisis intervention techniques. Initiated on 8/08/2014 and will continue until all staff members are trained. 3). Facility wide training on handling and caring for combative aggressive resident residing in the facility. Any staff that does not complete this in service by the end of 8/08/2014, will be removed from the schedule until in-servicing in completed. Initiated 8/07/2014 and will continue until all staff members are trained. 4). The facility's policy governing unmanageable resident's behavior (Problematic Behavior management - Clinical Protocol) was reviewed and revised. The policy was implemented on 8/08/2014. 5). All residents with aggressive behavior residing in the facility within the last 30 days will be reviewed by the IDT (interdisciplinary team). R1, R3, R6, R11, R12, R13, R14, R15, R16 and R17 care plans will be up-dated/revised as needed based on this audit. Initiated 8/07/2014 6). Prior to admission to the facility, residents will be assessed for adverse behaviors by Social Service for aggressive or unmanageable behaviors. 7). On-going tracking and trending will be reviewed and discussed by the IDT and QA. Initiated on 8/07/2014. 8). An in-Service was conducted for all staff on Working with Aggressive Residents. This in-service will be done upon hire, annually and short refresher session quarterly. Initiated on 8/07/2014. 9). An in-Service was conducted for all staff on Abuse, Preventions and Responding and Reporting. This in-service will be done upon hire, annually and short refresher session quarterly, starting 8/07/2014. 10). Each day the Administrator, Director of Nursing, Social Service Director will meet and reviews incidents of Abuse and or aggressive resident behavior to ensure appropriate staff response and documentation is complete. Corrective action will be taken when audit shows any deficient practices. Staff will be re-educated, counseling including up to and including disciplinary actions. Initiated on 8/08/2014 11). The Administrator/designee will prepare a report quarterly to the CQI/QA committee for any further corrective actions needed and further disposition of plan .

Based on observation, interview, and record review the facility failed to obtain a physician's order for use of an indwelling urinary catheter and provide appropriate care & services to prevent infections for a resident with an indwelling urinary catheter, for one (R3) of three residents reviewed for catheter use, in a sample of 24. Findings include: R3 is a [AGE] year old female with a [DIAGNOSES REDACTED]. On 10/26/11 at 9:30 AM, R3 was observed lying in her bed during wound care. R3 had an indwelling urinary catheter in place. Review of R3's current physician's orders on 10/26/11 revealed no physicians order for use of an indwelling urinary catheter, nor any orders for catheter monitoring and care. Review of R3's Treatment Flowsheet (10/23/11- 11/22/11) on 10/26/11 revealed no treatments for catheter care or monitoring. R3's Care Plan regarding bladder, dated 10/4/11, indicates R3 is incontinent of bladder due to dementia, and did not address use of an indwelling urinary catheter. On 10/26/11 at approximately 4:30 PM E1 (Administrator) was informed of lack of medical documentation regarding catheter use. On 10/28/11 at approximately 11:00 AM, E2 (Director of Nurses) stated she was unsure of when R3's use of an indwelling urinary catherer was initiated. When asked if R3 had a catherer assessment present, E2 stated she was unsure but would check. R3's Bladder Assessments dated 6/27/10 and 4/23/11 indicated R3 had an indwelling catheter. R3's Bladder Assessments dated 8/5/11 and 10/3/11 do not indicate the use of an indwelling catheter. Full Clinical/Body Obeservation completed on 9/28/11 indicated the presence of an indwelling urinary catheter. Serum Complete Blood Count (CBC) collected on 10/18/11, indicated the presence of elevated white blood cells (11.3 thous/cumm- normal range 4.8-10.8 thous/cumm). On 10/23/11, R3 had a documented temperature of 101.2 degrees F. On 10/28/11, review of R3's urine culture collected on 10/23/11 indicated presence of infection (proteus mirabilis).

Based on observations, interview and record review, the facility failed to adequately supervise cognitively impaired residents identified as high risk for falls, failed to fully investigate the reason for falls and failed to identify the root cause for the numerous falls. Five of 9 residents (R18, R8, R2, R19, R24) were reviewed for falls in the sample of 24 residents. As a result of this failure R18 sustained a left shoulder fractures, a left hip fracture for R24, a left arm fracture for R8, a left hand fracture for R2 and lacerations and abrasions for R19. The facility staff failed to provide timely x-ray services for R24 when notified by portable x-ray company it would be 5 hours before an x-ray could be performed. The findings include: 1) On [DATE] during the initial tour (9:15 AM to 10:06 AM ) of the dementia unit with E6 (nurse), in the 300 unit alcove, R18 was seated in her wheel-chair with the left arm immobilizer in place, her head down by chest and drool coming from her nose/mouth. There is a trough on the left armrest of the wheel-chair for her left sided weakness from her hemiparesis. R18 is orient to person and place. E6 never stated anything about R18's arm fracture as we observed her during the initial tour. Throughout the week, R18 would be seated in her wheel-chair with her left arm immobilizer in place, her head down toward chest and sleepy. R18 was easily aroused when her name was called. R18 would be positioned in various places, at the ,[DATE] nurses' station or the 300 unit alcove. During all meals on ,[DATE]-,[DATE] noon meals and [DATE] breakfast meal in the ,[DATE] dining room, R18 was very lethargic and needed numerous cues to wake up and eat. Review of the facility's incident logs document falls for R18 on [DATE] and [DATE]. Review of the incident reports document none of the falls were witnessed with the falls occurring at 9:53 A.M. and 7:47 A.M. respectively. There were no documented staff or resident statements. The [DATE] fall resulted in left arm fracture. R18 was found on the floor by her bed when the nurse aide left her at the edge of the bed to get assistance to help transfer R18 to the wheel-chair. R18 also sustained a bruise and laceration to the forehead. There was no documented interview provided with the nurse aide who left R18 unattended. There was verbal and physical altercation on [DATE] at 1:20 PM between R18 and another unidentified resident which resulted in a scratch on R18's forehead. This was unwitnessed. There was no investigation as to what precipitated the incident. The current quarterly minimum data set ((MDS) dated [DATE] and the significant change MDS dated [DATE] documents R18 to be extensive assist with one staff person for transfers with no ambulation occurring. R18's care plan for falls dated [DATE] documents her to be high risk for falls due to her left-sided weakness from her cerebral vascular accident and muscle weakness. The approaches are to occupy he with meaningful activities. R18's current care plan for falls dated [DATE] documents the risk of falls relates to cerebral vascular accident with left sided weakness, osteoarthrosis and muscle weakness. The approaches are to give verbal reminders not to ambulate without assistance and occupy resident with meaningful activities. 2) On [DATE] during the initial tour between 9:15 A.M to 10:06 A.M. of the dementia unit with E6 (nurse) and throughout the week, R2 was ambulating the unit with a walker. The walker height is too tall with the hand rest above his waist level. R2 would need reminders to use the walker correctly because at times he would be carry it. When R2 used the walker, his shoulders would be elevated due to the height of the walker. Review of the facility's incident log document falls on [DATE] at 9:47 A.M in the dining room which was not witnessed, on [DATE] at 9:52 P.M in his room not witnessed, on [DATE] at 7:30 A.M. in the 400 unit alcove which was witnessed, a fall on [DATE] at 8:55 A.M in the dining room where he is witnessed to be very lethargic, lost his balance and fell , a suspected fall on [DATE] at 8 A.M. due to swelling of left hand, and two other falls on [DATE] at 2:30 P.M. in R2's room and [DATE] at 11:23 A.M in the dining room. The incident report dated [DATE] documents R2 found on dining room floor. There were no investigation as to how it happened, no documented statements from staff nor was the lack of supervision addressed. The incident dated [DATE] documents R2 found on floor in his room and has swelling to his right hand, an abrasion and bruising to left elbow. No investigation as to how it happened nor is the lack of supervision addressed. The x-ray to the hand shows an old fracture of the 5TH metacarpal. The incident dated [DATE] documents R2 looses his balance while walking in the 400 unit alcove. R2 sustained a 4.4 by .5 gash with bleeding above his right eye. There were no inches or centrimeters indicated. No investigation into why he lost his balance and fell . The nurse aide who witnessed the incident is not identified. The incident dated [DATE] documents R2 is very lethargic and looses his balance and falls. There is no documentation of who witnessed the incident and why he was walking when so lethargic. The incident [DATE] documents R2 is found with swollen left hand. It is unclear if R2's hand was fractured. R2 does not complain of pain. There is no investigation as to how the hand became swollen. Review of the State's incident report dated [DATE] documents a fracture to the left hand. The incident of [DATE] R2 is found on the floor in his room next to urine on the floor. It was not witnessed but the documentation says R2 stepped into urine and slipped. It is unclear where this information was retrieved. The incident dated [DATE] documents R2 fell asleep in a chair in the dining room and slid to the floor. This was witnessed by activity aide but she not identified. R2 complained of pain to left shoulder. The incident dated [DATE] at 4:40 P.M. documents open blister/skin tear to right lower leg during the shower. There was no investigation into how he received the skin tear. R2's current care plan with original date of [DATE] documents the risk of falls related to dementia, anxiety, muscle weakness, daily use of psychotropics, antidepressants and diuretics. The approaches are for resident to ambulate with staff's assistance and monitor of need for additional fall protocol initiation. 3) On [DATE], [DATE] and [DATE] in the 400 unit alcove, R8 would sit on the couch and sleep. The only times she was awake and alert are meal-times and the occasional activity on [DATE] at 1:30 P.M. and [DATE] at 1:17 P.M. The activity would last for an half hour. R8 would minimally participate in the activities. R8 would ambulate with a slow steady gait. On [DATE] at 3:53 P.M, Z9 (brother of R8) states R8 is always sleepy when they visit, which is weekly. He stated she never wants to go for walks because she tired. Z9 stated R8 does not like to sleep in the bed and prefers the couch. On [DATE] at 1:30 P.M., E6 (nurse) stated R8 is always tired and wants to always sleep. On [DATE] at 1:15 P.M., E9 (nurse aide) stated R8 prefers to sleep on the couch instead of the bed. R8 has had 5 documented falls with one fall resulting in a left arm fracture per the facility's computerized incident log. The incident of [DATE] at 10:31 A.M. document R8 agitated and combative with staff during her shower. R8 looses her balance and falls. No injury. There is no documentation to support how and why it happened. The incident of [DATE] at 6:47 P.M. document R8 is found on the floor of another resident's room. An x-ray is done in the facility and results are no fracture. R8 continues to complain about pain to the arm on [DATE], [DATE] and [DATE]. There is swelling noted on [DATE]. It is [DATE] when R2 has rapid and shallow respiration. R8 states, "her arm hurts". Her left forearm and hand is swollen. R8's vitals are not normal but the vitals not documented. R8 was resistant and defiant about going to the hospital due to her behavior and cognition. On [DATE] at 7:29 A.M., R8 agrees to go to hospital. R8 returns at 6:18 P.M to the facility with left arm in sling. The arm is swollen with bruising. On [DATE] at 2:45 P.M. documents her left arm is fractured. The facility determines the fracture is due to behavior and cognition. The supervision and lethargic behavior are not addressed nor is the incident of R8 found on the floor of another resident's room investigated. The incident of [DATE] at 6 A.M documents R8 toilet herself and fell in the bathroom due to tripping on her pant leg. This incident was not witnessed. The intervention is to move her to the dementia unit for increased observations. The care plan for falls dated [DATE] documents an evaluation to rule out syncope will be done and to monitor the effects of acetaminophen and to apply a personal alarm. No documentation was provided on whether or not R8 has syncope nor what the effects are for acetaminophen, if any. The incident of [DATE] at 11:29 AM document R8 was attempting to get out of recliner and slid and sat on floor. It was witnessed. R8 has limited range of motion to the left arm. The nurses notes dated [DATE] at 4:15 P.M. in the ,[DATE] dining room document R8 sitting with elbows on table and eyes closed but easily aroused when name called. This documentation reflects R8 in the ,[DATE] unit when the care plan dated [DATE] documents R8 to be moved to dementia unit (,[DATE] unit) for increased supervision. The current care plan for falls dated [DATE] documents the potential for falls is due to arthritis and unsteady gait. R8 assessed for high risk for falls. The approaches are to monitor for pain, monitor the effectiveness and side effects of the acetaminophen and monitor the need for additional fall protocol. 4) On [DATE] at 11:58 A.M in the ,[DATE] unit dining room, R19 is seated in a regular chair at the table. R19 was gobbling his food at rapid rate using his fingers and utensils. When R19 was not eating, he would be sleepy with his eyes closed sitting on couch in the 300 unit alcove. When R19 ambulates, he keeps his head down and has a slow, unsteady gait. On [DATE] at 3:50 P.M. in the ,[DATE] unit dining room during an activity with E12 and E14 (both activity staff), R19 has his right sock off and foot bare, his left pant leg pulled up to his knee and he is sucking on the hem of the pants. No re-direction given to R19. R19 has had 6 falls with 2 falls resulting in abrasions per the facility's computerized incident log. The incident of [DATE] at 8:24 A.M documents R19 has an abrasion to the face. There was no documented report provided by the facility when repeatedly asked for on [DATE] and [DATE] at the daily meeting, and two times on [DATE] in the morning daily meeting from E1(administrator), Z1 and Z2 (corporate nurses). E2 is the acting director of nursing (D.O.N.) and assumed this position as of [DATE]st, 2011. Prior she was the assistant D.O.N. since [DATE] when first employed. E2 apologized she could not be more helpful. The incident of [DATE] documents an abrasions to right shoulder. The abrasion measured 8 by 3 centrimeters. It was unwitnessed and R19 was found on the floor. The incident report documents R19 as being lethargic and drowsy. Nurses' notes [DATE] at 5:15 A.M documents two abrasions, one on right shoulder and other on head. There was no documentation of an investigation on these incidents to determine how and when R19 sustained the abrasions. The incident of [DATE] at 12 AM documents R19 on the floor and it is unwitnessed. There was no investigation as to how it happened. The incident of [DATE] at 11:30 P.M. documents R19 on the floor in the fetal position. It was not witnessed. It is unclear what the facility determined from the investigation. There is a list of medications but it does not indicate what was decided. R19 was on .5 milligrams(mg) of risperdal at 9A.M. since [DATE] and 1mg of risperdal since [DATE]. The documented interventions were a scooped mattress, low bed and mats on floor when in bed after the [DATE] fall. There was no assessment or order seen for the scooped mattress. The care plan for falls dated [DATE] documents R19 is at risk for falls due to wandering, anti-hypertensive and psychotropic drug use with potential side effects. It documents R19 sustained a fall on [DATE], a fall on [DATE] while trying to re-positioned himself in bed, a fall on [DATE] and [DATE]. The current care plan for falls dated [DATE] documents a fall on [DATE] and documents he has a history of falls related to dementia, impaired decision making, poor posture and daily use of psychotropic medications. The approaches are direct to activities, assist with toileting after meals, place in supervised area. On [DATE] at 4:40 P.M. during the daily status, E1 (administrator), Z1 and Z2 (both corporate nurses) all stated the previous director of nursing was the one responsible for ensuring the incident reports were complete. They stated the previous D.O.N. left at the end of [DATE] after 6 month employment. On [DATE] at 9:30 A.M, Z1 and Z2 stated they gave all the information on the incidents. 5. R24's closed record review shows care plan dated [DATE] states R24 is at risk for falling due to unsteady gait, exhibits confusion and forgetfulness and experiences wandering. Interventions include "provide toileting assistance as needed." Event History dated [DATE] through [DATE] shows R24 sustained a fall on [DATE]. Nurses notes dated [DATE] at 8:11pm states R24 was found lying on the bathroom floor positioned on her back. Following the incident R24 told staff she was trying to transfer herself from the wheel chair to the toilet when she fell . Previous note dated [DATE] and [DATE] states R24 is on contact isolation for Methycillin Resistant Staphylococcus Aureus (MRSA) of the urine. This fall incident is not addressed on the care plan nor were new interventions put in place to prevent future falls. Facility was unable to provide evidence that a post-fall assessment was done. On [DATE] R24 had an unwitnessed fall. Nurses notes dated [DATE], 6:30 am, states R24 was observed in front of the wheelchair on her knees with her head on the floor. R24 sustained a laceration to the right side of her head and was sent out to the hospital for suturing of laceration. The care plan was updated on [DATE] to include physical and occupational therapy screening. R24 fell on [DATE], sustaining skin tear to her right elbow. Nursing notes dated [DATE], 6:20pm, states R24 was found by staff in a sitting position on the floor near her bed. Attempt was made to contact R24's physician. There was no further documentation regarding physician notification. This fall is not addressed in care plan with no update to the care plan. Post fall assessment dated [DATE] states R24 is to receive increased monitoring and supervision. R24 fell on [DATE] sustaining a right hip fracture. Nursing notes dated [DATE], 7:15 am states R24 was observed on the floor by her wheel chair in the television area. R24 complained of pain in her right and left hip with multiple dark purple areas on left and right arm and elbow. There was a skin tear on the left elbow. The physician ordered stat X-Rays to right and left hip. Portable X-Ray service provider notified facility staff that there would be a 4 to 6 hours delay in providing the service. At 11:20 am, R24 was in wheel chair in dining room, was pushed to her room to have X-Rays done. R24 was still complaining of pain in the left hip. The left leg was observed to be ,[DATE] inches shorter than the right, with R24 crying of pain. an order for [REDACTED]. At 12:56 pm, R24 still crying out in pain. X-Ray done, approximately five and one-half hours after fall. R24 was transferred to the hospital at 2:00 pm. R24 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. There is no evidence that the care plan was updated. R24 is not care planned for the fractured hip. A comprehensive assessment was conducted upon re-admission to the facility. Nursing notes dated [DATE], 9:32 pm describes R24 as not able to get up in a chair nor able to bear weight on left leg. R24 required to be fed by staff. R24 must be logged rolled by staff. R24 complains of pain when moved. R24 was referred to hospice care. Nurses notes dated [DATE], 2:43 pm states R24 has a Stage I pressure to left heel and right lateral ankle. On [DATE]. 3:01 pm, nursing notes states R24 is on contact isolation for urinary tract infection. On [DATE], 4:50 pm, R24 developed labored breathing and absent of vital signs and expired at 5:05 pm. The Facility's Falls Clinical protocol dated [DATE] states individual with history of falls will be identified; nurses will assess and document residents' fall risk factors; the physician will identify medical conditions affecting fall risk; falls occuring in the facility will be evaluated and documented. The Fall Prevention Program states measures will be implemented to address each resident's individual needs by assessing the risk of falls and implement appropriate interventions to provide necessary supervision and assistive devices as necessary.

Based on interviews, observation and record review the facility failed to prevent an accident for 1 of 4 residents (R2) reviewed for accidents/incidents in a sample of 4. This failure resulted in R2 rolling out of bed and sustaining a laceration to her right upper brow requiring 8 sutures. The findings include: R2 is a female resident with [DIAGNOSES REDACTED]. R2 is dependent on staff for all activities of daily living to include turning and re-positioning in bed per MDS (Minimum Data Set) dated 7/19/11. Incident report dated 5/27/11 documents that R2 fell out of her bed at 8:18 PM sustaining a laceration to her right upper brow. R2 was sent to the hospital and received 8 sutures to close the laceration. Interview with E2, DON (Director of Nursing) on 8/12/11 at 2:30 PM stated that R2 had been transferred to bed by E5, CNA (Certified Nurse Aide) and a new employee also a CNA. According to E2, R2 had been transferred into her bed properly but had been positioned to close to the edge of the bed which in turn led to her fall. E2 states that E5 was terminated from the facility as a result of this incident. E2 further states that E5 had left the nursing floor without notifying the nurse in charge, leaving only a new employee in training to monitor the residents of that unit. Interview with E3, LPN (Licensed Practical Nurse) on 8/12/11 at 2:10 AM states that R2 cannot move on her own. Interview with E4, CNA on 8/12/11 at 2:15 PM states that R2 cannot turn side to side but if she gets hot she has been known to throw her good leg over the side of the bed to remove her covers. E4 stated that is probably how she fell out of bed. E4 stated that it happened on second shift a few months ago when she was not working. E4 also added that if R2 was positioned to close to the edge of the bed it could happen (fall). Observation of R2 on 8/12/11 at 12:10 PM noted her up in her wheel chair wearing a splint to her left arm and tube feeding running. R2 was unable to speak but nodded her head "yes" that she was doing ok.

Based on observations, interview and record review, the facility failed to adequately supervise cognitively impaired residents identified as high risk for falls, failed to fully investigate the reason for falls and failed to identify the root cause for the numerous falls. Five of 9 residents (R18, R8, R2, R19, R24) were reviewed for falls in the sample of 24 residents. As a result of this failure R18 sustained a left shoulder fractures, a left hip fracture for R24, a left arm fracture for R8, a left hand fracture for R2 and lacerations and abrasions for R19. The facility staff failed to provide timely x-ray services for R24 when notified by portable x-ray company it would be 5 hours before an x-ray could be performed. The findings include: 1) On [DATE] during the initial tour (9:15 AM to 10:06 AM ) of the dementia unit with E6 (nurse), in the 300 unit alcove, R18 was seated in her wheel-chair with the left arm immobilizer in place, her head down by chest and drool coming from her nose/mouth. There is a trough on the left armrest of the wheel-chair for her left sided weakness from her hemiparesis. R18 is orient to person and place. E6 never stated anything about R18's arm fracture as we observed her during the initial tour. Throughout the week, R18 would be seated in her wheel-chair with her left arm immobilizer in place, her head down toward chest and sleepy. R18 was easily aroused when her name was called. R18 would be positioned in various places, at the ,[DATE] nurses' station or the 300 unit alcove. During all meals on ,[DATE]-,[DATE] noon meals and [DATE] breakfast meal in the ,[DATE] dining room, R18 was very lethargic and needed numerous cues to wake up and eat. Review of the facility's incident logs document falls for R18 on [DATE] and [DATE]. Review of the incident reports document none of the falls were witnessed with the falls occurring at 9:53 A.M. and 7:47 A.M. respectively. There were no documented staff or resident statements. The [DATE] fall resulted in left arm fracture. R18 was found on the floor by her bed when the nurse aide left her at the edge of the bed to get assistance to help transfer R18 to the wheel-chair. R18 also sustained a bruise and laceration to the forehead. There was no documented interview provided with the nurse aide who left R18 unattended. There was verbal and physical altercation on [DATE] at 1:20 PM between R18 and another unidentified resident which resulted in a scratch on R18's forehead. This was unwitnessed. There was no investigation as to what precipitated the incident. The current quarterly minimum data set ((MDS) dated [DATE] and the significant change MDS dated [DATE] documents R18 to be extensive assist with one staff person for transfers with no ambulation occurring. R18's care plan for falls dated [DATE] documents her to be high risk for falls due to her left-sided weakness from her cerebral vascular accident and muscle weakness. The approaches are to occupy he with meaningful activities. R18's current care plan for falls dated [DATE] documents the risk of falls relates to cerebral vascular accident with left sided weakness, osteoarthrosis and muscle weakness. The approaches are to give verbal reminders not to ambulate without assistance and occupy resident with meaningful activities. 2) On [DATE] during the initial tour between 9:15 A.M to 10:06 A.M. of the dementia unit with E6 (nurse) and throughout the week, R2 was ambulating the unit with a walker. The walker height is too tall with the hand rest above his waist level. R2 would need reminders to use the walker correctly because at times he would be carry it. When R2 used the walker, his shoulders would be elevated due to the height of the walker. Review of the facility's incident log document falls on [DATE] at 9:47 A.M in the dining room which was not witnessed, on [DATE] at 9:52 P.M in his room not witnessed, on [DATE] at 7:30 A.M. in the 400 unit alcove which was witnessed, a fall on [DATE] at 8:55 A.M in the dining room where he is witnessed to be very lethargic, lost his balance and fell , a suspected fall on [DATE] at 8 A.M. due to swelling of left hand, and two other falls on [DATE] at 2:30 P.M. in R2's room and [DATE] at 11:23 A.M in the dining room. The incident report dated [DATE] documents R2 found on dining room floor. There were no investigation as to how it happened, no documented statements from staff nor was the lack of supervision addressed. The incident dated [DATE] documents R2 found on floor in his room and has swelling to his right hand, an abrasion and bruising to left elbow. No investigation as to how it happened nor is the lack of supervision addressed. The x-ray to the hand shows an old fracture of the 5TH metacarpal. The incident dated [DATE] documents R2 looses his balance while walking in the 400 unit alcove. R2 sustained a 4.4 by .5 gash with bleeding above his right eye. There were no inches or centrimeters indicated. No investigation into why he lost his balance and fell . The nurse aide who witnessed the incident is not identified. The incident dated [DATE] documents R2 is very lethargic and looses his balance and falls. There is no documentation of who witnessed the incident and why he was walking when so lethargic. The incident [DATE] documents R2 is found with swollen left hand. It is unclear if R2's hand was fractured. R2 does not complain of pain. There is no investigation as to how the hand became swollen. Review of the State's incident report dated [DATE] documents a fracture to the left hand. The incident of [DATE] R2 is found on the floor in his room next to urine on the floor. It was not witnessed but the documentation says R2 stepped into urine and slipped. It is unclear where this information was retrieved. The incident dated [DATE] documents R2 fell asleep in a chair in the dining room and slid to the floor. This was witnessed by activity aide but she not identified. R2 complained of pain to left shoulder. The incident dated [DATE] at 4:40 P.M. documents open blister/skin tear to right lower leg during the shower. There was no investigation into how he received the skin tear. R2's current care plan with original date of [DATE] documents the risk of falls related to dementia, anxiety, muscle weakness, daily use of psychotropics, antidepressants and diuretics. The approaches are for resident to ambulate with staff's assistance and monitor of need for additional fall protocol initiation. 3) On [DATE], [DATE] and [DATE] in the 400 unit alcove, R8 would sit on the couch and sleep. The only times she was awake and alert are meal-times and the occasional activity on [DATE] at 1:30 P.M. and [DATE] at 1:17 P.M. The activity would last for an half hour. R8 would minimally participate in the activities. R8 would ambulate with a slow steady gait. On [DATE] at 3:53 P.M, Z9 (brother of R8) states R8 is always sleepy when they visit, which is weekly. He stated she never wants to go for walks because she tired. Z9 stated R8 does not like to sleep in the bed and prefers the couch. On [DATE] at 1:30 P.M., E6 (nurse) stated R8 is always tired and wants to always sleep. On [DATE] at 1:15 P.M., E9 (nurse aide) stated R8 prefers to sleep on the couch instead of the bed. R8 has had 5 documented falls with one fall resulting in a left arm fracture per the facility's computerized incident log. The incident of [DATE] at 10:31 A.M. document R8 agitated and combative with staff during her shower. R8 looses her balance and falls. No injury. There is no documentation to support how and why it happened. The incident of [DATE] at 6:47 P.M. document R8 is found on the floor of another resident's room. An x-ray is done in the facility and results are no fracture. R8 continues to complain about pain to the arm on [DATE], [DATE] and [DATE]. There is swelling noted on [DATE]. It is [DATE] when R2 has rapid and shallow respiration. R8 states, "her arm hurts". Her left forearm and hand is swollen. R8's vitals are not normal but the vitals not documented. R8 was resistant and defiant about going to the hospital due to her behavior and cognition. On [DATE] at 7:29 A.M., R8 agrees to go to hospital. R8 returns at 6:18 P.M to the facility with left arm in sling. The arm is swollen with bruising. On [DATE] at 2:45 P.M. documents her left arm is fractured. The facility determines the fracture is due to behavior and cognition. The supervision and lethargic behavior are not addressed nor is the incident of R8 found on the floor of another resident's room investigated. The incident of [DATE] at 6 A.M documents R8 toilet herself and fell in the bathroom due to tripping on her pant leg. This incident was not witnessed. The intervention is to move her to the dementia unit for increased observations. The care plan for falls dated [DATE] documents an evaluation to rule out syncope will be done and to monitor the effects of acetaminophen and to apply a personal alarm. No documentation was provided on whether or not R8 has syncope nor what the effects are for acetaminophen, if any. The incident of [DATE] at 11:29 AM document R8 was attempting to get out of recliner and slid and sat on floor. It was witnessed. R8 has limited range of motion to the left arm. The nurses notes dated [DATE] at 4:15 P.M. in the ,[DATE] dining room document R8 sitting with elbows on table and eyes closed but easily aroused when name called. This documentation reflects R8 in the ,[DATE] unit when the care plan dated [DATE] documents R8 to be moved to dementia unit (,[DATE] unit) for increased supervision. The current care plan for falls dated [DATE] documents the potential for falls is due to arthritis and unsteady gait. R8 assessed for high risk for falls. The approaches are to monitor for pain, monitor the effectiveness and side effects of the acetaminophen and monitor the need for additional fall protocol. 4) On [DATE] at 11:58 A.M in the ,[DATE] unit dining room, R19 is seated in a regular chair at the table. R19 was gobbling his food at rapid rate using his fingers and utensils. When R19 was not eating, he would be sleepy with his eyes closed sitting on couch in the 300 unit alcove. When R19 ambulates, he keeps his head down and has a slow, unsteady gait. On [DATE] at 3:50 P.M. in the ,[DATE] unit dining room during an activity with E12 and E14 (both activity staff), R19 has his right sock off and foot bare, his left pant leg pulled up to his knee and he is sucking on the hem of the pants. No re-direction given to R19. 5) R24's closed record review shows care plan dated [DATE] states R24 is at risk for falling due to unsteady gait, exhibits confusion and forgetfulness and experiences wandering. Interventions include "provide toileting assistance as needed." Event History dated [DATE] through [DATE] shows R24 sustained a fall on [DATE]. Nurses notes dated [DATE] at 8:11pm states R24 was found lying on the bathroom floor positioned on her back. Following the incident R24 told staff she was trying to transfer herself from the wheel chair to the toilet when she fell . Previous note dated [DATE] and [DATE] states R24 is on contact isolation for Methycillin Resistant Staphylococcus Aureus (MRSA) of the urine. This fall incident is not addressed on the care plan nor were new interventions put in place to prevent future falls. Facility was unable to provide evidence that a post-fall assessment was done. On [DATE] R24 had an unwitnessed fall. Nurses notes dated [DATE], 6:30 am, states R24 was observed in front of the wheelchair on her knees with her head on the floor. R24 sustained a laceration to the right side of her head and was sent out to the hospital for suturing of laceration. The care plan was updated on [DATE] to include physical and occupational therapy screening. R24 fell on [DATE], sustaining skin tear to her right elbow. Nursing notes dated [DATE], 6:20pm, states R24 was found by staff in a sitting position on the floor near her bed. Attempt was made to contact R24's physician. There was no further documentation regarding physician notification. This fall is not addressed in care plan with no update to the care plan. Post fall assessment dated [DATE] states R24 is to receive increased monitoring and supervision. R24 fell on [DATE] sustaining a right hip fracture. Nursing notes dated [DATE], 7:15 am states R24 was observed on the floor by her wheel chair in the television area. R24 complained of pain in her right and left hip with multiple dark purple areas on left and right arm and elbow. There was a skin tear on the left elbow. The physician ordered stat X-Rays to right and left hip. Portable X-Ray service provider notified facility staff that there would be a 4 to 6 hours delay in providing the service. At 11:20 am, R24 was in wheel chair in dining room, was pushed to her room to have X-Rays done. R24 was still complaining of pain in the left hip. The left leg was observed to be ,[DATE] inches shorter than the right, with R24 crying of pain. an order for [REDACTED]. At 12:56 pm, R24 still crying out in pain. X-Ray done, approximately five and one-half hours after fall. R24 was transferred to the hospital at 2:00 pm. R24 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. There is no evidence that the care plan was updated. R24 is not care planned for the fractured hip. A comprehensive assessment was conducted upon re-admission to the facility. Nursing notes dated [DATE], 9:32 pm describes R24 as not able to get up in a chair nor able to bear weight on left leg. R24 required to be fed by staff. R24 must be logged rolled by staff. R24 complains of pain when moved. R24 was referred to hospice care. Nurses notes dated [DATE], 2:43 pm states R24 has a Stage I pressure to left heel and right lateral ankle. On [DATE]. 3:01 pm, nursing notes states R24 is on contact isolation for urinary tract infection. On [DATE], 4:50 pm, R24 developed labored breathing and absent of vital signs and expired at 5:05 pm. The Facility's Falls Clinical protocol dated [DATE] states individuald with history of falls will be identified; nurses will assess and document residents' fall risk factors; the physician will identify medical conditions affecting fall risk; falls occuring in the facility will be evaluated and documented. The Fall Prevention Program states measures will be implemented to address each resident's individual needs by assessing the risk of falls and implement appropriate interventions to provide necessary supervision and assistive devices as necessary.

This requirement is not met as evidenced by: Based on record review, and interview, the facility failed to prevent 1 of 10 sampled residents(R1) from elopement (Exited Unsecured Bedroom Window) during the morning of 12-14-10. This failure resulted in R1's exposure to cold, snowy weather, which resulted in R1 experiencing Hypothermia and possible Frost Bite, of the 1st-4th digits of the left foot. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was determined to have begun on December 14, 2010 at 12:12pm, when R1 was found by the local police department approximately one mile from the facility. E1 ( Administrator), was notifed of the Immediate Jeopardy Past Non-Compliance on 2/17/11 at 2:57pm. Findings Include: On 12-14-10, R1, eloped from the facility. R1, exited through an unsecured bedroom window. The window that R1 eloped from, was located on the first floor. The window had two, "slide locks" that can be locked/unlocked by hand. Unlocked, the window was able to slide up enough for an averaged sized person to exit from. According to the National Weather Service, the outside temperature on 12-14-10, was 21 degrees Fahrenheit, with a "Mean" temperature of 14 degrees Fahrenheit. R1, was found approximately 1 mile from the facility, in a rural wooded location. R1, was found by the local police department. The police report, states that R1, was seen in the described area at 12:12pm. R1, was described as being "covered in snow, without a coat and shoes, in below zero weather." R1, was taken to the local hospital for treatment. According to the hospital report, R1 "arrived at 1:05pm, body temperature was, 91.9 degrees, F rectally , 1st-4th digits of the left foot cyanotic-possible frost bite." Other descriptions of R1 includes "arriving with only a T-Shirt, Pajama Bottoms, Socks without Shoes on, and with abrasions to both knees, and with Bluish Discoloration to both feet." Review of R1's record, indicates that he is a [AGE] year old resident, admitted to the facility in May of 2010, with medical [DIAGNOSES REDACTED]. R1, is classified as a high risk for elopement. On two previous attempts, both in July of 2010, R1 exited the facility by way of the front exit door. Upon review of the facility incident report regarding R1 elopement indicated that "R1 was last seen eating lunch around 12:00pm , where shortly around noon, he left the dining room.." . Further review, of the hospital report states that" R1 was quite possibly exposed to the elements for 90 minutes." Further review, of the police report, and the facility incident report both indicate that the police department notified the facility of R1 elopement. The facility was not aware of R1 elopement. Interview with Z1,(Attending Physician) on 2-17-11, at 12:15pm, indicated that because of R1 age, and the weather conditions R1 was exposed to, that it would not take long for R1's body temperature to drop. R1, returned to the facility on [DATE]. R1 discharge [DIAGNOSES REDACTED]. Interviews: 1. E1(Administrator) on 2-17-11 at 12:00pm , stated that he received the call from the police department that they had located R1 and were in the process of having him transferred to the hospital. E1 also stated that he was not aware that R1 was missing prior to receiving the phone call. E1 also stated that because of the serious nature of the incident, that he immediately secured all bedroom windows to prevent residents from exiting from them and updated all exit door alarms. 2. E3(Social Service Director) on 2-17-11 at 11:00am, stated that R1 was identified as an elopement risk and that interventions were in place. When asked, did R1 have the physical capability to exit from an unsecured window? E4 said yes. When asked, were there any interventions in place to secure the window ? E4 said just the standard window lock. 3. E5(Licensed Practical Nurse) 0n 2-17-11 at 9:45am, stated that she last saw R1 after lunch around 12:00pm. When asked, how did you find out that R1 was missing? E5 said that E1 informed the staff after he received the call from the police. When asked, did R1 have the physical capability to exit from an unsecured window? E5 said yes. 4. E4(Maintenance Director) on 2-17-11 at 10:15am, stated that after being informed of R1 elopement, he proceeded to do an exterior perimeter search. Without locating R1, he received instructions from E1 to secure the windows on the unit associated with R1 elopement by applying screws that will reduce the window lift up to the regulated height of 5.5 inches. E4 stated that the intervention was approved by the Assistant Fire Chief of the village where the facility is located. 5. E6(Certified Nursing Assistant) 0n 2-17-11 at 11:30am, stated that she last saw R1 on 12-14-10 at 12:00pm. When asked, did R1 have the physical capability of exiting from an unsecured window? E6 said yes. Review of the facility policy "Elopement" states that " it is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as possible." This did not occur, based on the fact that the facility was not aware that R1 was missing. The Immediate Jeopardy was removed on 12/15/10. E1 was notified per Daily Status Meeting. The deficiency was corrected on 12/21/10. The facility submitted the following plan of correction: R1, [DIAGNOSES REDACTED]. The following resident observations were updated on 12/15/10: 1. All windows through out the facility were secured so that they would limit the opening to 5 1/4 inches above the windown sill, completed 12/15/10. 2. Elopement risk assessments updated for all residents by Social Services Director. Those residents identified as potential risk for elopement risk behaviors currently have orders in place for elopement risk precautions and interventions, completed 12/15/10. 3. Elopement risk care plans updated for all residents by Social Service Director to reflect current interventions to promote compliance with elopement risk precautions, completed 12/15/10. 4. Licensed and unlicensed personnel re-educated on facility policy and procedure for electronic monitoring device and use of behavior occurrence forms, completed 12/15/10. 5. "Emergency" electronic monitoring device put in the narcotic box of each mediation cart. DON (Director of Nurses)/designee will monitor daily for compliance, completed 12/15/10. 6. Licensed personnel re-educated regarding "Emergency" electronic monitoring device placement and corresponding order in Physician Order Sheet, completed 12/15/10. 7. Z2, Social Service Consultant, presented re-education regarding: Exit Seeking Behaviors, the use of electronic monitoring devices, How to intervene when a resident is seeking an exit, How to document an elpement and/or exit seeking, completed 12/15/10 and 12/21/10. 8. Facility conducts Guardian Angel rounds daily which includes resident environment monitoring of potential safety issues and electronic monitoring device placement check, ongoing. 9. Social Service Director/designee updates the resident elopement risk binder as needed, ongoing.